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Are some types of stress better than others for people? Three prominent researchers on stress have taken very similar positions on this question, claiming that there are at least two kinds of stress that differ in their impact. Selye (1974, 1985), for instance, claimed one kind of stress is harmful and damaging, and is called distress; another kind is beneficial or constructive, and is called eustress (from the Greek eu, which means “good”). Similarly, as we saw earlier, Frankenhaeuser (1986) has described two components of stress: distress and effort. Distress with or without effort is probably more damaging than effort without distress. And Lazarus has described three types of stress appraisals—harm-loss, threat, and challenge—and noted:

Challenged persons are more likely to have better morale, because to be challenged means feeling positive about demanding encounters, as reflected in the pleasurable emotions accompanying challenge. The quality of functioning is apt to be better in challenge because the person feels more confident, less emotionally overwhelmed, and more capable of drawing on available resources than the person who is inhibited or blocked. Finally, it is possible that the physiological stress response to challenge is different from that of threat, so that diseases of adaptation are less likely to occur. (Lazarus & Folkman, 1984, p. 34)

There is a commonality to these three positions: to state it in its simplest form, there is good stress and bad stress—bad stress generally involves a strong negative emotional component. Cognitive appraisal processes play an important role in determining which kind of stress we experience. So, when an event or situation contains elements of bad stress, many people respond to difficult times by finding a larger meaning or with personal growth in which they feel that the experience has enriched their lives (Park, 2012).

Finally, in discussing whether stress is harmful, one other point should be made: individuals seem to differ in their susceptibility to the effects of stress. John Mason (1975) has proposed that these differences are like those that people show to the effects of viruses and bacteria. That is, not all people who are exposed to a disease-causing antigen, such as a flu virus, develop the illness—some individuals are more susceptible than others. Susceptibility to the effects of antigens and to stress varies from one person to the next and within the same individual across time. These differences result from biological variations within and between individuals, and from psychosocial variations, as we will see in the next chapter.

SUMMARY

Researchers have conceptualized stress in three ways. In one approach, stress is seen as a stimulus, and studies focus on the impact of stressors. Another approach treats stress as a response and examines the physical and psychological strains that stressors produce. The third approach proposes that stress is a process that involves continuous interactions and adjustments—or transactions—between the person and the environment. These three views lead to a definition of stress: the condition that results when person–environment transactions lead to a perceived discrepancy between the demands of a situation and the resources of the person’s biological, psychological, and social systems.

Transactions that lead to the condition of stress generally involve a process of cognitive appraisal, which takes two forms: primary appraisal focuses on whether a demand threatens the person’s well-being, and secondary appraisal assesses the resources available for meeting the demand. Primary appraisal produces one of three judgments: the demand is irrelevant, it is good, or it is stressful. A stressful appraisal receives further assessment for the amount of harm or loss, the threat of future harm, and the degree of challenge the demand presents. When primary and secondary appraisals indicate that our

resources are sufficient to meet the demands, we may experience little stress. But when we appraise a discrepancy in which the demands seem greater than our resources, we may feel a substantial amount of stress.

Whether people appraise events as stressful depends on factors that relate to the person and to the situation. Factors of the person include intellectual, motivational, and personality characteristics, such as the person’s self-esteem and belief system. With regard to situational factors, events tend to be appraised as stressful if they involve strong demands, are imminent, are undesirable and uncontrollable, involve major life transitions, or occur at an unexpected time in the life span.

Stressors produce strain in the person’s biological, psychological, and social systems. Emergency situations evoke a physiological fight-or-flight reaction, by which the organism prepares to attack the threat or flee. When stress is strong and prolonged, the physiological reaction goes through three stages: the alarm reaction, the stage of resistance, and the stage of exhaustion. This series of reactions is called the general adaptation syndrome. According to Selye, continuous high levels of stress can make the person vulnerable to diseases of adaptation, including ulcers and high blood pressure. The overall total

of physiological reaction to stressors, sometimes called allostatic load, may be a more important influence on health than the magnitude of the response to any single stressor. Factors that affect allostatic load include exposure to stressors, reactivity, recovery, and restoration.

Stress is linked to psychosocial processes. It can impair cognitive functioning, reduce people’s helping behavior, and increase their aggressiveness. Various emotions can accompany stress—these emotions include fear, anxiety, depression, and anger. Although the sources of stress may change as people develop, the condition of stress can occur at any time in the life span. Sometimes stress arises from within the person, such as when the person is ill or experiences conflict. Another source of stress is the family, such as in marital conflicts and serious illnesses or death in the family. Although women are more likely than men to be caretakers of elderly relatives, a meta-analysis found that the amount of care men and women give is similar. A new baby with a difficult temperament can be stressful for parents, and stress during pregnancy can lead to premature births. Other sources of stress include the community and society—for example, problems related to people’s jobs, environmental conditions, the qualities of their neighborhoods, and the experience of discrimination.

Researchers measure stress in several ways. One way assesses physiological arousal, such as changes in blood pressure and heart rate, with various sensors attached

to the body. Biochemical analyses of blood or urine samples can test for corticosteroids (for example, cortisol) and cate-cholamines (for example, epinephrine and norepinephrine). Other methods to measure stress use surveys of people’s experience of life events, daily hassles, and experience of different chronic stressors. Although stress can contribute to the development of illness, many psychologists believe that not all stress is harmful.

CREDITS

3-1 Frankenhaeuser, M. (1986). A psychobiological frame-work for research on human stress and coping. In M. H. Appley & R. Trumbull (Eds.), Dynamics of stress: Physiological, psychological, and social perspectives (pp. 101–116). New York: Plenum; with kind permis-sion from Springer Science+Business Media B.V.

3-2 Reprinted from Journal of Psychosomatic Research, Vol. 11. Holmes, T. H., & Rahe, R. H. The Social Readjust-ment Rating Scale, 213–218. Copyright (1967), with permission from Elsevier.

3-3 Ibid.

3-4 Sarafino, E. P., & Ewing, M. (1999). The Hassles Assessment Scale for Students in College: Measuring the frequency and unpleasantness of and dwelling on stressful events. Journal of American College Health, 48, 75–83. Reprinted with permission.

KEY TERMS

Note: If you read Modules 1 and 2 (from Chapter 2) with

the current chapter, you should include the key terms for

those modules.

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STRESS, BIOPSYCHOSOCIAL FACTORS, AND ILLNESS

Psychosocial Modifiers of Stress

Social Support

A Sense of Personal Control

Personality Factors in Stress

Type A Behavior and Beyond

How Stress Affects Health

Stress, Behavior, and Illness Stress, Physiology, and Illness Psychoneuroimmunology

Psychophysiological Disorders

Digestive System Diseases

Asthma

Recurrent Headache

Other Disorders

Stress and Cardiovascular Disorders

Hypertension

Coronary Heart Disease

Stress and Cancer

PROLOGUE

Two cataclysmic events riveted the world’s attention within a year of each other: the enormous tsunami in the Indian Ocean in December 2004 and hurricane Katrina,

which destroyed much of New Orleans and surrounding areas in August 2005. These events killed over 200,000 people and left even more injured and homeless. In New Orleans, hundreds of thousands of people were relocated, sometimes splitting up families, at least temporarily. Let’s contrast Katrina’s aftermath for two high school friends, Will and Barb, who were relocated far apart.

The initial impact of the hurricane on them was similar, but the amounts of stress that followed were different—Will’s stress was not as severe as Barb’s. One thing that helped Will was that his whole family remained together when relocated to a nearby town where they had relatives. The relatives provided consolation for Will’s loss, places for him to socialize, help in getting jobs for his parents, and assistance in getting their new house set up. How was Will doing 2 years later? He missed Barb, whom he hadn’t seen in over a year. But he was making a good adjustment in his new community, had a good relationship with his family, had begun attending a nearby community college and dating a student he met there, and was in good health.

Barb was not so fortunate, and her situation differed from Will’s in several major ways. Her immediate family was split up for several months until they relocated to a distant state when one of her parents got a job there. Barb had no extended family to help her and her parents or to provide emotional support in their grief. Her family lived in a cramped apartment in their new location,

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and their financial situation was very difficult. And Barb had never been as outgoing as Will—she felt awkward and insecure in making friends and meeting guys. Two years after Katrina, she was isolated and lonely. Although Barb graduated from high school, she then got a low-paying job with lots of overtime, which left her with little time or money to socialize. The stress in Barb’s life was taking its toll: she and her parents were arguing often, and her health was deteriorating. She had developed two painful illnesses—migraine headaches and a digestive system condition called irritable bowel syndrome—that worsened when she felt stress.

This chapter discusses issues introduced in Chapter 3 and examines in more detail the effects of stress on health. We begin by looking at psychosocial factors that can modify the stress people experience. Then we consider how stress affects health and the development of specific illnesses. In this chapter we address many questions about stress and illness that are of great concern today. Why can some people experience one traumatic event after another without ill effects, but others cannot? Are angry and hard-driving people more likely to have a heart attack than people who are easy-going? Can stress delay people’s recovery from illness?

if needed—that is, perceived support. As we will see later, received and perceived support can have different effects on health.

Types of Social Support

What specifically does social support provide to the person? It appears to provide four basic functions (Cutrona & Gardner, 2004; Uchino, 2004). Emotional or esteem support conveys empathy, caring, concern, positive regard, and encouragement toward the person. It gives the person comfort and reassurance with a sense of belongingness and of being loved in times of stress, as Will received from his immediate and extended family after Katrina. Tangible or instrumental support involves direct assistance, as when people give or lend the person money or help out with chores in times of stress. Will’s relatives helped his parents get jobs and set up the new house. Informational support includes giving advice, directions, suggestions, or feedback about how the person is doing.

PSYCHOSOCIAL MODIFIERS OF STRESS

People’s reactions to stress vary from one person to the next and from time to time for the same person. These variations often result from psychological and social factors that seem to modify the impact of stressors on the individual. Let’s look at some of these modifiers, beginning with the role of social support.

SOCIAL SUPPORT

We saw in the experiences of Will and Barb how important social ties and relationships can be during troubled times. The social support Will got from his family tempered the impact of his stressful loss and probably helped him adjust. Social support refers to comfort, caring, esteem, or help available to a person from other people or groups (Uchino, 2004). Support can come from many sources—the person’s spouse or lover, family, friends, physician, or community organizations. People with social support believe they are loved, valued, and part of a social network, such as a family or community organization, that can help in times of need. So, social support refers to actions actually performed by others, or received support. But it also refers to one’s sense or perception that comfort, caring, and help are available

A patient receiving informational support from her physician.

For example, a person who is ill might get information from family or a physician on how to treat the illness. Companionship support refers to the availability of others to spend time with the person, thereby giving a feeling of membership in a group of people who share interests and social activities.

What type of support do people generally need and get? The answer depends on the stressful circumstances. For instance, Figure 4-1 shows that cancer patients find emotional and esteem support to be especially help-ful, but patients with less serious chronic illnesses find the different types of support equally helpful (Martin et al., 1994). Another study had college students fill out a questionnaire, rating the degree to which their current relationships provided them with different types of sup-port, and then keep a daily record of their stress and social experiences for 2 weeks (Cutrona, 1986). The daily records revealed that most of the stressors were rela-tively minor, such as having car trouble or an argument with a roommate, but one-fifth of the students reported a severe event, such as a parent’s diagnosis of cancer or the ending of a long-term romantic relationship. As you might expect, individuals received more social support following stressful events than at less stressful times. Tangible support occurred very infrequently, but infor-mational and emotional/esteem support occurred often. Emotional/esteem support appeared to protect individ-uals from negative emotional consequences of stress.

Figure 4-1 Percentage of patients with cancer and with non-life-threatening disorders (chronic headache or irritable bowel syndrome) whose reports of the “most helpful” social support they received described the emotional/esteem, instrumental, or tangible types of support. Notice that the cancer patients found emotional or esteem support especially helpful. (Data from Martin et al., 1994, Figure 1.)

Who Gets Social Support?

Not everyone gets the social support he or she needs. Many factors determine whether people receive support (Antonucci, 1985; Broadhead et al., 1983; Wortman & Dunkel-Schetter, 1987). Some factors relate to the potential recipients of support. People are unlikely to receive support if they are unsociable, don’t help others, and don’t let others know that they need help. Some people are not assertive enough to ask for help, or feel that they should be independent or not burden others, or they feel uncomfortable confiding in others, or don’t know whom to ask. Other factors relate to the potential providers of support. For instance, they may not have the resources needed, or may be under stress and in need of help themselves, or may be insensitive to the needs of others. Old age is a time when social support sometimes declines: the elderly may exchange less support because of the loss of a spouse or because they may feel reluctant to ask for help if they become unable to reciprocate. Whether people receive social support also depends on the size, intimacy, and frequency of contact of individuals in their social network—the people a person knows and contacts (Cutrona & Gardner, 2004; Wills & Fegan, 2001).

How can we assess people’s social support, given the different types of support and the complex relationships that are involved? One highly regarded instrument is the Social Support Questionnaire, which consists of items, such as, “Who helps you feel that you truly have something positive to contribute to others?” (Sarason et al., 1983). For each item, the respondents list the people they can rely on and then indicate their overall degree of satisfaction with the support available. Using this instrument, these researchers have found that some people report high levels of satisfaction with support from a small number of close friends and relatives, but others need a large social network. (Go to .)

Gender, Sociocultural, and Age Differences in Receiving Support

The amount of social support individuals receive appears to depend on their gender and sociocultural group membership. Some evidence suggests that women receive less support from their spouses than men do and seem to rely heavily on women friends for social support (Greenglass & Noguchi, 1996). These gender differences may result from the greater intimacy that seems to exist in the friendships of females than males and may reflect mainly differences in the emotional and esteem support males and females seek out and give (Heller, Price, & Hogg, 1990). Such gender differences could also reflect the fact that women generally respond to their own and others’ stress with greater attention to personal relationships (Taylor et al., 2000). Research on social

ASSESS YOURSELF

How Much Emotional Support Do You Get?

Think of the 10 people to whom you feel closest. For some of them, you may not feel a strong bond—but they are still among the closest 10 people in your life. Write their initials in the following spaces:

In the corresponding spaces below each of the following four questions, rate each person on a 5-point scale, where 1 = “not at all” and 5 = “extremely.”

How reliable is this person; is this person there when you need him or her?

How much does this person make you feel he or she cares about you?

How much do feel you can confide in this person?

Add together all of the ratings you gave across all of the people and questions. A total score between 120 and 150 is fairly typical and suggests that you can get a reasonably good level of emotional support when you need it. Source: Based on material in Schaefer, Coyne, & Lazarus

(1981).

How much does this person boost your spirits when you feel low?

networks in the United States has revealed interesting gender and sociocultural relationships (Gottlieb & Green, 1987): Black Americans have smaller social networks than Whites and Hispanics, and men’s networks are larger than women’s among Black and Hispanic groups but not among nonminority people. Hispanics tend to focus mainly on extended families as their networks, Whites have broader networks of friends and coworkers, and Blacks focus on family and church groups. As older adults age and develop chronic illnesses, they feel lonelier and perceive their social networks as becoming smaller than they were (Barlow, Liu, & Wrosch, 2015; Wrosch, Rueggeberg, & Hoppmann, 2013).

Social Support, Stress, and Health

A favorite fortune cookie reads, “Friendship is to people what sunshine is to flowers.” Does the social support of friends, relatives, and other people affect our stress and health? Social support may reduce the stress people experience. For example, studies of job stress have shown that the greater the social support available to employees, the lower the psychological strain they report (Cottington & House, 1987; LaRocco, House, & French, 1980). Other research has found that blood pressure during work is lower for workers who have high social support than for those with less support (Karlin, Brondolo, & Schwartz, 2003), and positive interactions with spouses can reduce the effects of job stress on cortisol levels (Ditzen, Hoppmann, & Klumb, 2008). People with better social support also have larger nighttime decreases in blood pressure, suggesting better

restorative processes (Troxel et al., 2010). And social support has been associated with reduced stress from a variety of other sources, such as living near the damaged nuclear power plant at Three Mile Island (Fleming et al., 1982).

Experiments have assessed people’s physiological strain while they were engaged in a stressful activ-ity (such as giving a speech or performing mental arithmetic) either alone or in the presence of one or more individuals. Strain in these experiments is often assessed as cardiovascular reactivity—that is, an increase in blood pressure and/or heart rate from a baseline level. However, other aspects of the physiological stress response, including stress hormones such as corti-sol have been examined as well (Uchino, 2006). We’ll consider a few findings. First, while giving a speech, people often show less reactivity if a supportive per-son is present than if speaking alone (Lepore, Allen, & Evans, 1993; Uchino & Garvey, 1997). Second, reactivity is lower with a friend present than with a supportive stranger (Christenfeld et al., 1997). Third, sometimes the presence of supportive people can increase reactivity, especially if their presence functions as an audience that increases the support recipient’s worries about being evaluated negatively (Taylor et al., 2010). Fourth, reac-tivity is also lower in the presence of the person’s pet than alone (Allen, Blascovich, & Mendes, 2002). Fifth, other findings suggest that the benefits of social support on reactivity may depend on the person’s personality: people who are defensive—they avoid information or feelings that threaten their self-concept—show higher reactivity under stress when social support is given

(Westmaas & Jamner, 2006). Similarly, hostile individ-uals can also show increased reactivity during stressful activities when accompanied by friends, perhaps because they mistrust their friends or are concerned about being evaluated (Holt-Lunstad, Smith, & Uchino, 2008).

Having social support also seems to benefit people’s health (Cutrona & Gardner, 2004; Uchino, 2004). For instance, a prospective study had more than 4,700 men and women between 30 and 69 years of age report on four aspects of social support: marital status, contacts with family and friends, church membership, and formal and informal group associations (Berkman & Syme, 1979). Mortality data collected over the next 9 years revealed that the greater the degree of social support the subjects had, the lower the likelihood of their dying during the period of the study. Figure 4-2 shows an example of these findings. In each age category, individuals who had few contacts with friends and relatives had higher mortality rates than those with many contacts. This relationship applied to deaths from all causes and deaths from several specific diseases, including cancer and heart disease. Other research has shown that social support is associated with a lower risk of developing heart disease, and among people who have already developed heart disease social support is associated with lower risk of additional heart attacks and death from heart disease

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Figure 4-2 Percentage of adults who died within 9 years as a function of the number of contacts with friends and relatives and the subjects’ ages at the start of the study, in 1965. (Data from Berkman & Syme, 1979, Table 2.)

(Barth, Schneider, & von Kanel,¨ 2010). Chronic loneliness, an indicator of low social support, also predicts higher mortality rates (Patterson & Veenstra, 2010). A meta-analysis of nearly 150 studies confirmed the association between low social support and increased risk of death (Holt-Lunstad, Smith, & Layton, 2010). This link was similar in strength to many important health risk factors, such as smoking and a sedentary life style, and applied across all major causes of death for men and women. Thus, social support is an important predictor of health.

Because this research is quasi-experimental, the relationship found between social support and mortality is correlational. How do we know whether social support leads to better health or whether the influence is the other way around? That is, could the people who had less social support be less active socially because they were already sick at the start of the study? Berkman and Syme provided some evidence that this was not the case. For instance, the subjects had been asked about past illnesses at the initial interview, and those with high levels of social support did not differ from those with low levels of support. But better evidence comes from a similar study of more than 2,700 adults who were medically examined at the start of the research (House, Robbins, & Metzner, 1982). This research found that people with less social support had higher mortality rates and that the initial health of those with low social support was the same as that of those with high support. Many studies of social support and future health have checked that initial differences in health do not explain the prospective association between support and health (Holt-Lunstad, Smith, & Layton, 2010). However, the correlational design still means that we cannot be certain that good support causes good health. Unexamined third variables could still play a role. For example, twin studies demonstrate that social support and the quality of our personal relationships are at least partially influenced by genetic factors (Spotts, Prescott, & Kendler, 2006). So, it is possible that genetic factors influence both the development of social support and future health, without support playing a direct causal role in health.

Researchers have also studied the association between social support and the likelihood that people will recover quickly from serious illness. Although early findings were inconsistent (Wortman & Dunkel-Schetter, 1987), newer research has found more consistently positive results, showing, for example, that heart disease and surgery patients with high levels of social support recover more quickly than comparable patients with less support (Cutrona & Gardner, 2004; King & Reis, 2012; Wills & Fegan, 2001). Social support is only one of many factors that affect health (Smith, Fernengel, et al., 1994),

but it appears to have a strong impact on the health of some individuals, and a weak influence on the health of others. For instance, some evidence indicates that the recovery of many patients who believe they can cope with the emotional demands of their illness does not benefit from social support (Wilcox, Kasl, & Berkman, 1994).

How May Social Support Affect Health?

We have seen that prolonged exposure to high levels of stress can lead to illness. To explain how social support may influence health, researchers have proposed two main theories: the “buffering” and the “direct effects” (or “main effects”) hypotheses (Cutrona & Gardner, 2004; Wills & Fegan, 2001). According to the buffering hypoth-esis, social support affects health by protecting the person against the negative effects of high stress. A graphical illustration of the buffering hypothesis appears in Figure 4-3a. As the graph shows, this protective function is effective only, or mainly, when the person encounters a strong stressor. Under low-stress conditions, little or no buffering occurs. Research has shown that the buffering process does occur (Wills & Fegan, 2001). For example, a study of job stress found that social support had a much stronger association with lower blood pressure during stressful rather than nonstressful work times (Karlin, Brondolo, & Schwartz, 2003).

How may buffering work? Here are two ways. First, when people encounter a strong stressor, such as a major financial crisis, those who have high levels of social support may be less likely to appraise the situation as stressful than those with low levels of support. Individuals with high social support may expect that someone they know will help them, such as by lending

money or giving advice on how to get it. Second, social support may modify people’s response to a stressor after the initial appraisal. For instance, people with high social support might have someone provide a solution to the problem, convince them that the problem is not very important, or cheer them on to “look on the bright side.” People with little social support are much less likely to have any of these advantages—so the negative impact of the stress is greater for them.

The direct effects hypothesis maintains that social support benefits health and well-being regardless of the amount of stress people experience—the beneficial effects are similar under high and low stressor intensities, as depicted in Figure 4-3b. How do direct effects work? One way is that people with high levels of social support may have strong feelings of belongingness and self-esteem. The positive outlook this produces may be beneficial to health independently of stress: studies have found lower blood pressures in daily life and in laboratory tests among middle-aged and younger adults with higher levels of social support regardless of stress levels (Carels, Blumenthal, & Sherwood, 1998; Uchino et al., 1999). Other evidence suggests that high levels of support may encourage people to lead healthful lifestyles (Broman, 1993; Peirce et al., 2000). People with social support may feel, for example, that because others care about them and need them, they should exercise, eat well, and not smoke or drink heavily.

The buffering and direct effects hypotheses apply when a stressor occurs, but the health effects of social support may result from preventing stress as well. A newer theory, the stress prevention model, suggests that social support may be helpful because it can

High

Low

Figure 4-3 Illustration of two ways social support may benefit health and well-being. Graph (a) illustrates the buffering hypothesis, which proposes that social support modifies the negative health effects of high levels of stress. Graph (b) depicts the direct effects hypothesis, which proposes that the health benefits of social support occur regardless of stress.

provide advice or resources that help us avoid or minimize exposure to stressful events and circumstances (Uchino & Birmingham, 2011). For example, supportive friends and family members may help us make good choices about how to avoid interpersonal conflicts, stress from too many commitments, or financial difficulties. As discussed in Chapter 3, levels of stress exposure are an important influence on allostatic load, and social support could contribute to better health by reducing this overall burden.

Does Social Support Always Help?

Social support does not always reduce stress and benefit health. Why not? For one thing, although support may be offered or available to us, we may not perceive it as supportive (Dunkel-Schetter & Bennett, 1990; Wilcox, Kasl, & Berkman, 1994). This may happen because the help is insufficient or the wrong kind, or we may not want help. When we do not perceive help as supportive, it is less likely to reduce our stress. For example, when people need tangible or instrumental support but receive emotional support, or if they need emotional support but receive tangible support, they perceive the received support as unhelpful and ineffective (Horowitz et al., 2001). Support that is responsive to the recipient’s needs is the most beneficial (Maisel & Gable, 2009). Further, receiving support can sometimes convey the message to the recipient that they are inadequate to handle their problems on their own, resulting in lower self-esteem (Lepore, Glaser, & Roberts, 2008). These possible negative consequences of received support may be the reason that people’s perceived support is a better predictor of future health than their actual received support (Uchino et al., 2012).

Despite the advantages of perceived support, some intriguing research suggests that “invisible support” is best. By studying couples and asking each partner separately whether they gave or received support on a given day, researchers have found the most beneficial effects of support on reducing negative mood during high stress days when the partner reported giving support but the recipient was unaware of it (Belcher et al., 2011; Bolger & Amarel, 2007; Bolger, Zuckerman, & Kessler, 2000). Perhaps a “light touch” that is responsive to the recipients’ needs without making them feel less competent or as though they are a burden on the support providers can maximize the benefits of support in many instances.

Marriage is often thought to convey protective health benefits by providing social support. Consistent with this idea, studies have found that married people live longer

than divorced and never-married individuals (Kaplan & Kronick, 2006; Murphy & Bennett, 2004; Sbarra, Law,

Portley, 2011). James Lynch (1990) has argued that being lonely or having a “broken heart” is a risk factor for heart disease because widowed, divorced, and never-married individuals have higher death rates from heart disease than married people do. Some evidence indeed suggests that loneliness can increase the risk of heart disease and early death (Patterson & Veenstra, 2010; Thurston & Kubzansky, 2009), but other findings suggest that marriage itself is not the crucial factor:

Studies have found that a health protective role of marriage often occurs more for men and women who think their marital quality is high (Gallo et al., 2003; Umberson et al., 2006).

Research on middle-aged men and women with no symptoms of heart disease found similar low rates of atherosclerosis in people living with a spouse or a partner (unmarried), but much higher rates for people living alone, either single or widowed (Kop et al., 2005).

Married people generally show lower blood pressure than do single people, but people in unhappy marriages show higher blood pressure than single individuals (Holt-Lunstad et al., 2009).

Frequent contact with a spouse, presumably a source of social support, can protect against worsening atherosclerosis over time, unless the marriage is per-ceived as low in quality (Janicki et al., 2005).

Compared to higher quality marriages, those charac-terized by more frequent and severe marital conflicts are associated with more severe atherosclerosis (Smith, Uchino et al., 2012).

These findings suggest that social support, and not specifically marriage, is the crucial factor. When it comes to marriage and health, simply being married is not everything; quality matters.

Last, sometimes social ties can harm a person’s health. For one thing, strain or conflict in relation-ships can increase chances of developing serious illness (De Vogli et al., 2007), probably because, as discussed in Chapter 3, conflict in relationships evokes a strong physiological stress response. Further, people with high levels of stress and frequent social contacts are more likely than others to develop infectious illnesses, such as colds (Hamrick, Cohen, & Rodriguez, 2002). Also, social ties harm health when people encourage unhealthful behavior (Burg & Seeman, 1994; Kaplan & Toshima, 1990; Suls, 1982). We’ll look at three examples. First, people may set a bad example—for instance, children are more likely to start smoking and drinking if their friends and family engage in these behaviors and less

likely to use seat belts and eat a balanced diet if friends and family don’t. Second, people may encourage individ-uals who are overweight or have high blood pressure to eat prohibited foods, saying, “A little more cheesecake can’t hurt” or “You can make up for it by dieting next week.” Third, families may be overprotective toward a person with a serious illness, such as heart disease, and discourage the patient’s need to become more active or to go back to work. This can interfere with reha-bilitation and make the patient increasingly dependent and disabled.

In summary, people perceive and receive various types of support from friends, family, and others. Social support tends to reduce people’s stress and benefit their health, but some types of support or other aspects of relationships do not. (Go to .)

A SENSE OF PERSONAL CONTROL

Another psychosocial factor that modifies the stress people experience is the degree of control people feel they have in their lives. People generally like the feeling of having some measure of control over the things that happen to them, and they strive for a sense of personal control—the feeling that they can make decisions and take effective action to produce desirable outcomes and avoid undesirable ones (Contrada & Goyal, 2004). Studies have found that people who have a strong sense of personal control report experiencing less strain from stressors (McFarlane et al., 1983; Suls & Mullen, 1981).

Types of Control

How can feelings of personal control reduce the stress people experience? People can use several types of control to influence events in their lives and reduce their stress (Cohen et al., 1986; Thompson, 1981). We’ll focus on two. Behavioral control involves the ability to take concrete action to reduce the impact of a stressor. This action might reduce the intensity of the event or shorten its duration. For example, a pregnant woman who has taken natural childbirth classes can use special breathing techniques during delivery that reduce the pain of labor. Cognitive control is the ability to use thought processes or strategies to modify the impact of a stressor, such as by thinking about the event differently or focusing on a pleasant or neutral thought. While giving birth, for instance, the mother might think about the positive meanings the baby will give to her life, or she could focus her mind on an image, such as a pleasant day she had at the beach. Cognitive control appears to be especially effective in reducing stress (Cohen et al., 1986). For example, cognitive reappraisal of stressful stimuli or events as less threatening can reduce negative emotions and physiological stress responses (John & Gross, 2004).

Beliefs about Oneself and Control

People differ in the degree to which they believe they have control over their lives. Most people believe they have at least some control, but others think they have almost none. The latter is shown in the case study of

CLINICAL METHODS AND ISSUES

Social Support, Therapy, and Cognitive Processes

Years ago, a reporter asked actress Melina Mercouri about psychotherapy in her native country; she replied that in Greece people don’t need therapists, they have friends. Although her view oversimplifies the therapy process, therapy does include two features friends can provide: social support and the opportunity for disclosure of or expressive writing about negative experiences and feelings. James Pennebaker and other researchers have found that people’s talking or writing about traumatic or very emotional experiences for a few sessions of 15–30 minutes has beneficial effects that last for months. This reduces their stress and negative feelings and seems to improve their health, as reflected in the number of physician visits and episodes

of chronic illness symptoms (Pennebaker, 1990; Smyth, Pennebaker, & Argio, 2012). Although the effects of disclosure on psychological and physical health are not very large, they have been confirmed in a meta-analysis of over 140 studies (Frattaroli, 2006). Other research has shown that simply describing the benefits gained from traumatic events or the success in managing one’s stress, can have similar effects (King & Miner, 2000; Leake, Friend, & Wadhwa, 1999). Why does disclosure help? An experiment tested this issue with breast cancer patients and found that the benefits of disclosure are linked to the reduced autonomic arousal, such as heart rate, that occurs when people express negative memories (Low, Stanton, & Danoff-Burg, 2006).

a chronically unemployed man named Karl, who was referred to therapy by the Veterans Administration and with some help

applied for a job and got it. But this did not raise his expectancies of being able to get another job should he have to do so. Indeed, he attributed his success entirely to good fortune. He believed that the employer probably was partial to veterans or just happened to be in a good mood that day . . .[and] that the occurrence of reinforcement was outside his own personal control. (Phares, 1984, pp. 505–506)

People who believe they have control over their successes and failures are described as possessing an internal locus of control. That is, the control for these events lies within themselves—they are responsible. Other people, like Karl, who believe that their lives are controlled by forces outside themselves, for example, by luck, have an external locus of control (Rotter, 1966). A questionnaire called the I-E Scale is used for measuring the degree of internality or externality of a person’s beliefs about personal control.

Another important aspect of personal control is our sense of self-efficacy—the belief that we can succeed at a specific activity we want to do (Bandura, 1986, 2004). People estimate their chances of success in an activity, such as quitting smoking or running a mile, on the basis of their prior observations of themselves and others. They decide whether to attempt the activity according to two expectations:

Outcome expectancy— that the behavior, if properly carried out, would lead to a favorable outcome.

Self-efficacy expectancy— that they can perform the behav-ior properly.

For example, you may know that by taking and doing well in a set of college honors courses you can graduate with a special diploma or certificate, but if you think of the likelihood of achieving that feat as “zilch,” you’re not likely to try. For people engaged in a stressful activity, increases in heart rate and blood pressure generally correspond to their level of mental effort in dealing with the demands of the situation—the greater their effort, the greater the cardiovascular reactivity (Gendolla

Wright, 2005). People with strong self-efficacy for the activity may be less threatened and exert less mental effort because they know they can manage the demands of the situation more easily. Hence, they generally show less psychological and physiological strain than do those with a weaker self-efficacy (Bandura, Reese, & Adams, 1982; Bandura et al., 1985; Holahan, Holahan, & Belk, 1984).

Determinants and Development of Personal Control

On what basis do people judge that they have control over things that happen in their lives? We make these assessments by using information we gain from our successes and failures throughout life (Bandura, 1986, 2004; Warner et al., 2014). Our sense of control also develops through social learning, in which we learn by observing the behavior of others (Bandura, 1969, 1986). During childhood, people in the family and at school are important others, serving as models of behavior, agents of reinforcement, and standards for comparison. At the other end of the life span, people tend to be relatively external in locus of control—that is, beliefs that chance and powerful others affect their lives are greater in the elderly than in younger adults (Lachman, 1986). So, among adults who develop serious illnesses, those who are elderly are more inclined to prefer having professionals make health-related decisions for them (Woodward & Wallston, 1987).

Gender and Sociocultural Differences in Personal Control

Gender and sociocultural differences in personal control often develop, depending on the social experiences individuals have. Sometimes parents and teachers inadvertently lead girls more than boys toward beliefs in external control and in low self-efficacy for certain activities (Dweck & Elliott, 1983). This socialization may carry over to old age: among elderly cardiac patients, men report greater self-efficacy than women for being able to walk various distances, a common rehabilitation behavior (Jenkins & Gortner, 1998). Self-efficacy beliefs generally can play an important role in the process of rehabilitation for heart patients (Woodgate & Brawley, 2008). Because people who are poor or from minority groups generally have limited access to power and economic advancement, they tend to have external locus of control beliefs (Lundin, 1987). Perhaps for similar reasons, locus of control beliefs tend to be more external among people from non-Western than Western societies (Cheng et al., 2013).

When People Lack Personal Control

What happens to people who experience high levels of stress over a long period of time and feel that nothing they do matters? They feel helpless—trapped and unable to avoid negative outcomes. A worker who cannot seem to please her boss no matter what she does, a student who cannot perform well on exams, or a patient who is unable to relieve his severe low back pain—each of these situations can produce apathy. As a result, these

This homeless woman probably sees little personal control in her life and feels very helpless.

people may stop striving for these goals, come to believe they have no control over these and other events in their lives, and fail to exert control even when they could succeed. This is the condition Martin Seligman (1975) has called learned helplessness—which he describes as a principal characteristic of depression. Research has shown that people can learn to be helpless by being in uncontrollable situations that lead to repeated failure, such as in trying to stop an unpleasant noise (Hiroto & Seligman, 1975).

Seligman and his colleagues have extended the the-ory of learned helplessness to explain two important observations (Abramson, Seligman, & Teasdale, 1978). First, being exposed to uncontrollable negative events does not always lead to learned helplessness. Sec-ond, depressed people often report feeling a loss of self-esteem. The revised theory proposes that people who experience uncontrollable negative events apply a cognitive process called attribution, in which they make judgments about three dimensions of the situation:

Internal-external. People consider whether the

situation results from their own personal inability to

control outcomes or from external causes that are beyond anyone’s control. For example, suppose a boy receives physical therapy for a serious injury but cannot seem to meet the goals each week, which he could attribute either to his own lack of fortitude or to the rehabilitation program design. Either judgment may make him stop trying. He is likely to suffer a loss of self-esteem if he attributes the difficulty to a lack of personal strength, but not if he attributes the difficulty to external causes.

Stable-unstable. People assess whether the situa-tion results from a cause that is long-lasting (stable) or temporary (unstable). If they judge that it is long-lasting, as when people develop a chronic and disabling disease, they are more likely to feel helpless and depressed than if they think their condition is temporary.

Global-specific. People consider whether the situation results from factors that have global and wide-ranging effects or specific and narrow effects. Individuals who fail at stopping smoking cigarettes and make a global judgment—for example, “I’m totally no good and weak-willed”—may feel helpless and depressed. But others who fail and make a specific judgment, such as “I’m not good at controlling this part of my life,” are less likely to feel helpless.

Thus, people who tend to attribute negative events in their lives to stable and global causes are at high risk for feeling helpless and depressed. If their judgments are also internal, their depressive thinking is likely to include a loss of self-esteem as well. People who believe bad events result from internal, stable, and global factors while good events result from external, unstable, and specific factors have a pessimistic explanatory style (Kamen & Seligman, 1989). Attributing negative events to external, unstable, and specific causes, in contrast, reflects an optimistic explanatory or attributional style.

How does lacking personal control affect people in real-life stressful conditions? Studies have examined this question with college students and children. For instance, of college students in dormitories, those who lived on crowded floors reported more stress and less ability to control unwanted social interaction and showed more evidence of helplessness, such as giving up in competitive games, than those on uncrowded floors (Baum, Aiello, & Calesnick, 1978; Rodin & Baum, 1978). In a study of fifth-graders, students were given an impossible task to arrange blocks to match a pictured design (Dweck & Repucci, 1973). Children who attributed their failure to stable, uncontrollable factors, such as their own lack of ability, showed poorer performance on subsequent problems than those who attributed failure to unstable, modifiable factors, such as a lack of effort.

Thus, the children’s attributions were linked to their feelings of helplessness.

Personal Control and Health

There are two ways in which personal control and health may be related. First, people who have a strong sense of personal control may be more likely or able to maintain their health and prevent illness than those who have a weak sense of control. Second, once people become seriously ill, those who have a strong sense of control may adjust to the illness and promote their own rehabilitation better than those who have a weak sense of control. Both types of relationships have been examined.

To study these relationships, researchers have used several approaches to measure people’s personal con-trol. One of the best-developed health-related measures of personal control is the Multidimensional Health Locus of Control Scales (Wallston, Wallston, & DeVellis, 1978). This instrument contains 18 items divided into three scales that assess:

Internal health locus of control,the belief that control of one’s health lies within the person.

Powerful-others’ health locus of control, the belief that one’s health is controlled by other people, such as physicians.

Chance locus of control,the belief that luck or fate controls health.

As you can see, the powerful-others and chance scales are directed toward assessing the degree to which people believe important external sources have control over their health.

Does a sense of personal control influence peo-ple’s health? Studies have shown that pessimistic and hopeless people—those who believe they have little control—have poorer health habits, have more illnesses, and are less likely to take active steps to treat their illness than are people with a greater sense of control (Kamen

Seligman, 1989; Lin & Peterson, 1990; Rasmussen, Scheier, & Greenhouse, 2009; Whipple et al., 2009). Peo-ple with higher levels of personal control engage in more physical activity, which leads to their having greater strength and lower waist sizes (Infurna & Gerstorf, 2014). Personal control can also help people adjust to becom-ing seriously ill (Thompson & Kyle, 2000). Patients with illnesses such as kidney failure or cancer who score high on internal or powerful-others’ health locus of control suffer less depression than those with strong beliefs in the role of chance (Devins et al., 1981; Marks et al., 1986). The belief that either they or someone else can influence the course of their illness allows patients to be hope-ful about their future. Moreover, patients with strong

internal locus of control beliefs probably realize they have effective ways for controlling their stress.

Personal control also affects the efforts patients make toward rehabilitation—in particular, feelings of self-efficacy enhance their efforts. A study demonstrated this with older adult patients who had serious respiratory diseases, such as chronic bronchitis and emphysema (Kaplan, Atkins, & Reinsch, 1984). The patients were examined at a clinic and given individualized pre-scriptions for exercise. They rated on a survey their self-efficacy—that is, their belief in their ability to per-form specific physical activities, such as walking different distances, lifting objects of various weights, and climbing stairs. Correlational analyses revealed that the greater the patients’ self-efficacy for doing physical activity, the more they adhered to the exercise prescription.

Health and Personal Control in Old Age

Here are two things we know about elderly people who live in nursing homes: First, they often show declines in their activity and health after they begin living in nursing homes. Second, residents of nursing homes frequently have few responsibilities or opportunities to influence their everyday lives. Could it be that the declines in activity and health among nursing-home residents result in part from their dependency and loss of personal control that the nursing home procedures seem to encourage?

Ellen Langer and Judith Rodin (1976) studied this issue by manipulating the amount of responsibility allowed residents of two floors of a modern, high-quality nursing home. The residents on the two floors were similar in physical and psychological health and prior socioeconomic status. On one floor, residents were given opportunities to have responsibilities—for example, they could select small plants to care for and were encouraged to make decisions about participating in activities and rearranging furniture. In comparison, residents of the other floor continued to have little personal control. For example, they were assigned to various activities without choice, and when they were given plants, they were told that the staff would take care of them. Assessments revealed that the residents who were given more responsibility became happier and more active and alert than the residents who had little control. A year and a half later, the residents who were given responsibility were still happier and more active than those who had little control (Rodin & Langer, 1977). Moreover, comparisons of health data during these 18 months showed that the residents with responsibility were healthier and had half the rate of mortality than the residents with little control.

Other research with residents of a retirement home also demonstrated the importance of personal control for physical and psychological well-being and showed that withdrawing opportunities for personal control may impair people’s health (Schulz, 1976; Schulz & Hanusa, 1978). The results of these studies suggest two important conclusions. First, personal control—even over relatively simple or minor events—can have a powerful effect on people’s health and psychological condition. Second, health care workers and researchers need to consider the nature of the personal control they introduce and what the impact will be if it is removed.

To summarize the material on personal control, people differ in the degree to which they believe they have control over the things that happen in their lives. People who experience prolonged, high levels of stress and lack a sense of personal control tend to feel helpless. Having a strong sense of control seems to benefit people’s health and help them adjust to becoming seriously ill. A sense of personal control contributes to people’s hardiness, which is the next psychosocial modifier of stress we will examine.

PERSONALITY FACTORS IN STRESS

Researchers have long been interested in how some personality traits can enable individuals to withstand high levels of stress without becoming distressed or physically ill, whereas other personality traits seem to make people vulnerable to those problems (Williams et al., 2011).

Early in the development of the field of health psychology, researchers Suzanne Kobasa and Salvatore Maddi suggested that a broad array of personality traits—called hardiness—differentiates people who do and do not get sick under stress (Kobasa & Maddi, 1977). Hardiness includes three characteristics: (1) Control refers to people’s belief that they can influence events in their lives—that is, a sense of personal control. (2) Commitment is people’s sense of purpose or involvement in the events, activities, and with the people in their lives. For instance, people with a strong sense of commitment tend to look forward to starting each day’s projects and enjoy getting close to people. (3) Challenge refers to the tendency to view changes as incentives or opportunities for growth rather than threats to security. Although the concept of hardiness has been highly influential, tests of the theory have found conflicting results, and some evidence indicates that surveys used to measure hardiness may simply be measuring the tendency to experience negative affect, such as the tendency to be anxious, depressed, or hostile (Funk, 1992). Nonetheless,

the idea that personality traits such as hardiness help people withstand stress has received research support.

Sense of Coherence, Optimism, and Resilience

We’ll look at three examples of personality concepts similar to hardiness. The first is sense of coherence, developed by Aaron Antonovsky (1979, 1987). This trait involves the tendency of people to see their worlds as comprehensible, manageable, and meaningful. People’s strong sense of coherence has been linked to reduced levels of stress and illness symptoms (Jorgensen, Frankowski, & Carey, 1999) and of early death (Haukkala et al., 2013). Second, optimism is the view that good things are likely to happen; it is similar to the optimistic versus pessimistic explanatory style described previously. Optimists tend to experience life’s difficulties with less distress than do pessimists, and they tend to have better health habits, have better mental and physical health, and recover faster when they become ill (Carver, Scheier, & Segerstrom, 2010; Ronaldson et al., 2015).

Third, resilience refers to high levels of three inter-related positive components of personality: self-esteem, personal control, and optimism (Major et al., 1998). Resilient people appraise negative events as less stress-ful; they bounce back from adversities and recover their strength and spirit. For example, resilient children develop into competent, well-adjusted individuals even when growing up under extremely difficult conditions (Garmezy, 1983; Werner & Smith, 1982). The following case of a 10-year-old boy living in a Minneapolis slum shows what this means. He lives

with his father, an ex-convict now dying of cancer, his illiterate mother, and seven brothers and sisters, two of whom are mentally retarded. Yet his teachers describe him as an unusually competent child who does well in his studies and is loved by almost everyone in the school. (Pines, 1979, p. 53)

Even when facing adversity, resilient people seem to make use of positive emotions and find meaning in the experience (Ong et al., 2006; Tugade & Fredrickson, 2004). Although such resilience was once considered rare, it now appears that probably most adults move on with their lives and do not suffer serious depression after a trauma, such as the loss of a close relative or friend (Bonanno, 2004).

Why are some individuals resilient and others not? Part of the answer may lie in their genetic endowments. Resilient people may have inherited traits, such as relatively easy temperaments, that enable them to cope better with stress and turmoil. Another part lies in their

experiences. Resilient people who overcome a history of stressful events often have compensating experiences and circumstances in their lives, such as special talents or interests that absorb them and give them confidence, and close relationships with friends or relatives. The concepts of hardiness, resilience, optimism, and coherence have a great deal in common, and scales used to measure these traits may be tapping overlapping personality strengths.

Personality Strengths and Health

In theory, the personality strengths we’ve discussed make people better able to deal with stressors and less likely to become emotionally distressed and physiologically aroused by stressful events, leading them to remain healthier. The assets or strengths reflected in one’s sense of coherence, optimism, and resilience, should prevent the spiraling process that can lead from stress to illness from taking hold. Studies have generally supported the prediction that these traits should be associated with lower risks of physical illness. For example, a meta-analysis of studies for a variety of health conditions found that optimism is associated with a reduced risk of developing physical illnesses and with more positive illness outcomes among individuals who are already suffering from disease (Rasmussen, Scheier, & Greenhouse, 2009). Prospective studies have also shown that people who are optimistic or have strong skills in self-regulation are at lower risk of life-threatening medical conditions, such as heart disease (Kubzansky et al., 2011; Tindle et al., 2009). And a prospective study found that people who have a strong sense of coherence had far lower mortality rates from cardiovascular disease and cancer over a 6-year period than people low on this trait (Surtees et al., 2003). Taken together, positive personality traits like optimism and sense of coherence, appear to protect health (Boehm & Kubzansky, 2012). Future research will need to clarify what these positive personality traits are and how they affect health.

Personality and Health in Old Age

Old age is a time when very difficult life events often occur, particularly those that involve reduced income, failing health and disability, and the loss of one’s spouse and close friends. Personality strengths like those described earlier can be important in meeting these diffi-culties. For example, older people with a strong sense of purpose in life seem to live longer, even when the possi-bly overlapping effects of negative emotions like depres-sion are taken into account (Boyle et al., 2009). What other positive traits are important to health in old age?

Elizabeth Colerick (1985) studied 70- to 80-year-old men and women for the quality she called stamina, which

is similar to hardiness. This research was undertaken to determine how people who do and do not have stamina in later life deal with setbacks, such as the loss of a loved one. She identified with questionnaires and interviews two groups: one with high stamina and one with low stamina. She found that stamina in old age is character-ized by “a triumphant, positive outlook during periods of adversity,” as illustrated by the following interview excerpts from two different high-stamina people:

The key to dealing with loss is not obvious. One must take the problem, the void, the loneliness, the sorrow and put it on the back of your neck and use it as a driving force. Don’t let such problems sit out there in front of you, blocking your vision . . . . Use hardships in a positive way. (p. 999)4-1

I realize that setbacks are a part of the game. I’ve had ’em, I have them now, and I’ve got plenty more ahead of me. Seeing this—the big picture—puts it all into perspective, no matter how bad things get. (p. 999)4-2

In contrast, low-stamina people described a negative outlook and feelings of helplessness and hopelessness in facing life events in old age. One woman who had undergone surgery for colon cancer said:

I was certain that I would die on the table . . . never wake up . . . . I felt sure it was the end. Then I woke up with a colostomy and figured I have to stay inside the house the rest of my life. Now I’m afraid to go back to the doctor’s and keep putting off my checkups. (p. 999)4-3

In summary, people with high degrees of positive personality traits, such as optimism and sense of coherence, may have some protection against the harmful effects of stress on health. The fact that several similar traits are related to future health suggests that they belong within an organizing framework that could help in understanding how personality can modify stress. We’ll turn now to a widely accepted framework—the five-factor model of personality—that has been useful in this way, especially because it helps to organize traits that are sources of resilience or sources of vulnerability.

The Five-Factor Model of Personality

A general consensus has emerged among personality researchers that five broad traits provide a reasonably thorough description of normal variations in human personality (Costa & McCrae, 1992; Digman, 1990). These traits, listed in Table 4.1, can be used to create an organized and systematic catalogue of modifiers of stress responses (Smith & MacKenzie, 2006; Smith & Williams, 1992). The traits of the five-factor model can be

measured with well-established, validated personality scales to test for associations with health. In this way, researchers can examine and answer questions regarding which general dimensions of personality modify stress and influence health.

Research has consistently found correlations between the personality strengths discussed earlier and emotional stability—the opposite of neuroticism of the five-factor model (Smith & MacKenzie, 2006). Neuroti-cism and its components, such as anxiety, sadness or depressive symptoms, and irritability, predict earlier death and several other negative health outcomes (Chida & Steptoe, 2008; Houle, 2013; Kubzansky et al., 2006; Suls & Bunde, 2005). Measures of personality strengths, like optimism and sense of coherence, also correlate with other five-factor traits, especially extraver-sion, conscientiousness, and openness. And the positive traits of the five-factor model have been linked to good future health, particularly longevity (Kern & Friedman, 2008; Taylor, Whiteman et al., 2009; Terracciano et al., 2008).

How do the traits of the five-factor model of per-sonality relate to health? Some traits may lead people to perform healthful behaviors, as conscientiousness appears to do (Turiano et al., 2015). Also, personality traits associated with better health are generally asso-ciated with less exposure to stressors at work and in relationships, less physiological reactivity, better recov-ery from stress, and better restoration (Williams et al., 2011). In contrast, personality traits linked to poor health are consistently related to greater exposure to stressors, greater reactivity, less recovery from stress, and less restoration, as reflected in better sleep and lower lev-els of physiological stress responses during sleep. What’s more, traits included in the five-factor model are also linked to one of the best known psychosocial modifiers of stress, the Type A or B behavioral and emotional style.

TYPE A BEHAVIOR AND BEYOND

The history of science has many stories about researchers accidently coming upon an idea that changed their focus and led to major discoveries. Such was the case for bacteriologist Alexander Fleming, for instance: when bacteria cultures he was studying developed unwanted molds, he happened to notice some properties of the molds that led to the discovery of penicillin. Serendipity also led to the discovery of the “Type A” behavior pattern. Cardiologists Meyer Friedman and Ray Rosenman were studying the diets of male heart disease victims and their wives when one of the wives exclaimed: “If you really want to know what is giving our husbands heart attacks, I’ll tell you. It’s stress, the stress they receive in their work, that’s what’s doing it” (Friedman & Rosenman, 1974, p. 56). These researchers began to study this possibility and noticed that heart patients were more likely than nonpatients to display a pattern of behavior we now refer to as Type A.

Defining and Measuring Behavior Patterns

The Type A behavior pattern consists of four character-istics (Chesney, Frautschi, & Rosenman, 1985; Friedman

Rosenman, 1974):

Competitive achievement orientation. Type A individuals strive toward goals with a sense of being in competition—or even opposition—with others, and not feeling a sense of joy in their efforts or accomplishments.

Time urgency. Type A people seem to be in a constant struggle against the clock. Often, they quickly become impatient with delays and unproductive time, schedule commitments too tightly, and try to do more than one thing at a time, such as reading while eating or watching TV.

Anger/hostility. Type A individuals tend to be easily aroused to anger or hostility, which they may or may not express overtly.

Vigorous vocal style. Type A people speak loudly, rapidly, and emphatically, often “taking over” and generally controlling the conversation.

In contrast, the Type B behavior pattern consists of low levels of competitiveness, time urgency, and hostility. People with the Type B pattern tend to be more easygoing and “philosophical” about life—they are more likely to “stop and smell the roses.” In conversations, their speech is slower, softer, and reflects a more relaxed “give and take.”

Type A behavior is measured in several ways. The Structured Interview has been considered the “gold standard” of Type A assessments. It consists of a series of questions that require about 15 to 20 minutes, and it is intended to obtain not only self-reports of competitiveness, time urgency, and anger/hostility, but also to obtain an actual sample of Type A versus B behavior. The questions are asked in such a way that Type A people will reveal their competitive, impatient, hostile, and vigorous style not simply in what they say, but in how they say it. In contrast, Type Bs display their more relaxed and easy-going style. The interview is time-consuming and expensive to use, but it measures all four Type A characteristics (competitiveness, time urgency, anger/hostility, vocal style) better than self-report, paper-and-pencil survey measures do, and its scores are more consistently associated with health, especially heart disease (Miller et al., 1991).

Behavior Patterns and Stress

Individuals who exhibit the Type A behavior pattern react differently to stressors from those with the Type B pattern. Type A individuals respond more quickly and strongly to stressors, often interpreting them as threats to their personal control (Glass, 1977). Type A individ-uals also often choose more demanding or pressured activities at work and in their leisure times, and they

often evoke angry and competitive behavior from others (Smith & Anderson, 1986). Hence, they have greater exposure to stressors, too.

We saw in Chapter 3 that the response to a stressor—or strain—includes a physiological compo-nent called reactivity, such as increased blood pressure, catecholamine, or cortisol levels compared to base-line levels. Type A people often show greater reactivity to stressors than Type Bs, especially during situations involving competition, debates and arguments, or other stressful social interactions (Contrada & Krantz, 1988; Glass et al., 1980).

Age and Developmental Differences in Type A Behavior

Longitudinal studies suggest that adult Type A behavior may have its roots in the person’s early temperament, and although behavior patterns often change over time, many individuals exhibit the same pattern across many years (Bergman & Magnusson, 1986; Carmelli et al., 1991; Carmelli, Rosenman, & Chesney, 1987). Still, cross-sectional studies have found that the Type A behavior pattern among Americans becomes more prevalent with age from childhood through middle age or so and then declines (Amos et al., 1987; Moss et al., 1986). But some of the decline in prevalence in old age could be the result of Type A individuals dying at earlier ages than Type Bs.

Heredity also affects the development of Type A and B behavior. Research with identical (monozygotic) and fraternal (dizygotic) twins has found a genetic role in the development of both temperament (Buss & Plomin, 1975, 1986) and Type A behavior (Carmelli, Rosenman,

Chesney, 1987; Rebollo & Boomsma, 2006). That is, identical twins are more similar to each other in temperament and behavior patterns than are fraternal twins. They are much more similar than fraternal twins in their reactivity to stressors, too (Ditto, 1993; Turner

Hewitt, 1992). Demographic and genetic variations in Type A behavior are important because of the relationships researchers have found between reactivity and health, such as in the development of heart disease.

If you have not read Chapter 2, “The Body’s Physical Systems,” and your course has you read the modules

from that chapter distributed to later chapters, read Module 5 (“The Cardiovascular System”) now.

Type A Behavior and Health

How are people’s health and behavior patterns related? Researchers have studied this issue in two ways. First, studies have examined whether Type A individuals are at greater risk than Type Bs for becoming sick with any

of a variety of illnesses, such as asthma and indigestion, but the associations appear to be weak and inconsistent (Orfutt & Lacroix, 1988; Suls & Sanders, 1988).

Second, studies have focused on the Type A pattern as a risk factor for coronary heart disease

(CHD)—illnesses in which atherosclerosis narrows the coronary arteries, which supply blood to the heart muscle. This narrowing causes several manifestations of CHD. Angina is chest pain that occurs when the supply of oxygen carried by blood to the heart muscle is not suf-ficient to meet the muscle’s demand. When the demand exceeds the supply available through the narrowed coro-nary arteries, the heart muscle becomes ischemic—the heart is not getting enough oxygen. If the blood supply is blocked severely enough and for a long enough period of time, the ischemic portion of the heart muscle dies. This is called a myocardial infarction, or what is commonly called a “heart attack.” A severely ischemic heart sometimes develops a lethal disturbance in rhythm, causing it to stop pumping blood through the body. This is the usual cause of sudden cardiac death, where the victim dies within a few minutes or hours of first noticing symptoms.

Dozens of studies have been done to assess the link between Type A behavior and CHD—an example is a large-scale prospective study of 3,000 39- to 59-year-old initially healthy men who were tested for their behavior patterns using the Structured Interview (Rosenman et al., 1976). A follow-up 81∕2 years later showed that the Type A individuals were twice as likely as Type Bs to have developed CHD and to have died of CHD. Other studies have found similar results, but it depends on how Type A behavior was measured: the link between Type A behavior and CHD is clearest in studies using the Structured Interview (Miller et al., 1991).

Type A’s “Deadly Emotion”

Why would the link between Type A behavior and CHD depend on the way behavior patterns are measured? It could be that people are not completely honest and accurate in describing their own behavior on self-report surveys, whereas observational measures are less “filtered” in this way. However, it also could be the content of the measures. We saw earlier that the Structured Interview assesses all four components of Type A behavior well. This isn’t so for available surveys, which assess competitive achievement and time urgency well but measure anger/hostility much less well and do not measure the vocal style at all. These discrepancies prompted researchers to examine the role of individual Type A components, which revealed that anger/hostility is the main aspect of Type A behavior in the link with CHD (Everson-Rose & Lewis, 2005; Smith, Gallo et al., 2012). Anger/hostility seems to be Type A’s deadly emotion: people who are chronically hostile have an increased risk of developing CHD.

A study that supports this idea examined the records of 255 physicians who had taken a psychological test that

included a scale for hostility while they were in medical school 25 years earlier (Barefoot, Dahlstrom, & Williams, 1983). For the physicians with high scores on the hostility scale, the rates of both CHD and overall mortality during the intervening years were several times higher than for those with low hostility scores. The researchers measured hostility with a widely used test, the Cook-Medley Hostility Scale, which has 50 true/false items, such as “It is safer to trust nobody” and “Some of my family have habits that bother and annoy me very much” (Cook

Medley, 1954). This scale measures anger, as well as cynicism, suspiciousness, and other negative traits (Friedman, Tucker, & Reise, 1995). In pursuing anger and hostility as the toxic element within the Type A pattern, a wide variety of self-report and behavioral measures of these traits have been used (Smith, 1992). A meta-analysis of the many studies of the topic found that anger and hostility are associated with an increased risk of CHD in initially healthy individuals (Chida & Steptoe, 2009). Furthermore, among people who already have CHD, anger and hostility are associated with increased risk of poor medical outcomes, such as additional heart attacks or death from CHD.

What links anger and hostility to the development of CHD? Here again, the four stress processes of exposure, reactivity, recovery, and restoration seem important. Angry and hostile people experience more conflict with others at home and work (Smith et al., 2004), indicating greater stress exposure. The suspicious and mistrusting style of hostile persons is likely to make them cold and argumentative during interactions with others, sometimes even with friends and family members. The resulting conflict and reduced social support may, in turn, contribute to the maintenance or even worsening of their hostile behavior toward others in a vicious circle or self-fulfilling prophecy (Smith et al., 2004). Furthermore, hostile people show very high levels of reactivity in difficult interpersonal situations, particularly at work and with family members (Brondolo et al., 2009; Chida & Hamer, 2008b; Smith & Gallo, 1999).

Four other factors also link hostility and CHD. First, unlike nonhostile people, hostile people do not respond to social support with reduced physiological reactivity during stressful situations (Holt-Lunstad, Smith, & Uchino, 2008; Vella, Kamarck, & Shiffman, 2008), perhaps because they are distrusting or worry that support providers will evaluate them negatively. Second, their sleep quality is more likely to suffer during stressful periods (Brissette & Cohen, 2002). Third, anger and hostility are related to several unhealthy conditions and behaviors, such as heavy drinking, obesity, and cigarette smoking, that put people at risk for CHD (Bunde & Suls, 2006; Nabi et al., 2009; Patterson et al., 2008). Although

anger and hostility generally are associated with CHD even when these health behaviors and conditions are taken into account, some evidence suggests that they are at least part of the link between these personality traits and health (Boyle et al., 2007; Everson et al., 1997). Fourth, we’ll discuss later in this chapter that cardiovascular reactivity and other physiological stress responses can contribute to the development of coronary atherosclerosis and other indications of CHD. Combining these and other stress processes takes a major toll on the cardiovascular system.

Are There Other Dangerous Aspects of the Type A Pattern?

Anger might not be the only unhealthy Type A behavior (Houston et al., 1992, 1997). Social dominance—the tendency or motive to exert power, control, or influence over other people—is also associated with coronary atherosclerosis and CHD (Siegman et al., 2000; Smith, Uchino et al., 2008). Further, this personality trait is associated with greater physiological reactivity or strain during challenging interpersonal tasks and situations, such as arguments or debates, and efforts to influence other people also evoke larger increases in blood pressure and stress hormones (Newton, 2009; Smith, Ruiz, & Uchino, 2000).

As a summary of the role of psychosocial modifiers of stress, we have seen that social support, personal control, various personality traits, and aspects of the Type A and B behavior patterns are factors that can modify the impact of stress on health. High levels of social support, personal control, and related personality traits, are generally associated with reduced stress and resulting illnesses; Type A behavior, especially the anger/hostility component, is associated with increased stress and cardiovascular illness. The remainder of this chapter examines health problems that are affected by people’s experience of stress. We begin by considering how stress leads to illness.

HOW STRESS AFFECTS HEALTH

Why does stress lead to illnesses in some individuals, but not others? One answer: other factors influence the effects of stress. This idea forms the basis of the diathesis-stress model, the view that people’s vulnerability to a physical or psychological disorder depends on the inter-play of their predisposition to the disorder (the diathesis) and the amount of stress they experience (Steptoe & Ayers, 2004). The predisposition can result from organic structure and functioning, often genetically determined,

or from prior environmental conditions, such as living in a community that promotes tobacco use. For example, chronically high levels of stress are especially likely to lead to CHD if the person’s body produces high lev-els of cholesterol. Or students are likely to catch cold around final exams week if their immune system func-tioning is impaired. This concept may explain why not all individuals in the following experiment caught cold.

Researchers conducted an interesting experiment: they gave people nasal drops that contained a “common cold” virus or a placebo solution and then quarantined them to check for infection and cold symptoms (Cohen, Tyrrell, & Smith, 1991). Before the nasal drops were administered, the subjects filled out questionnaires to assess their recent stress. Of these people, 47% of those with high stress and 27% of those with low stress developed colds. Other studies have produced three related findings. First, people under chronic, severe stress are more vulnerable to catching cold when exposed to the virus than people under less stress (Cohen et al., 1998). Second, people who experience a lot of positive emotions, such as feeling energetic or happy, are less likely to catch a cold or the flu when exposed to the viruses than are people with less of these emotions (Cohen et al., 2006). Third, people who have sleep problems prior to exposure to the virus are more likely to develop colds than those who sleep well (Cohen et al., 2009).

What is it about stress that leads to illness? The causal sequence can involve two routes: (1) a direct route, resulting from changes stress produces in the body’s physiology, or (2) an indirect route, affecting health through the person’s behavior. Figure 4-4 gives a summary of these routes. Let’s look first at the behavioral route.

STRESS, BEHAVIOR, AND ILLNESS

Stress can affect behavior, which, in turn, can lead to illness or worsen an existing condition. We can see the behavioral links between stress and illness in many stressful situations, such as when a family undergoes a divorce. In many cases during the first year following the separation, the parent who has the children is less available and responsive to them than she or he was before, resulting in haphazard meals, less regular bedtimes, and delays in getting medical attention, for instance. These and other adverse childhood experiences can lead to the eventual adoption of unhealthful or risky behaviors, such as smoking, alcohol abuse, and poor diet (Gilbert et al., 2015).

People who experience high levels of stress tend to behave in ways that increase their chances of becoming ill or injured (Weidner et al., 1996; Wiebe & McCallum,

Stress

Figure 4-4 Summary of behavioral and phys-iological avenues by which stress leads to illness. See text for additional information about these avenues.

Behavior

Increase

Dietary fat

Tobacco use

Alcohol use

Accidents

Decrease

Dietary fruits and vegetables

Exercise

Sleep

Physiology

Increase

Blood pressure

Unfavorable lipids in blood

Activated platelets in blood

Clotting factors in blood

Stress hormones (catecholamines,

corticosteroids)

Decrease

Immune function

1986). For instance, compared with people with low stress, those with high stress are more likely to eat higher fat diets with less fruit and vegetables, engage in less exercise, smoke cigarettes, and consume more alcohol (Baer et al., 1987; Cartwright et al., 2003; Ng & Jeffery, 2003). Stress can also induce eating, even when the person is not hungry (Michels et al., 2015). These behaviors are associated with the development of various illnesses. In addition, stress impairs sleep (Hall et al., 2004), and the resulting inattention and carelessness probably play a role in the relatively high accident rates of people under stress. Studies have found that children and adults who experience high levels of stress are more likely to suffer accidental injuries at home, in sports activities, on the job, and while driving a car than individuals under less stress (Johnson, 1986; Quick et al., 1997). Further, disrupted sleep can itself be stressful, and as described previously, poor sleep interferes with a key way that the body is restored physiologically.

STRESS, PHYSIOLOGY, AND ILLNESS

Stress produces many physiological changes in the body that can affect health, especially when stress is chronic and severe. In Chapter 3, we discussed the concept of allostatic load in which the strain involved in reacting repeatedly to intense stressors produces wear and tear on body systems that accumulate over time and lead to illness (McEwen & Stellar, 1993). Adverse childhood experiences increase allostatic load in adolescence (Doan, Dich, & Evans, 2014). A study found that for elderly individuals whose allostatic load increased or decreased across a 3-year period, those with increased loads had higher mortality rates during

the next 4 years (Karlamangla, Singer, & Seeman, 2006). Connections have been found between illness and the degree of reactivity people show in their cardiovascular, endocrine, and immune systems when stressed.

Cardiovascular System Reactivity and Illness

Cardiovascular reactivity refers to physiological changes that occur in the heart, blood vessels, and blood in response to stressors. Before middle age, people’s degree of cardiovascular reactivity is generally stable, showing little change when retested with the same stressors years later (Sherwood et al., 1997; Veit, Brody, & Rau, 1997). In later years, cardiovascular reactivity increases with age, which corresponds to increases in risk of cardiovascular illness (Uchino et al., 2005, 2006).

Research has discovered links between high cardiovascular reactivity and the development of CHD, hypertension, and stroke (Everson et al., 2001; Henderson & Baum, 2004; Manuck, 1994). For example, high levels of job stress are associated with high blood pressure and abnormally enlarged hearts (Schnall et al., 1990), and people’s laboratory reactivity to stress in early adulthood is associated with their later devel-opment of high blood pressure (Menkes et al., 1989) and atherosclerosis (Matthews, Schwartz et al., 2006). The blood pressure reactivity that people display in laboratory tests appears to reflect their reactivity in daily life (Turner et al., 1994). Meta-analyses have found that greater cardiovascular reactivity and poor cardiovascular recovery after stressors were associated with greater risk of cardiovascular disease, including high blood pressure and atherosclerosis, and mortality (Chida & Steptoe, 2010; Panaite et al., 2015).

You may be thinking, “Heart rate and blood pressure rise during exercise, which is healthy. Why is cardio-vascular reactivity during stress unhealthy?” One reason is that the rise in heart rate and blood pressure during psychological stress is excessive (Carroll, Phillips, & Balanos, 2009). During physical exertion, such as exercise, rises in heart rate and blood pressure are due to increases in the body’s need for oxygen to meet the metabolic demands of those activities—for instance, muscles need more oxygen to do the work of climbing stairs compared to sitting—and the cardiovascular system responds accordingly. During psychological stressors, however, increases in heart rate and blood pressure are exaggerated, well beyond what the body actually requires, as if we need to make a “fight-or-flight” response. It is the excess that is unhealthy.

Psychological stress also produces several other cardiovascular changes that relate to the development of CHD. For instance, the blood of people under stress contains high concentrations of activated platelets (Everson-Rose & Lewis, 2005; Patterson et al., 1994) and clotting factors that thicken the blood, which can contribute to a heart attack (Wirtz et al., 2006). Stress also produces unfavorable levels of cholesterol (Patterson et al., 1995; Steptoe & Brydon, 2005) and inflammatory substances circulating in the blood (Steptoe, Hamer, & Chida, 2007). These changes in blood composition pro-mote atherosclerosis—the growth of plaques (inflamed, fatty patches) within artery walls—and narrow and stiffen the arteries, thereby increasing blood pressure and the risk of a heart attack or stroke.

Stephen Manuck and his colleagues (1995) have demonstrated the link between stress and atheroscle-rosis in research with monkeys. In one study, over many months, some of the subjects were relocated periodically to different living groups. This required stressful adjust-ments among the animals as they sought to re-establish the social hierarchies these animals naturally form, especially for higher-ranking or dominant animals to retain their status. The remaining subjects stayed in stable living groups. The stressed monkeys who had held dominant status in their living groups developed greater atherosclerosis than the dominant animals in the low-stress condition, and greater than the lower ranking or subordinate monkeys in either living condition. These effects were prevented when the animals were given a drug that blocked sympathetic nervous system excitation of the heart muscle, strongly implicating the role of chronic or recurring activation of the “fight-or-flight” response in development of atherosclerosis. Similar effects on atherosclerosis have been found in rabbits that were subjected to stressful living conditions (McCabe et al., 2002). Although these links are probably

somewhat different in humans, the ability to perform true experiments in which chronic stress is manipulated in animals over long periods of time provides evidence that supports the findings of observational studies of human stress and cardiovascular disease.

Other research suggests that it is not just the excitatory effects of the sympathetic nervous system on the cardiovascular system that contribute to cardio-vascular disease. If the sympathetic system functions like the “gas pedal” in activating stress responses, the parasympathetic nervous system is also important as a “brake” on such reactivity. The stress-dampening function of the parasympathetic system can be measured via increases and decreases in heart rate that are due to respiration: these changes cause heart rate to slow down when we breathe out and speed up when we breathe in. The magnitude of this change in heart rate—sometimes called “vagal tone” because it is caused by activity of the vagus nerve—is a good indicator of the strength of an individual’s parasympathetic stress dampening system. Research has linked higher vagal tone with lower risk of cardiovascular disease (Thayer & Lane, 2007). That is, good parasympathetic “brakes” on stress are protective.

Endocrine System Reactivity and Illness

Part of reactivity involves activation of the adrenal glands, both by sympathetic nervous system stimulation of these glands and via the hypothalamus-pituitary-adrenal axis, as described in previous chapters. In this pro-cess, the adrenal glands release hormones—particularly catecholamines and corticosteroids—during stress (Henderson & Baum, 2004; Rohleder, 2014). The increased endocrine reactivity that people display in these tests appears to reflect their reactivity in daily life (Williams et al., 1991). One way in which high levels of these hormones can lead to illness involves their effects on the cardiovascular system. For example, the magnitude of people’s cortisol responses to a laboratory stressor predicts their risk of developing hypertension: a recent study found that people who showed larger increases in cortisol in response to difficult mental tasks were more likely to develop hypertension over the next 3 years (Hamer & Steptoe, 2012). An intense episode of stress with high levels of these hormones can cause the heart to beat erratically and may even lead to sudden cardiac death (Williams, 2008). In addition, chronically high levels of catecholamines and corticosteroids, such as cortisol, increase inflammation and can contribute to the development of atherosclerosis, heart attack, and cancer (Matthews, Zhu et al., 2006; Rohleder, 2014). But social support may help: people with high levels of support tend to exhibit lower endocrine reactivity and

inflammation than those with lower levels (Seeman & McEwen, 1996; Yang, Schorpp, & Harris, 2014).

Stress also seems to contribute to health through endocrine system pathways that involve fat stored in the abdominal cavity. The metabolic syndrome is a set of risk factors including high levels of cholesterol and other blood fats, elevated blood pressure, high levels of insulin in the blood or an impaired ability of insulin to facilitate transportation of glucose out of the

blood stream, and large fat deposits in the abdomen (Masharani, 2015). The metabolic syndrome seems to be worsened by exposure to stressors and related physiological stress responses, especially heightened neuroendocrine activity. The metabolic syndrome also promotes chronic inflammation in the blood stream and elsewhere, increasing the risk of cardiovascular disease and other serious conditions, such as diabetes (Goldbacher & Matthews, 2007; Rizvi, 2009).

If you have not read Chapter 2, “The Body’s Physical Systems,” and your course has you read the modules

from that chapter distributed to later chapters, read Module 6 (“The Immune System”) now.

Immune System Reactivity and Illness

The release of catecholamines and corticosteroids during arousal affects health in another way: these stress responses alter the functioning of the immune system (Kemeny, 2007; Segerstrom & Miller, 2004). The effects of acute and chronic stress on the immune system can be measured in several ways, such as the extent to which immune system cells proliferate in response to antigens, or the ability of such cells to destroy foreign microorganisms or viruses. Immune system functioning can also be measured by whether an individual has a successful immune response to a flu vaccination—for example, increases in cortisol and epinephrine are associated with decreased activity of T cells and B cells against antigens.

Brief stressors typically activate some components of the immune system, especially nonspecific immunity, while suppressing specific immunity. Chronic stressors, in contrast, more generally suppress both nonspecific and specific immune functions. Chronic stressors also increase inflammation, an important process that disrupts immune function when it occurs on a long-term basis (Kemeny, 2007; Segerstrom & Miller, 2004). Levels of inflammation can be measured through several different “markers” or signs of inflammation circulating in the blood or present in saliva. These can be measured in response to specific stressors, or in more stable levels of sustained or chronic inflammation.

Immune processes protect the body against cancers that result from excessive exposure to harmful chemical or physical agents called carcinogens, which include radiation (nuclear, X-ray, and ultraviolet types), tobacco smoke, and asbestos (AMA, 2003). Carcinogens can damage the DNA in body cells, which may then develop into mutant cells and spread. Fortunately, people’s exposure to carcinogens is generally at low levels and for short periods of time, and most DNA changes probably

do not lead to cancer (Glaser et al., 1985). When mutant cells develop, the immune system attacks them with killer T cells. Actually, the body begins to defend itself against cancer even before a cell mutates by using enzymes to destroy chemical carcinogens or to repair damaged DNA. But research has shown that high levels of stress reduce the production of these enzymes and the repair of damaged DNA (Glaser et al., 1985; Kiecolt-Glaser & Glaser, 1986). Among people with cancer, those with high levels of killer-T-cell activity have a better prognosis than those with low levels of activity (Kemeny, 2007; Uchino et al., 2007).

If stress disrupts the immune system, the person can be vulnerable to a great variety of health conditions, from infection with the common cold virus, to infection with sepsis, a life-threatening illness (Marsland, Bachen,

Cohen, 2012; Ojard et al., 2015), to cancer (Lutgendorf

Sood, 2011). Adults who had adverse childhood expe-riences are also vulnerable to infection (Cohen et al., 2013). And a mother’s chronic stress during pregnancy can lead to premature delivery and low birth weight, with serious effects for child health and development (Coussons-Read et al., 2012; Dunkel Schetter, 2011).

PSYCHONEUROIMMUNOLOGY

We have seen in this and earlier chapters that psycho-logical and biological systems are interrelated—as one system changes, the others are often affected. The recog-nition of this interdependence and its connection to health and illness led researchers to form a field of study called psychoneuroimmunology. This field focuses on the relationships between psychosocial processes and the activities of the nervous, endocrine, and immune sys-tems (Ader & Cohen, 1985; Byrne-Davis & Vedhara, 2004; Kemeny, 2007). These systems form a feedback loop: the nervous and endocrine systems send chemical messages in the form of neurotransmitters and hormones that

increase or decrease immune function, and cells of the immune system produce chemicals, such as cytokines and ACTH, which feed information back to the brain. The brain appears to serve as a control center to maintain a balance in immune function, because too little immune activity leaves the individual open to infection and too much activity may produce autoimmune diseases.

Emotions and Immune Function

People’s emotions—both positive and negative—play a critical role in the balance of immune functions. Research has shown that pessimism, depression, and stress from major and minor events are related to impaired immune function (Byrne-Davis & Vedhara, 2004; Leonard, 1995; Marsland, Bachen, & Cohen, 2012). For example, research compared immune variables of caregiver spouses of Alzheimer’s disease patients with matched control subjects and found that the caregivers had lower immune function and reported more days of illness over the course of about a year (Kiecolt-Glaser et al., 1991). Another study compared individuals who received a flu vaccination and found that those who developed and maintained a high level of flu antibodies over 5 months had experienced less stress in the interim than those with fewer antibodies (Burns, Carroll et al., 2003).

Positive emotions can also affect immune func-tion, giving it a boost (Futterman et al., 1994; Stone et al., 1994). In the study by Arthur Stone and his coworkers, adult men kept daily logs of positive and negative events and gave saliva samples for analyses of antibody content. Negative events were associated with reduced antibodies only for the day the events occurred, but positive events enhanced antibody content for the day of occurrence and the next two.

Some stressful situations start with a crisis, and the ensuing emotional states tend to continue and suppress immune processes over an extended period of time. This was demonstrated with healthy elderly individuals who were taking part in a longitudinal study of the aging process (Willis et al., 1987). These people were asked to contact the researchers as soon as they were able if they experienced any major crisis, such as the diagnosis of a serious illness or the death of a spouse or child; 15 of them did so. A month after the crisis, and again months later, the researchers assessed the people’s cortisol and lymphocyte blood concentrations, recent diets, weights, and psychological distress. Because the subjects were already participating in the longitudinal study, comparable data were available from a time prior to the crisis. Analysis of these data revealed that lymphocyte concentrations, caloric intake, and

body weight decreased, and cortisol concentrations and psychological distress increased, soon after the crisis. By the time of the last assessment several months later, however, all of these measures had returned almost to the precrisis levels. Similarly, a study found that people who become unemployed show impaired immune function that recovers after they get a new job (Cohen et al., 2007).

When people react to short-term, minor events, such as doing difficult math problems under time pressure, changes in the number and activity of immune cells occur for fairly short periods of time—minutes or hours (Delahanty et al., 1996). The degree of change depends on which immune system component is measured and the event’s characteristics—long-lasting and intense interpersonal events seem to produce especially large immune reductions (Herbert & Cohen, 1993). Of course, immune system reactivity varies from one person to the next, but a person’s degree of response to a type of event seems to be much the same when tested weeks apart (Marsland et al., 1995). This suggests that an individual’s reaction to specific stressors is fairly stable over time.

One key process of the immune system— inflammation—is receiving increased attention because it is implicated in a wide variety of serious medical conditions (Gouin et al., 2008; Libby, Ridker, & Hansson, 2009; Steptoe, Hamer, & Chida, 2007). Stress can evoke increases in inflammatory substances in the blood, as can chronic levels of negative affect (Howren, Lamkin, & Suls, 2009; Steptoe, Hamer, & Chida, 2007). In turn, inflammation can lead to atherosclerosis, rheumatoid arthritis, and other chronic conditions, and seems to generally accelerate age-related diseases. One puzzling thing to note in this area is the fact that one stress response, the release of cortisol, generally decreases inflammation. But emerging perspectives suggest that under conditions of chronic stress the immune system becomes less sensitive to the normal anti-inflammatory effects of cortisol, so that inflammatory responses remain activated and can eventually damage health (Segerstrom & Miller, 2004).

Psychosocial Modifiers of Immune System Reactivity

As we’ve seen, psychosocial factors in people’s lives may modify the stress they experience. Such factors seem to affect immune system responses, too. For instance, social support affects the immune function of people under long-term, intense stress. People who have strong social support have stronger immune systems and smaller immune impairments in response to stress than others

with less support (Kennedy, Kiecolt-Glaser, & Glaser, 1990; Levy et al., 1990).

A related psychosocial modifier is disclosure— describing one’s feelings about stressful events. An experiment with college students examined the effect of expressing such feelings on blood levels of antibodies against the Epstein-Barr virus, a widespread virus that causes mononucleosis in many of those who are infected (Esterling et al., 1994). The students were randomly assigned to three conditions that met in three weekly 20-minute sessions in which they described verbally or described in writing a highly stressful event they had experienced, or wrote about a trivial (non-stress-related) topic, such as the contents of their bedrooms. The students in each condition had the same level of immune control against the virus before the study, but blood samples taken a week after the last session revealed that immune control improved substantially in the verbal condition, moderately in the written condition, and declined slightly in the control (trivial topic) condition, as Figure 4-5 depicts. Other research has found that describing feelings about stressful events is more effective in enhancing immune function in cynically hostile people than in nonhostile individuals (Christensen et al., 1996).

The influence of optimism on immune function appears to depend on whether the stress is short-term or chronic (Segerstrom, 2005). Optimism is associated with better immune functioning when stressors are mild or brief, but worse when stressors are complex or persistent. This may be because optimists tend to persevere in physiologically taxing efforts to influence persistent or uncontrollable stressors. Optimism has

Figure 4-5 Percent change in immune control against the Epstein-Barr virus, as reflected in blood concentrations of specific antibodies, for subjects having sessions for verbal expression of stress feelings, written expression of stress feelings, or a control condition. (Based on data from Esterling

et al., 1994, Figure 3.)

also been associated with lower levels of inflammation (Roy et al., 2010). (Go to .)

Lifestyles and Immune Function

Do people’s lifestyles affect the functioning of their immune systems? Some evidence suggests that they do. People with generally healthful lifestyles—including exercising, getting enough sleep, eating balanced meals, and not smoking—show stronger immune functioning than those with less healthful lifestyles (Kusaka, Kondou,

Morimoto, 1992). Other studies have found that sleeping poorly can impair immune function the next day (Irwin et al., 1994), and people who smoke are more susceptible to catching colds than those who don’t (Cohen et al., 1993).

Conditioning Immune Function

Research on psychoneuroimmunology with animals has revealed that the influence of psychological processes on immune function is not limited to the effects of stress. The impact may be far more broad and pervasive. Robert Ader and Nicholas Cohen (1975, 1985) have shown that immune suppression can be conditioned. In their original research, they were actually studying how animals learn to dislike certain tastes. The procedure used a single conditioning trial: the subjects (rats) received saccharin-flavored water to drink (which they seemed to like) and then got an injection of a drug that induces nausea. To see whether the rats’ subsequent dislike of the taste depended on its strength, some subjects received more saccharin flavoring than others in this conditioning trial. Over the next several weeks, the drug was not used, but the animals continued to receive saccharin-flavored water. During this time, the researchers noticed a curious thing: a number of rats had fallen ill and died—and these animals tended to be the ones that had consumed the greatest amount of saccharin in the conditioning trial.

How did these deaths relate to immune suppres-sion? Because the nausea-inducing drug used in the conditioning trial was also known to suppress immune function temporarily, Ader and Cohen hypothesized that the continued intake of saccharin water served as a conditioned stimulus, suppressing the ability of the rats to fight infection. Subsequent experiments by these researchers and others confirmed this hypothesis and demonstrated that conditioning can raise or lower immune function and can influence both anti-body-mediated and cell-mediated immune processes (Kusnecov, 2001). Similar conditioning effects have been demonstrated in humans, such as cancer patients who receive medications that impair immune function.

HIGHLIGHT

Stress and Wound Healing

We usually think of the central task of immune systems as the detection and destruction of foreign invaders or antigens and the destruction of abnormal cells. But another important function of the immune system is wound healing. Whether wounds result from accidental injuries or are intentional, as in surgery, the immune system plays a key role in repairing the injured tissue, as well as keeping the site from becoming infected. If stress can impair the immune system, can it also interfere with wound healing? Experiments in which mild wounds were inflicted, such as with a precise suction cup, on participants with their permission suggest it can (Kiecolt-Glaser et al., 2005; Robles, 2007). After the wound was made, each subject experienced either a strong stressor, such as an argument or a difficult interview, or a neutral event. The wounds healed more slowly over the next days or weeks in

participants who experienced the stressor than those who had the control (neutral) condition.

In another study, kidney donors completed ques-tionnaires to assess their stress and personality traits prior to the surgical removal of the kidney (Maple et al., 2015). During about 2 weeks after the surgery, high-resolution ultrasound imaging was used to assess the wounds in these people. Higher levels of life stress before the surgery and lower levels of opti-mism and conscientiousness were associated with slower healing. Other research has found that inter-ventions to reduce stress, such as exercise or written disclosure about past traumas, can facilitate wound healing after injury (Emery et al., 2005; Koschwanez, et al., 2013; Weinman et al., 2008). These results may have important implications for patients undergoing surgery.

PSYCHOPHYSIOLOGICAL DISORDERS

The word psychosomatic has a long history, and was coined to refer to symptoms or illnesses that are caused or aggravated by psychological factors, mainly emotional stress (Sarafino, 2004b). Although many professionals and the general public still use this term, the concept has undergone some changes and now has a new name: psychophysiological disorders, which refers to physical symptoms or illnesses that result from the interplay of psychosocial and physiological processes. This definition clearly uses a biopsychosocial perspective. We will discuss several illnesses traditionally classified as psychosomatic. Some of these illnesses will be examined in greater detail in later chapters.

DIGESTIVE SYSTEM DISEASES

Several psychophysiological disorders can afflict the digestive system. Ulcers and inflammatory bowel disease are two illnesses that involve wounds in the digestive tract that may cause pain and bleeding (McQuaid, 2015). Ulcers are found in the stomach and the duodenum, or upper section of the small intestine. Inflammatory bowel disease, which includes ulcerative colitis and Crohn disease, can occur in the colon (large intestine) and the small intestine. Another illness, irritable bowel syndrome, produces abdominal pain, diarrhea, and constipation (McQuaid, 2015). Although

these diseases afflict mainly adults, similar symptoms occur in childhood (Blanchard et al., 2008).

Most ulcers are produced by a combination of gastric juices eroding the lining of the stomach and duodenum that has been weakened by bacterial infec-tion (McQuaid, 2015). But stress plays a role, too (Levenstein, 2002). In a classic study, a patient (called Tom) agreed to cooperate in a lengthy and detailed examination of gastric function (Wolf & Wolff, 1947). Tom was unique in that many years earlier, at the age of 9, he had had a stomach operation that left an opening to the outside of the body. This opening, which provided the only way he could feed himself, was literally a window through which the inside of his stom-ach could be observed. When Tom was subjected to stressful situations, his stomach-acid production greatly increased. When he was under emotional tension for several weeks, there was a pronounced reddening of the stomach lining. Another study reported similar effects with a 15-month-old girl who had a temporary stomach opening. Her highest levels of acid secretion occurred when she was angry (Engel, Reichsman, & Segal, 1956).

The physical causes of inflammatory bowel disease and irritable bowel syndrome are not well understood, but stress is related to flare-ups of these illnesses (Blanchard et al., 2008; Kiank, Tache,´ & Larauche, 2010). The development and course of irritable bowel syndrome have been linked to stress early in life, chronic stress, and

recent stress, which appear to impact the disease through immune processes (Chang, 2011; O’Malley et al., 2011). Stress can contribute to and result from episodes of irritable bowel syndrome (Weinland et al., 2011), and psychotherapy can reduce its symptoms (Henrich et al., 2015).

ASTHMA

Asthma is a respiratory disorder in which inflammation, spasms, and mucous obstruct the bronchial tubes and lead to difficulty in breathing, with wheezing or coughing. This ailment is prevalent around the world—in the United States it afflicts about 8% of adults and 10% of children (AAFA, 2015). Asthma attacks appear to result from a combination of three factors: allergies, respiratory infections, and biopsychosocial arousal, such as from stress or exercise (AAFA, 2015; Lehrer et al., 2002). Stress early in life may contribute to susceptibility to asthma, and later stress can make the condition worse (Wright, 2011). In most cases, the cause of an attack is largely physical, but sometimes it may be largely psychosocial.

Professionals working with hospitalized children have noticed that the asthma symptoms of many children decrease shortly after admission to the hospital, but reappear when they return home (Purcell, Weiss, & Hahn, 1972). Are these children allergic to something in their own houses, such as dust, that isn’t in the hospital? This question was tested with asthmatic children who were allergic to house dust (Long et al., 1958). Without the children knowing, the researchers vacuumed the children’s homes and then sprayed the collected dust from each house into their individual hospital rooms. The result: none of the children had respiratory difficulty when exposed to their home dust, which suggests that psychosocial factors may be involved. Findings of other research indicate that stress can trigger asthma attacks (Lehrer et al., 2002; Sarafino, 1997; Tobin et al., 2015). Several psychosocial factors have been implicated in the development of asthma, the occurrence of asthma attacks, and the inflammatory processes that worsen asthma, including adverse childhood experiences and family patterns that involve low social support (Chen et al., 2010; Gilbert et al., 2015; Marin et al., 2009; Miller, Gaudin et al., 2009; Scott et al., 2008). A meta-analysis of this research indicated that the association between stress-related psychosocial factors and asthma is bidirectional; stress and negative emotions can contribute to the development and worsening of asthma, and having asthma can contribute to future stress and negative emotion (Chida, Hamer, & Steptoe, 2008).

RECURRENT HEADACHE

Many people suffer chronically from intense headaches. Although there are many types of recurrent headache, two of the most common are called tension-type and migraine headache. Tension-type headache (or muscle contraction headache) seems to be caused by a combination of a central nervous system dysfunction and persistent contraction of the head and neck muscles (Aminoff & Kerchner, 2015; Holroyd, 2002). The pain it produces is a dull and steady ache that often feels like a tight band of pressure around the head. Recurrent tension-type headaches occur twice a week or more, and may last for hours, days, or weeks (Dalessio, 1994).

Migraine headache seems to result from dilation of blood vessels surrounding the brain and a dysfunction in the brainstem and trigeminal nerve that extends throughout the front half of the head (Aminoff & Kerchner, 2015; Goadsby, 2005; Holroyd, 2002). The pain often begins on one side of the head near the temple, is sharp and throbbing, and lasts for hours or, sometimes, days (Dalessio, 1994). Sometimes migraines begin with or follow an aura, a set of symptoms that signal an impending headache episode. These symptoms usually include sensory phenomena, such as seeing lines or shimmering in the visual field. This may be accompanied by dizziness, nausea, and vomiting. Recurrent migraine is marked by periodic debilitating symptoms, which occur about once a month, with headache-free periods in between (Dalessio, 1994).

Most adults and children have headaches at least occasionally, and tension-type headaches are common (Aminoff & Kerchner, 2015). The prevalence of migraine varies widely across cultures, but is about 10% overall, is far greater in females than males, and increases with age from childhood to middle age, and then declines (Stewart, Shechter, & Rasmussen, 1994). Many children experience their first headaches in the preschool years, and chronic headaches have been reported in boys and girls as young as 6 years of age (Andrasik, Blake, & McCarran, 1986). Figure 4-6 presents a drawing by an 11-year-old girl named Meghan to describe her experience of migraine headache pain.

What triggers headaches? They often are brought on by hormonal changes, missing a meal, sunlight, sleeping poorly, and consuming certain substances, such as alcohol or chocolate. Research has also shown that stressors—particularly the hassles of everyday living—are common triggers of migraine and tension-type headaches (Aminoff & Kerchner, 2015; Nash & Thebarge, 2006; Robbins, 1994). For instance, after people retire, their frequency of headaches drops, and this decrease is greatest among people who had stress-prone personality traits such as hostility or Type A

Figure 4-6 Drawing by 11-year-old Meghan of her experience of migraine headache pain. The lower left-hand corner has a self-portrait with a dramatic facial expression. When a headache begins, Meghan typically retreats to her bedroom “to ride out the storm,” lying down in a darkened room. (From

Andrasik, Blake, & McCarran, 1986, Figure 18.1.)4-4

behavior and among people who retired from high-stress jobs (Sjosten¨ et al., 2011). Yet some individuals with chronic headache have attacks when they are not under great stress, and others fail to have headaches when they are under stress. Stress appears to be one of many factors that produce headaches, but the full nature of these causes is not yet known.

Although current evidence implicates both bio-logical and psychosocial causes for each of the psychophysiological disorders we have considered, the evidence is sketchy and the nature of the interplay of these factors is unclear. The remainder of this chapter focuses on the role of stress in the development of cardiovascular disorders and cancer.

OTHER DISORDERS

There are several other psychophysiological disorders for which stress appears to be involved. One of these illnesses is arthritis—a chronic and very painful disease that produces inflammation and stiffness of the small joints, such as in the hands. About 50 million Americans have this disease, and its victims are primarily women (AF, 2015). Stress seems to play a role in the development of arthritis (Harris et al., 2013) and in triggering or aggravating episodes of inflammation, pain, and limitations in physical activity (Parrish et al., 2008). Another stress-related problem involves skin disorders, such as hives, eczema, and psoriasis, in which the skin develops rashes or becomes dry and flakes or cracks (MedlinePlus, 2015). Stress can trigger or aggravate episodes. In many cases, allergies are identified as contributing to episodes of these skin problems.

STRESS AND CARDIOVASCULAR DISORDERS

We’ve seen that psychosocial modifiers of stress can affect health—for instance, that being chronically angry and hostile increases one’s risk of CHD. Such findings suggest that stress may be a factor in the development of cardiovascular disorders, the number-one cause of death in the United States and many other countries. We’ll look more closely at the role of stress in hypertension and CHD.

HYPERTENSION

Hypertension—the condition of having high blood pres-sure consistently over several weeks or more—is a major risk factor for CHD, stroke, and kidney disease

(AHA, 2015; NKF, 2015). In the United States, about 30% of adults are classified as hypertensive, having blood pressures at or above 140 (systolic) over 90 (diastolic) (NCHS, 2015). By comparison, the hyperten-sion rates elsewhere are (Hajjar, Kotchen, & Kotchen, 2006):

Australia, 21%–32%

Canada, 20%

Europe, 44% (across several nations)

Worldwide, 26%

Because lesser elevations in blood pressure are now known to increase risk substantially, current guidelines designate less than 120/80 as “normal,” or conveying little risk, as shown in Table 4.2. Prevalence rates for hypertension increase in adulthood, particularly after about 40 years of age (NCHS, 2015). Some cases of hypertension are caused by, or are secondary to, disorders of other body systems or organs, such as the kidneys or endocrine system. Secondary hypertension can usually be cured by medical procedures. But the vast majority—over 90%—of hypertensive cases are classified as primary or essential hypertension, in which the causes of the high blood pressure are unknown.

To say that the causes for essential hypertension are unknown is somewhat misleading. In cases of essential hypertension, physicians are unable to identify any biomedical causes, such as infectious agents or organ damage. But many risk factors are associated with the development of hypertension—and there is evidence implicating the following as some of the risk factors for hypertension (AHA, 2015; Hajjar, Kotchen, & Kotchen, 2006):

Obesity

Dietary elements, such as high salt, fats, and cholesterol

Excessive alcohol use

Physical inactivity

Family history of hypertension

Psychosocial factors, such as chronic stress, anger, and anxiety

Table 4.2 Blood Pressure Categories (values in mm Hg units)

Stress, Emotions, and Hypertension

People’s occupations provide sources of stress that can have an impact on their blood pressure. Traffic controllers at airports provide an example. Sidney Cobb and Robert Rose (1973) compared the medical records of thousands of men employed as air traffic controllers or as second-class airmen, separating the data for different age groups, because blood pressure increases with age. Comparisons for each age group revealed prevalence rates of hypertension among traffic controllers that were several times higher than for airmen. The researchers also compared the records of traffic controllers who experienced high and low levels of stress, as measured by the traffic density at the air stations where they worked. Figure 4-7 depicts the results: for each age group, prevalence rates of hypertension were higher for traffic controllers working at high-stress locations than for those at low-stress sites.

Aspects of social environments, such as crowding and aggression, are also linked to stress and hyperten-sion. Experiments with animals have shown that living in crowded, aggressive conditions induces chronic hyper-tension (Henry et al., 1993). Research with humans compared people living in crowded and uncrowded

Age in years

Figure 4-7 Prevalence of hypertension per 1,000 air traffic controllers as a function of stress and age. Hypertension rates increase with age and stress. (Data from Cobb & Rose,

Source: Based on AHA, 2015. 1973, Table 3.)

neighborhoods to see if these living conditions influ-ence blood pressure (Fleming et al., 1987). The people from the two types of neighborhoods were similar in important characteristics, such as age, gender, and family income. While working on a stressful cognitive task, the subjects showed greater increases in heart rate and systolic and diastolic pressure if they lived in crowded neighborhoods. Other research has found that high psychological stress and cardiovascular reactivity may be risk factors for, or even a cause of, hyperten-sion (Chida & Steptoe, 2010; Sparrenberger et al., 2009; Tuomisto et al., 2005). We saw in Chapter 3 that post-traumatic stress disorder represents a severe form of stress-related difficulty; it is associated with increased risk of hypertension (Abouzeid et al., 2012). Stress may also contribute to hypertension through its effects on promoting obesity, an important factor in hypertension (Wardle et al., 2011). Taken together, the evidence sug-gests that chronic stress contributes to the development of hypertension.

Studies on pessimism, anger, and hostility have revealed important links to the development of hyperten-sion; we’ll consider three. First, blood pressure is higher in pessimistic than optimistic individuals (Raikk¨onen¨ et al., 1999). Second, people who are hypertensive are more likely to be chronically hostile and resentful than are normotensive people, those with normal blood pressure (Diamond, 1982). Anger and higher nighttime blood pres-sure are also related (Beatty & Matthews, 2009). Third, resting blood pressure is higher among individuals who ruminate or dwell on angry events than among people who don’t ruminate (Hogan & Linden, 2004).

Interestingly, the effects of stress on blood pressure can complicate the medical diagnosis of hypertension. Some people become anxious when medical profes-sionals measure their blood pressure, producing an elevated reading that actually is not representative of their usual blood pressure levels, leading to a false diagnosis of hypertension. If undetected, this “white coat hypertension” can lead to unnecessary medical treatment (McGrady & Higgins, 1990; Ogedegbe et al., 2008).

Stress and Sociocultural Differences in Hypertension

The impact of stress on hypertension may be particularly relevant for Black people in the United States, who have a much higher prevalence rate of high blood pressure than Whites do (NCHS, 2015). In a study of Black and White people in Detroit, the highest blood pressure readings found were those of Blacks living in high-stress areas of the city—neighborhoods that were crowded and had high crime rates and low incomes—but Blacks

and Whites who lived in low-stress areas had similar blood pressures (Harburg et al., 1973). Two other findings suggest that perceived racism is a stressor that plays a major role in the high rates of hypertension among African Americans. First, Black women’s blood pressure reactivity to stressors is higher among those who feel that racial discrimination underlies the mistreatment they’ve experienced than those who do not (Guyll, Matthews,

Bromberger, 2001). Second, blood pressure in waking daily life is higher among Black men and women who perceive frequent racism in their lives than those who do not (Dolezsar et al., 2014).

Few cases of essential hypertension are likely to be caused by emotional factors alone (Schneiderman

Hammer, 1985). Most cases of high blood pressure probably involve several of the determinants listed earlier in this section. (Go to .)

CORONARY HEART DISEASE

Epidemiologists have studied the distribution and frequency of CHD over many decades in many different cultures. The data they have collected suggest that CHD is, to some extent, a disease of modernized societies—that is, the incidence rate of heart disease is higher in technologically advanced countries than in other nations (Susser, Hopper, & Richman, 1983). In advanced societies, people live long enough to become victims of CHD, which afflicts mainly older individuals, and are more likely than those in less developed countries to have certain risk factors for CHD, such as obesity and low levels of physical activity. Also, the psychosocial stressors of advanced societies are different from those in other societies and may be more conducive to the development of heart disease. For instance, people in less advanced societies may have more social support to protect them from the effects of stress and perceive less reason for anger and hostility, which we’ve already seen can increase the risk of CHD.

The link between stress and CHD has considerable support (Williams, 2008). For example, job stress, conflict in close relationships, post-traumatic stress disorder, stress-related personality factors such as anger and optimism, and low levels of social support predict the development of CHD, as indicated by myocardial infarctions or death from CHD (Barth, Schneider, & von Kanel,¨ 2010; Boehm & Kubzansky, 2012; Chida & Steptoe, 2009; Dedert et al., 2010; De Vogli et al., 2007; Eller et al., 2009; Kivimaki¨ et al., 2012; Kubzansky et al., 2009; Smith, Uchino et al., 2012). Links between stress and CHD could occur across various phases of the disease. Stress could contribute to the initiation and progression of atherosclerosis years before the first symptoms occur;

HIGHLIGHT

Does Acculturation Increase Blood Pressure?

Does adapting to living in a new Western culture put people at risk for hypertension? To answer this question, Patrick Steffen and his colleagues (2006) performed a meta-analysis on blood pressure data from 125 studies that had compared people who were or were not living in a new Western culture. This analysis revealed several interesting findings. First, blood pressure was substantially higher among people adapting to a new culture. Second, the higher blood pressures were not the result of differences in body weight or cholesterol levels. Third, the impact of acculturation on blood pressure was greater for men than for women and greater for people who relocated

from rural to urban areas than from urban to rural. Fourth, the impact of adapting to a new culture decreased with time: the effect of acculturation on blood pressure was far greater in the first months after relocating than after several years. Acculturation is stressful, but people adapt in time. The stress of acculturation has also been linked to risk for developing the metabolic syndrome (Peek et al., 2009), which combines high blood pressure with high cholesterol, abdominal fat, and impaired glucose metabolism. Hence, the health risks of acculturation may extend beyond hypertension to include other cardiovascular diseases and diabetes.

later, when atherosclerosis is advanced, stress could contribute to the occurrence of ischemia, myocardial infarction, or disturbances in the heart rhythms. Still later when CHD is clear, stress could lead to worse outcomes, such as recurrent heart attacks or coronary death.

Research has supported links at each of these phases. For example, anger is associated with arterial stiffness, a very early sign of atherosclerosis (Shimbo et al., 2007). And among African American women, atherosclerosis is more advanced for those who perceive high levels of stress, unfair treatment, and racial discrimination in their lives than those who do not perceive these things (Troxel et al., 2003). Also, high job strain from daily stressors is associated with greater progression of atherosclerosis over time (Kamarck et al., 2012). Later in the development of CHD, a variety of stressful events and negative emotions such as episodes of anger can precipitate heart attacks in people with advanced atherosclerosis (Bhattacharyya & Steptoe, 2007). Finally, anger, depression, anxiety, living in stressful neighborhoods, and low levels of social support have all been found to predict poor CHD medical outcomes, including recurring heart attacks and death (Barth, Schneider, & von Kanel,¨ 2010; Chida & Steptoe, 2009; Martens et al., 2010; Nicholson, Kuper, & Hemingway, 2006; Scheffler et al., 2008).

What processes link stress and CHD? We’ve discussed three processes already (Kop, 2003; Williams, 2008). First, stress evokes increases in lipids and inflam-matory substances in the blood, cardiovascular reactivity, and increases in catecholamine and corticosteroid release by the endocrine glands. These physiological

responses, especially if they become chronic, can damage the arteries and heart, promote atherosclerosis, and lead to hypertension. These same processes can cause advanced and unstable coronary artery plaques to rupture, causing a blood clot that can close off an artery that otherwise brings blood and oxygen to the heart muscle—the most common cause of heart attack. Second, stress can cause cardiac arrhythmia, especially if the heart is susceptible to ischemia. When severe, arrhythmias can cause a cardiac episode and sudden death. Third, stress is associated with behavioral risk factors for CHD, such as cigarette smoking and high levels of alcohol use. Later in this book we’ll examine in greater detail various risk factors and issues relating to CHD and the next stress-related illness, cancer.

STRESS AND CANCER

The idea that stress and other psychosocial factors con-tribute to the development of cancer has a long history. The physician Galen, who practiced in Rome during the second century A.D., believed that individuals who were sad and depressed, or “melancholy,” were more likely to develop cancer than those who were happy, confident, and vigorous (Sklar & Anisman, 1981). Similar ideas have appeared in the writings of physicians in later eras. Cancer is a term that refers to a broad class of disease in which cells multiply and grow in an unrestrained manner. As such, cancer does not refer to a single illness, but to dozens of disease forms that share this characteristic (ACS, 2015). It includes, for instance, leukemias, in which the bone marrow produces excessive numbers of white

blood cells, and carcinomas, in which tumors form in the tissue of the skin and internal organ linings. Some cancers take longer to develop or follow more irregular courses in their development than do others.

Does stress play a role in cancer? Early evidence linking stress and cancer came from research using retrospective methods (Sklar & Anisman, 1981). This research generally had cancer patients fill out life events questionnaires to assess the stress they experienced during the year or so preceding the diagnosis. Although some studies found that the appearance of cancer was associated with self-reported high levels of prior stress, others did not (Steptoe & Ayers, 2004), and problems with retrospective methods cloud the interpretation of the results of these studies. Because the cancer diagnoses were typically made years after the disease process started, the patients’ cancers were probably present prior to and during the year for which they reported high levels of stress. Also, the patients’ perceptions or recollections of prior stress may have been distorted by their knowledge that they have cancer. More recent, better designed research using prospective or longitudinal approaches has also produced inconsistent results, but

a meta-analysis of the large number of studies found that stress-related psychosocial factors predicted the initial occurrence of cancer, as well as the medical course of the disease, including cancer survival and death (Chida et al., 2008).

The effects of stress on cancer are probably influ-enced by many factors. If stress plays a causal role in cancer development or progression, it may do so by impairing the immune system’s ability to combat the disease, increasing inflammation, and by increasing behavioral risk factors, such as smoking cigarettes. As in the case of CHD, cancer progresses in a complex manner. In the case of solid tissue cancers or malignant tumors, cancer progression eventually involves a process called angiogenesis, the recruitment of a blood supply to permit growth of the tumor beyond early stages. Further, cancer can spread beyond the tissue where it originally occurred, a process called metastasis. Recent research has begun to identify ways in which physiological stress responses can influence angiogenesis and metastasis, as well as the health behavior and immune system processes thought to link stress and cancer (Antoni, Lutgendorf et al., 2006; Lutgendorf & Sood, 2011).

SUMMARY

Researchers have identified several psychosocial factors that modify the impact of stress on the individual. One of these factors is social support—the comfort, caring, esteem, or help a person actually receives or simply perceives as available from others. There are four basic types of support: emotional or esteem, tangible or instrumental, informational, and companionship. Whether people receive social support depends on characteristics of the recipients and of the providers of support and on the composition and structure of the social network. Social support appears to reduce the stress people experience and to enhance their health. The greater people’s social support, the lower their mortality rates and likelihood of becoming ill. These benefits seem to accrue in accordance with the buffering and direct effects hypotheses. That is, social support may buffer a person against the negative effects of high levels of stress and may enhance health regardless of the level of stress by simply providing encouragement for leading healthful lifestyles, for instance.

Another psychosocial modifier of stress is people’s sense of personal control over events in their lives, such as through behavioral and cognitive control. Personal control includes beliefs about one’s locus of control—that is, whether control is internal or external to the person—and self-efficacy. People acquire a sense of personal control

from their successes and failures and through the process of social learning. Individuals who experience prolonged, high levels of stress and have a weak sense of personal control tend to feel helpless. The cognitive process of attribution seems to be important in the development of learned helplessness. A strong sense of personal control tends to benefit people’s health and help them adjust to a serious illness if it occurs. Hardiness and similar personality traits are additional psychosocial modifiers of stress that may help people remain healthy when under stress; the five-factor model of personality can help organize the growing list of personality traits that modify stress.

One other psychosocial modifier of stress is people’s tendency toward either the Type A or the Type B behavior pattern. The Type A behavior pattern consists of four characteristics: competitive achievement orientation, time urgency, anger or hostility, and a vigorous or controlling vocal style. Compared with Type Bs, Type A individuals respond more quickly and strongly to stressors both in their overt behaviors and in their physiological reactivity. Anger/hostility is the component of this pattern that is most closely associated with the development of coronary heart disease (CHD) and hypertension.

Chronic stress may affect health in two ways. First, it may increase health-compromising behaviors, such as

alcohol and cigarette use. Second, it produces changes in the body’s physical systems, as when the endocrine sys-tem releases catecholamines and corticosteroids, which can cause damage to the heart and blood vessels and impair immune system functioning. The physical effects of stress can even impair healing of wounds. Psychoneuroimmunol-ogy is the field of study that focuses on how psychosocial processes and the nervous, endocrine, and immune sys-tems are interrelated. Stress also plays a role in many psychophysiological disorders, such as ulcers, inflamma-tory bowel disease, irritable bowel syndrome, asthma, and tension-type and migraine headache. In addition, stress is strongly implicated in the development of hypertension and CHD, and may also affect cancer.

CREDITS

4-1 Reprinted from Social Science and Medicine, Vol. 21. Colerick, E. J. Stamina in later life, 997–1006. Copyright (1985), with permission from Elsevier.

4-2 Ibid.

4-3 Ibid.

4-4 Andrasik, F., Blake, D. D., & McCarran, M. S. (1986). A biobehavioral analysis of pediatric headache. In N. A. Krasnegor, J. D. Arasteh, & M. F. Cataldo (Eds.), Child health behavior: A behavioral pediatrics perspective (pp. 394–434). New York: Wiley. Reprinted with permission of John Wiley & Sons, Inc.

KEY TERMS

Note: If you read Modules 5 and 6 (from Chapter 2) with

the current chapter, you should include the key terms for

those modules.

5

COPING WITH AND REDUCING STRESS

Coping with Stress

What Is Coping?

Functions and Methods of Coping

Reducing the Potential for Stress

Enhancing Social Support Managing Interpersonal Problems Improving One’s Personal Control Organizing One’s World Better Exercising: Links to Stress and Health Preparing for Stressful Events

Reducing Stress Reactions:

Stress Management

Medication

Behavioral and Cognitive Methods

Massage, Meditation, and Hypnosis

Using Stress Management to Reduce Coronary Risk

Modifying Type A Behavior

Treating Hypertension

PROLOGUE

One morning while taking a shower before going to psychology class, Cicely felt a small lump in her breast. She was sure it had not been there before. It didn’t

hurt, but she was momentarily alarmed—her mother had had breast cancer a few years before. “It could be a pimple or some other benign growth,” she thought. Still, it was very worrisome. She decided not to consult her physician about it yet because she thought, “it may not be anything.” Over the next several days, she anxiously examined the lump daily. This was a very stressful time for her, and she slept poorly. After a week without the lump changing, she decided to take action and see her physician.

Another young woman, Beth, had a similar experi-ence. Finding a lump on her breast alarmed her, but she didn’t deal with the stress as rationally as Cicely did. Beth’s initial fright led her to reexamine her breast just once, and in a cursory way. She told herself, “There isn’t really a lump on my breast, it’s just a rough spot,” and convinced herself that she should not touch it because, she thought, “That will only make it worse.” During the next few months, Beth worried often about the “rough spot” and avoided touching it, even while washing. She became increasingly moody, slept poorly, and developed many more headaches than usual. Beth finally men-tioned the “rough spot” to a friend who convinced her to have her physician examine it.

People vary in the ways they deal with stress. Sometimes people confront a problem directly and rationally, as Cicely did, and sometimes they do not. For these two women, the way they dealt with their stress had the potential for affecting their health. Because Beth

112

did not face up to the reality of the lump, she delayed seeking medical attention and experienced high levels of stress for a long time. If the lump were malignant, delaying treatment would allow the cancer to progress and spread. As we have seen, prolonged stress can have adverse health effects even in healthy people.

In this chapter we discuss the ways people can and do deal with stress. Through this discussion, you will find answers to questions you may have about the methods people use in handling stress. Are some methods for coping with stress more effective than others? How can people reduce the potential for stress in their lives? When people encounter a stressor, how can they reduce the strain it produces?

COPING WITH STRESS

Individuals of all ages experience stress and try to deal with it. During childhood years, people learn ways to manage feelings of stress that arise from the many fearful situations they experience (Sarafino, 1986). For instance, psychologist Lois Murphy (1974, p. 76) has described the progress and setbacks a 4-year-old named Molly had made in dealing with the terror she felt during thunderstorms. In her last steps at gaining control over her fear, she experienced two storms a few months apart. During the first storm, she awoke and didn’t cry, “but I just snuggled in my bed,” she said later. In the second storm, she showed no outward fear and comforted her frightened brother, saying, “I remember when I was a little baby and I was scared of thunder and I used to cry and cry every time it thundered.” Like most children, Molly became better able to cope with the stress of storms as she grew older. What’s more, in the last steps of her progress she showed pride in having mastered her fear.

WHAT IS COPING?

Because the emotional and physical strain that accom-panies stress is uncomfortable, people are motivated to do things to reduce their stress. These “things” are what is involved in coping.

What is coping? Several definitions of coping exist (Lazarus & Folkman, 1984). We’ll use a definition based on how we defined stress in Chapter 3, when we saw that stress involves a perceived discrepancy between the demands of the situation and the resources of the person. Coping is the process by which people try to manage the perceived discrepancy between the demands and resources they appraise in a stressful situation. Notice the word manage in this definition. It indicates that coping efforts

can be quite varied and do not necessarily succeed. Although coping efforts can be aimed at correcting or mastering the situation, they may also simply help the person alter his or her perception of a discrepancy, tolerate or accept the harm or threat, or escape or avoid the situation (Lazarus & Folkman, 1984; Carver & Connor-Smith, 2010). For example, a child who faces a stressful exam in school might cope by claiming to feel nausea and staying home.

We cope with stress through our cognitive and behavioral transactions with the environment. Suppose you are overweight and smoke cigarettes, and your physician has asked you to lose weight and stop smoking because several factors place you at very high risk for developing heart disease. This presents a threat— you could become disabled or die—and is stressful, especially if you don’t think you can change your behavior. How might you cope with this? Some people would cope by seeking information about ways to improve their ability to change. Other people would simply find another doctor who is not so directive. Others would attribute their health to fate or “the will of God,” and leave the problem “in His hands.” Still others would try to deaden this and other worries with alcohol, which would add to the risk. People use many different methods to try to manage the appraised discrepancy between the demands of the situation and their resources.

The coping process is not a single event. Because coping involves continuous transactions with the envi-ronment, the process is best viewed as a dynamic series of appraisals and reappraisals that adjust to shifts in person–environment relationships. In coping with the threat of serious illness, people who try to change their lifestyles may receive encouragement and better relationships with their physician and family, but indi-viduals who ignore the problem are likely to experience worse and worse health and relations with these people. Each shift in direction is affected by the transactions that preceded it and affects subsequent transactions (Lazarus & Folkman, 1984).

FUNCTIONS AND METHODS OF COPING

You have probably realized by now that people have many ways of coping with stress. Because of this, researchers have attempted to organize coping approaches on the basis of their functions and the methods they employ. (Go to .)

Functions of Coping

According to Richard Lazarus and his colleagues, coping can serve two main functions (Lazarus, 1999;

ASSESS YOURSELF

Your Focuses in Coping

Think about a very stressful personal crisis or life event you experienced in the last year—the more recent and stressful the event, the better it is for this exercise. How did you handle this situation and your stress? Some of the ways people handle stressful experiences are listed below. Mark an “X” in the space preceding each one you used.

Tried to see a positive side to it

Tried to step back from the situation and be more objective

Prayed for guidance or strength

Sometimes took it out on other people when I felt angry or depressed

Got busy with other things to keep my mind off the problem

Decided not to worry about it because I figured everything would work out fine Took things one step at a time

Read relevant material for solutions and considered several alternatives

Drew on my knowledge because I had a similar experience before

Talked to a friend or relative to get advice on handling the problem

Talked with a professional person (e.g., doctor, clergy, lawyer, teacher, counselor) about ways to improve the situation

Took some action to improve the situation

Count how many of the first six ways you marked— these are examples of “emotion-focused” ways. How many of the second six—“problem-focused”—ways did you mark? When you read the upcoming text material entitled “Functions of Coping,” answer these questions: Did you use mostly emotion- or problem-focused methods? Why, and what functions did your methods serve? (Source: Based on material in Billings and Moos, 1981.)

Lazarus & Folkman, 1984). It can alter the problem causing the stress or it can regulate the emotional response to the problem.

Emotion-focused coping is aimed at controlling the emotional response to the stressful situation. People can regulate their emotional responses through behavioral and cognitive approaches. Examples of behavioral approaches include using alcohol or drugs, seeking emotional social support from friends or relatives, and engaging in activities, such as sports or watching TV, which distract attention from the problem. Cognitive approaches involve how people think about the stressful situation. In one cognitive approach, people redefine the situation to put a good face on it, such as by noting that things could be worse, making comparisons with individuals who are less well off, or seeing something good growing out of the problem. We can see cognitive approaches in two statements of women with breast cancer (Taylor, 1983, pp. 1163 and 1166). The first one points out that it took a serious illness to put things in perspective, saying, “You find out that things like relationships are really the most important things you have—the people you know and your family—everything else is just way down the line.” And the second woman compares herself and empathizes with young women with breast cancer: “To lose a breast when you’re so young must be awful. I’m 73; what do I need a breast for?” People who want to redefine a stressful situation can generally find a way to

do it because there is almost always some aspect of one’s life that can be viewed positively (Taylor, 1983).

Other emotion-focused cognitive processes include strategies Freud called “defense mechanisms,” which involve distorting memory or reality in some way (Cramer, 2000). For instance, when something is too painful to face, the person may deny that it exists, as Beth did with the lump on her breast. This defense mechanism is called denial. In medical situations, individuals who are diagnosed with terminal diseases often use this strategy and refuse to believe they are really ill. This is one way people cope by using avoidance strategies. But strategies that promote avoidance of the problem are helpful mainly in the short run, such as during an early stage of a prolonged stress experience (Suls & Fletcher, 1985). This is so for individuals who are diagnosed with a serious illness, for instance. As a rule of thumb, the effectiveness of avoidance-promoting methods seems to be limited to the first couple of weeks of a prolonged stress experience. Thereafter, coping is better served by giving the situation attention.

People tend to use emotion-focused approaches when they believe they can do little to change the stress-ful conditions (Lazarus & Folkman, 1984). An example of this is when a loved one dies—in this situation, people often seek emotional support and distract themselves with funeral arrangements and chores at home or at work. Other examples can be seen in situations in which

individuals believe their resources are not and cannot be adequate to meet the demands of the stressor. A child who tries very hard to be the “straight A” student his or her parents seem to want, but never succeeds, may reap-praise the situation and decide, “I don’t need their love.” Coping methods that focus on emotions are important because they sometimes interfere with getting medi-cal treatment or involve unhealthful behaviors, such as using cigarettes, alcohol, and drugs to reduce tension. People often use these substances in their efforts toward emotion-focused coping (Wills, 1986).

Problem-focused coping is aimed at reducing the demands of a stressful situation or expanding the resources to deal with it. Everyday life provides many examples of problem-focused coping, including quitting a stressful job, negotiating an extension for paying some bills, devising a new schedule for studying (and sticking to it), choosing a different career to pursue, seeking medical or psychological treatment, and learning new skills. People tend to use problem-focused approaches when they believe their resources or the demands of the situation are changeable (Lazarus & Folkman, 1984). For example, caregivers of terminally ill patients use problem-focused coping more in the months prior to the death than during bereavement (Moskowitz et al., 1996).

Sometimes people don’t cope effectively with stress. Reprinted with special permission of King Features Syndicate, Inc.

To what extent do people use problem-focused and emotion-focused approaches in coping with stress in their lives? Andrew Billings and Rudolf Moos (1981) studied this issue by having nearly 200 married couples fill out a survey. The respondents described a recent personal crisis or negative life event that happened to them and then answered questions that were very similar to the ones you answered in the self-assessment exercise. The outcomes of this research revealed some interesting relationships. Both the husbands and the wives used more problem-focused than emotion-focused methods to cope with the stressful event, but the wives reported using more emotion-focused approaches than the husbands did. People with higher incomes and educational levels reported greater use of problem-focused coping than those with lower incomes and educational levels. Last, individuals used much less problem-focused coping when the stress involved a death in the family than when it involved other kinds of problems, such as illness or economic difficulties.

Can problem-focused and emotion-focused coping be used together? Yes, and they often are. For instance, a study had patients with painful arthritis keep track of their daily use of problem- and emotion-focused coping (Tennen et al., 2000). Most often, they used the two types of coping together; but when they used only one type, three-quarters of the time it was problem-focused coping. We can see an example of both types of coping in a man’s experience when a coworker accused him of not sending out the appropriate letters for a job. In describing how he reacted to this stressful situation, he said he first confirmed that the coworker’s accusation

was not true, that everything [letters] had gone out. There’s always a chance you might be wrong so I checked first. Then I told him. No, everything had gone out. My immediate reaction was to call him on the carpet first. He doesn’t have any right to call me on something like this. Then I gave it a second thought and decided that that wouldn’t help the situation. (Kahn et al., cited in Lazarus & Folkman, 1984, p. 155)

This example shows problem-focused coping in confirming that the letters had gone out, and emotion-focused coping in controlling his angry impulse “to call him on the carpet.”

Some coping processes occur between people, rather than on one’s own (Revenson & Lepore, 2012). For example, relationship-focused coping involves emotion- or problem-focused coping intended to manage or maintain social relationships during stress, such as by trying to bolster each other’s emotional needs. Compromising and empathizing with partners are examples of this approach. In dyadic coping, partners work together, recognizing their

interdependence in dealing with a shared stressor, as when a couple collaborates in trying to manage household finances when money is tight.

Coping Methods and Measurement

What specific methods—that is, skills and strategies— can people apply in stressful situations to alter the prob-lem or regulate their emotional response? Researchers have described about 400 methods and incorporated sets of them into dozens of instruments to assess overall coping and categories of coping types (Skinner et al., 2003). Table 5.1 lists two dozen coping methods that are easy to conceptualize, without stating definitions, to give you a sense of the great variety of possible methods people can use.

Unfortunately, instruments to measure coping haven’t been very useful so far. They were typically developed with the expectation that the scores would predict mental or physical health, but they often don’t (Coyne & Racioppo, 2000; Skinner et al., 2003), and they don’t seem to be very accurate in measuring people’s coping. Most measures of coping are retrospective, ask-ing respondents about the methods used in the past week, month, or more. Do you remember exactly how you coped 2 weeks ago with a stressful event, such as a poor grade on a test or an argument with a close friend? A study tested the accuracy issue by having peo-ple report daily for a month on the coping strategies they used with the most negative event that occurred that day (Todd et al., 2004). The subjects used a list with descriptions of 16 strategies that comprise a widely used coping survey for the daily reports; at the end of the study they filled out the survey to report on the whole month. Comparisons of daily and full-month reports showed weak correspondence for about half of the coping meth-ods, suggesting that assessments of coping pertaining to more than the past week or so are inaccurate for many methods.

Researchers are currently working to identify the coping methods that are most important—those that can be measured accurately and are related to psychological and health outcomes, such as people’s development of and recovery from illnesses. Let’s look at some directions that look promising (Carver & Connor-Smith, 2010; Folkman & Moskowitz, 2004).

Engaging positive emotions. One approach for coping with stress involves the use of positive emotions to soften or balance against feelings of distress. For instance, Susan Folkman (1997; Folkman & Moskowitz, 2004) has found that individuals who were caring for a dying spouse or partner and then lost that person report both positive and negative emotions occurring together during times of great stress. As an example, a gay man described the difficulty of tending for his partner during the extreme sweating episodes he, like many AIDS patients, had many times each day and noted that he feels “proud, pleased that I can comfort him . . . .

We are still making our love for each other the focal point” (Folkman, 1997, p. 1213). Some people tend to give attention to emotionally positive information over negative material, and this preference seems to increase in later adulthood (Reed, Chan, & Mikels, 2014). People who favor positive information show stronger immune functioning (Kalokerinos et al., 2014).

Finding benefits or meaning. People who are trying to cope with severe stress often search for benefits or meaning in the experience, using beliefs, values, and goals to give it a positive significance (Folkman, 1997; Park, 2012; Sears, Stanton, & Danoff-Burg, 2003). They find benefits or meaning in many ways, such as

when people whose loved ones have died from a dis-ease become advocates for research on that disease; finding that new or closer bonds with others have been formed because of having experienced or survived a natural disaster together; or finding that the event has clarified which goals or priorities are important and which are not. (Folkman, 1997, p. 1215)5-1

Table 5.1 Methods of Coping with Stressful Situations (listed alphabetically)

Note: Superscripted letters refer to the method’s most likely function,

= problem-focused and

= emotion-focused coping, but some methods may serve either function. Source: Based on Skinner et al., 2003, Table 3.

A meta-analysis of over 80 studies found partial support for a role of benefit finding in coping: it was associated with less depression and greater feelings of well-being, but was not related to anxiety and self-reports of physical health (Helgeson, Reynolds, & Tomich, 2006).

Engaging in emotional approach. In emotional approach, people cope with stress by actively processing and expressing their feelings (Stanton et al., 2000). To assess emotional approach, people rate how often they engage emotional processing (in such activities as, “I take time to figure out what I’m really feeling” and “I delve into my feelings to get a thorough understanding of them”) and emotional expression (“I take time to express my emotions”). Emotional approach probably includes the method of disclosure of negative experiences and feelings we discussed in Chapter 4 as a way of reducing stress and enhancing health.

Accommodating to a stressor. Another way to cope is to adapt or adjust to the presence of the stressor and carry on with life (Carver & Connor-Smith, 2010; Morling

Evered, 2006). For instance, people with chronic pain conditions may come to accept that the pain is present and engage in everyday activities as best they can.

Research has found psychological and health ben-efits for each of these coping methods (Folkman & Moskowitz, 2004). For example, researchers tested women with breast cancer for emotional approach soon after medical treatment and for psychological and health status 3 months later (Stanton et al., 2000). They found that high levels of emotional expression were associated with improved self-perceived health, increased vigor, fewer medical visits for cancer-related problems, and decreased distress, but high levels of emotional process-ing were linked with increased distress. It may be that emotional processing includes or leads to rumination, in which people have intrusive thoughts and images that per-petuate their stress (Baum, 1990). For example, people may think repeatedly about how they or others are to blame for their problems or have “flashbacks” of painful or angry events. People who often ruminate take longer for their blood pressure to decrease after starting to think about arousing events and report having poorer health habits and health than individuals who seldom have such thoughts (Gerin et al., 2006; Nowack, 1989).

Using and Developing Methods of Coping

No single method of coping is uniformly applied or effective with all stressful situations (Ilfeld, 1980; Pearlin

Schooler, 1978). Four issues about people’s patterns in using different coping methods should be mentioned. First, people tend to be consistent in the way they cope with a particular type of stressor—that is, when faced

with the same problem, they tend to use the same methods they used in the past (Stone & Neale, 1984). Second, people seldom use just one method to cope with a stressor. Their efforts typically involve a combination of problem- and emotion-focused strategies (Tennen et al., 2000). Third, the methods people use in coping with short-term stressors may be different from those they use under long-term stress, such as from a serious chronic illness (Aldwin & Brustrom, 1997). Fourth, although the methods people use to cope with stress develop from the transactions they have in their lives, a genetic influence is suggested by the finding that identical twins are more similar than fraternal twins in the coping styles they use (Busjahn et al., 1999).

Psychologists assume that coping processes change across the life span—but the nature of these changes is unclear because there is little research, especially longitudinal studies, charting these changes (Aldwin & Brustrom, 1997; Lazarus & Folkman, 1984). Some aspects of the changes in coping that occur in the early years are known. Infants and toddlers being examined by their pediatricians are likely to cope by trying to stop the examination (Hyson, 1983). We saw earlier in the case of Molly that young children develop coping skills that enable them to overcome many of their fears, making use of their expanding cognitive abilities. As they grow, children come to rely increasingly on cognitive strategies for coping (Brown et al., 1986; Miller & Green, 1984). So, for example, they learn to think about something else to distract themselves from stress. More and more, they regulate their feelings with emotion-focused methods, such as playing with toys or watching TV, especially when they can’t do anything to solve the problem, such as a serious illness in their parents (Compas et al., 1996).

Few studies have examined changes in methods of coping from adolescence to old age. One study used interviews and questionnaires to compare the daily hassles and coping methods of middle-aged and elderly men and women (Folkman et al., 1987). The middle-aged individuals used more problem-focused coping, whereas the elderly people used more emotion-focused approaches. Why do adults use less problem-focused and more emotion-focused coping as they get older? These changes probably result, at least in part, from differences in what people must cope with as they age. The elderly individuals in this study were retired from full-time work and reported more stress relating to health than did the middle-aged people, who reported more stress relating to work, finances, and family and friends. The stressors encountered in middle age are more changeable than those in old age. But the age groups also differed in outlook: regardless of the source of stress, the elderly people appraised their problems as less changeable than

the middle-aged individuals did. As we saw earlier, people tend to use problem-focused approaches when they believe the situation is changeable, and rely on emotion-focused coping when they do not.

Because most adults are married or partnered, adults’ coping strategies usually operate and develop jointly as a system, with each member’s coping pro-cesses shared by and influencing the other’s, as in the relationship-focused and dyadic coping described ear-lier. This sharing and social influence in coping may be clearest when a couple copes with long-term major stres-sors, such as the diagnosis, treatment, and future course of a life-threatening or disabling illness in them or their children (Berg & Upchurch, 2007; Compas et al., 2015; Revenson & Lepore, 2012). Their psychological adjust-ment to the stressors will depend on the type of illness, how effective their joint coping strategies are, and the quality of their relationship.

Gender and Sociocultural Differences in Coping

Studies of gender differences in coping have generally found that men are more likely to report using problem-focused strategies and women are more likely to report using emotion-focused strategies in dealing with stressful events (Marco, 2004). But when the men and women are similar in occupation and education, few, if any, gender differences are found (Davis, Burleson, & Kruszewski, 2011; Greenglass & Noguchi, 1996). These results suggest that societal sex roles affect the coping patterns that men and women report.

Billings and Moos (1981) found that people with higher incomes and educational levels report greater use of problem-focused coping than those with lower incomes and educational levels. This finding suggests that the social experiences of disadvantaged people lead many of them to believe they have little control over events in their lives. In general, disadvantaged individuals—a category that typically includes dispro-portionately more minority group members—are more likely to experience stressful events and less likely to cope with them effectively (Marco, 2004). Thus, people in Asian cultures and African- and Hispanic-Americans tend to use more emotion-focused and less problem-focused coping than White Americans do.

We have examined many ways people cope with stress. Each method can be effective and adaptive for the individual if it neutralizes the current stressor and does not increase the likelihood of future stressful situations. In the next section, we consider how people can reduce the potential for stress for themselves and for others.

REDUCING THE POTENTIAL FOR STRESS

Can people become “immune” to the impact of stress to some extent? Some aspects of people’s lives can reduce the potential for stressors to develop and help individuals cope with problems when they occur. Efforts taken that prevent or minimize stress are called proactive coping, and they typically use problem-focused methods (Carver & Connor-Smith, 2010). We will look at several proactive coping methods. (Go to .)

ENHANCING SOCIAL SUPPORT

We have all turned to others for help and comfort when under stress at some time in our lives. If you have ever had to endure troubled times on your own, you know how important social support can be. But social support is not helpful only after stressors appear, it also can help avert problems in the first place. Consider, for example, the tangible support newlyweds receive, such as items they will need to set up a household. Without these items, the couple would be saddled either with the financial burden of buying the items or with the hassles of not having them.

Although people from all walks of life can lack the social support they need, some segments of the population have less than others (Antonucci, 1985; Broadhead et al., 1983; Ratliff-Crain & Baum, 1990). For instance:

Men tend to have larger social networks than women, but women seem to use theirs more effectively for support.

Many elderly individuals live in isolated conditions and have few people on whom to rely.

Network size is related to social prestige, income, and education—the lower these variables are for individuals, the smaller their social networks tend to be.

Furthermore, the networks of people from lower socioeconomic classes are usually less diverse than those of people from higher classes—that is, lower-class networks contain fewer nonkin members. In contemporary American society, the traditional sources of support have shifted to include greater reliance on individuals in social and helping organizations. This is partly because extended family members today have different functions and live farther apart than they did many decades ago (Pilisuk, 1982).

Social support is a dynamic process. People’s needs for, giving of, and receipt of support change over time. Unfortunately, people who experience high levels of chronic stress, such as when their health declines severely, often find that their social support

HIGHLIGHT

Do Religiousness and Spirituality Reduce Stress and Enhance Health?

Here’s an intriguing finding: religiousness and spirituality—that is, people’s personal involvement in a religion and their more general involvement in a search for the sacred aspects or ultimate meaning of life—is associated with lower anxiety and depression, better physical health, and longer life (Chida, Steptoe, & Powell, 2009; Masters & Hooker, 2012; Park, 2012). Some reasons for this link have been proposed: some religions promote healthy lifestyles, such as by preaching against smoking; religious involvement provides social support; and religious people may find meaning or benefits in the adversities they experience more readily than nonreligious people. To the extent that these processes happen, they are likely to reduce stress and enhance health. But keep in mind two issues; first, some people are involved in a religion for utilitarian reasons, such

as to promote status or political goals, and their stress reactions do not seem to benefit from their involvement (Masters & Hooker, 2012). Second, the link between religiousness and lower mortality applies to people who were initially healthy, not to individuals who were already sick (Chida, Steptoe, & Powell, 2009).

One other reason for the link between religiousness and health that some people have proposed is that religious people may receive direct help from their God, especially if others pray for their health. This idea has been disconfirmed. A meta-analysis on data from 14 studies on the role of people’s praying to help another person found no impact of that prayer on the object person’s health or life condition (Masters, Spielmans, & Goodson, 2006). The health or life conditions of people who are or are not the objects of prayer are not different.

Teachers can help enhance children’s social support by having them work together.

resources deteriorate at the same time (Barlow, Liu, & Wrosch, 2015; Lepore, 1997; Wortman & Dunkel-Schetter, 1987). These results are disheartening because they suggest that people whose need for social support is greatest may be unlikely to receive it.

People can enhance their ability to give and receive social support by joining community organizations, such as social, religious, special interest, and self-help groups. These organizations have the advantage

of bringing together individuals with similar problems and interests, which can become the basis for sharing, helping, and friendship. In the United States, there are many widely known self-help groups, including Alcoholics Anonymous and Parents without Partners, and special-interest groups, including the American Association of Retired People and support groups for people with specific illnesses, such as arthritis or AIDS. Although groups like these are helpful, we do not yet know which ones work best for specific problems (Hogan, Linden, & Najarian, 2002). People are most likely to join a support group for a serious illness if it is embarrassing or stigmatizing, such as AIDS or breast cancer (Davison, Pennebaker, & Dickerson, 2000). Isolated people of all ages—especially the elderly—with all types of difficulties should be encouraged to join suitable organizations.

Communities can play a valuable role in enhanc-ing people’s resources for social support by creating programs to help individuals develop social networks, such as in occupational and religious settings, and by providing facilities for recreation and fitness, arrang-ing social events, and providing counseling services. But social support may not be effective if the recipient interprets it as a sign of inadequacy or believes his or her personal control is limited by it. Providing effective social support requires sensitivity and good judgment. (Go to )

MANAGING INTERPERSONAL PROBLEMS

Many of the most troubling types of stress involve con-flicts with other people. Such conflicts can be avoided or minimized through adaptive interpersonal behav-ior, especially by being assertive. Assertiveness involves expressing one’s opinions and preferences directly, but without insult or intimidation directed toward the other person. Faced with a potential disagreement or excessive demand, some people respond either aggressively, trying to intimidate or control the other person, or unassertively, failing to express their wishes or opinions. Unassertive people tend to appraise potentially stressful situations as threats and to respond with maladaptive physiological

changes (Tomaka et al., 1999). In contrast, assertive people tend to appraise such situations as challenges, which leads to less stress and better outcomes of the situation, as when they negotiate a more satisfactory resolution (O’Connor, Arnold, & Maurizio, 2010).

Assertiveness training helps people find the middle ground between nonassertive and aggressive behavior, enabling them to stand up for themselves in an effective and constructive manner and avoiding or reducing stress (Alberti & Emmons, 2008; Greenberg, 2013). For example, a study found that assertiveness training was useful in reducing the acculturation stress international students often experience when they come to the United States (Tavakoli et al., 2009).

HIGHLIGHT

The Amish Way of Social Support in Bereavement

The Amish people in North America form a conservative religious sect that settled in Pennsylvania in the 18th century. Amish families gen-erally live in colonies that now exist in many states and Canada. These families have a strongly religious orien-tation and a serious work ethic that revolves around farming. Their way of life is quite distinctive: they wear uniquely simple and uniform clothing; speak mainly a Pennsylvania-German dialect; and reject modern devices, using horse-driven buggies instead of automobiles, for example. Their social lives require adherence to strict rules of conduct and obedience to patriarchal authority.

One feature of Amish life is that community members give assistance to one another in all times of need. Their way of dealing with death provides a good example, as Kathleen Bryer (1986) has studied and described. Before death, a person who is seriously ill receives care from his or her family. This generally occurs at home, rather than in a hospital. The Amish not only expect to give this care, but see it as a positive opportunity. A married woman who was asked about caring for a dying relative replied, “Oh yes, we had the

chance to take care of all four of our old parents before they died. We are both so thankful for this” (p. 251). Death typically occurs in the presence of the family.

Upon someone’s death, the Amish community swings into action. Close neighbors notify other members of the colony, and the community makes most of the funeral arrangements. The family receives visits of sympathy and support from other Amish families, some of whom come from other colonies far away and may not even know the bereaved family. In contrast to the social support most Americans receive in bereavement, Amish supportive efforts do not end shortly after the funeral—they continue at a high level for at least a year. Supportive activities include evening and Sunday visiting, making items and scrapbooks for the family, and organized quilting projects that create fellowship around a common task. Moreover, Amish individuals often give extraordinary help to bereaved family members. For instance, the sister of one widower came to live with him and care for his four children until he remarried. The community encourages widowed individuals to remarry in time, and they often do so.

An Amish funeral procession. The Amish provide social sup-port to one another in many ways, particularly after a member dies.

IMPROVING ONE’S PERSONAL CONTROL

When life becomes stressful, people who lack a strong sense of personal control may stop trying, thinking, “Oh, what’s the use.” Instead of feeling that they have power and control, they feel helpless. For instance, people with a painful and disabling chronic illness may stop doing physical therapy exercises. When seriously ill patients who feel little personal control face a new severe stressor, they show more emotional distress than others who feel that they have more control (Benight et al., 1997). The main psychological help such people need is to bolster their self-efficacy and reduce their passiveness and helplessness (Smith & Wallston, 1992). A pessimistic outlook increases people’s potential for stress and can have a negative effect on their health.

How can a person’s sense of control be enhanced? The process can begin very early. Parents, teachers, and other caregivers can show a child their love and respect, provide a stimulating environment, encourage and praise the child’s accomplishments, and set reasonable standards of conduct and performance that he or she can regard as challenges, rather than threats. At the other end of the life span, nursing homes and families can allow elderly people to do things for themselves and have responsibilities, such as in cleaning, cooking, and arranging social activities. One woman described the prospect of living with her children in the following way: “I couldn’t stand to live with my children, as much as I love them, because they always want to take over my life” (Shupe, 1985, p. 191). For people with serious illnesses, health psychologists can help those with little control by training them in effective ways to cope with stress (Thompson & Kyle, 2000).

ORGANIZING ONE’S WORLD BETTER

“Where did I put my keys?” you have surely heard someone ask frantically while running late to make an appointment. People often feel stress when they see they don’t have enough time to do the tasks of the day. They need to organize their worlds to make things happen efficiently. This can take the form of keeping an appointment calendar, designating certain places for certain items, or putting materials in alphabetized file folders, for instance. Organizing one’s world reduces frustration, wasted time, and the potential for stress.

An important approach for organizing one’s time is called time management. It consists of three elements (Lakein, 1973). The first element is to set goals. These goals should be reasonable or obtainable ones, and they should include long-term goals, such as graduating college next year, and short-term ones, such as getting

good grades. The second element involves making daily to-do lists with priorities indicated, keeping the goals in mind. These lists should be composed each morning or late in the preceding day. Each list must be written—trying to keep the list in your head is unreliable and makes setting priorities difficult. The third element is to set up a schedule for the day, allocating estimated time periods to each item in the list. If an urgent new task arises during the day, the list should be adjusted to include it.

EXERCISING: LINKS TO STRESS AND HEALTH

You have probably heard from TV, radio, magazine, and newspaper reports that exercise and physical fitness can protect people from stress and its harmful effects on health. These reports cite a wide range of benefits of exercising, from increased intellectual functioning and personal control to decreased anxiety, depression, hostility, and tension. Do exercise and fitness reduce the potential for stress and its effects on health?

Correlational and retrospective studies of this question have found that people who exercise or are physically fit often report less anxiety, depression, and tension in their lives than do people who do not exercise or are less fit (Dishman, 1986; Holmes, 1993). Although these results are consistent with the view that exercise and fitness reduce stress, there are two problems in interpreting them. First, the reduction in self-reported stress and emotion may have resulted partly from a placebo effect—that is, the subjects’ expectations that psychological improvements would occur (Desharnais et al., 1993). Second, the results of correlational research do not tell us what causes what. Do exercise and fitness cause people to feel less stress? Or are people more likely to exercise and keep fit if they feel less stress and time pressures in their lives? Fortunately, there is stronger evidence for the beneficial effects of exercise and fitness on stress and health.

An experiment by Bram Goldwater and Martin Collis (1985) examined the effects of 6-week exercise programs on cardiovascular fitness and feelings of anxiety in healthy 19- to 30-year-old men who were randomly assigned to one of two groups. In one group, the men worked out 5 days a week in a vigorous fitness program, including swimming and active sports, such as soccer; the second group had a more moderate program with less demanding exercise activities. Compared with the men in the moderate program, those in the vigorous program showed greater gains in fitness and reductions in anxiety. Other experiments have shown similar beneficial effects of exercise on depression and anxiety with men and women, particularly if the programs last

at least 2 or 3 months (Phillips, Kiernan, & King, 2001; Stonerock et al., 2015).

Research has also assessed the role of exercise on stress and cardiovascular function. Although most stud-ies were correlational, finding that people who exercise or are physically fit show less reactivity to stressors and are less likely to be hypertensive than individuals who do not exercise or are less fit, some used experimental methods (Blumenthal, Sherwood et al., 2002; Dimsdale, Alpert, & Schneiderman, 1986). We’ll consider two experiments. In the first, healthy young adults who had sedentary jobs and had not regularly engaged in vigorous physical activity in the previous year were recruited (Jennings et al., 1986). During the next 4 months, these people spent 1 month at each of four levels of activity, ranging from below normal (which included 2 weeks of rest in a hospital) to much above-normal activity (daily vigorous exercise for 40 minutes). Heart rate and blood pressure were measured after each month. The much above-normal level of activity reduced heart rate by 12% and systolic and diastolic blood pressure by 8% and 10% compared with the normal sedentary activity level. Below-normal activity levels did not alter heart rate or blood pressure. In the second, researchers had undergraduates experience a stress condition and then engage in moderate exercise or sit quietly for 3 minutes (Chafin, Christenfeld, & Gerin, 2008). Measures taken soon after revealed that exercise enhanced recovery from stress: the individuals who exercised had lower blood pressure levels than those who sat.

Do exercise and fitness prevent people from devel-oping stress-related illnesses? The results of several studies suggest they do (Phillips, Kiernan, & King, 2001). For example, one study used prospective methods by first assessing the subjects’ recent life events and fitness, and then having them keep records concerning their health over the next 9 weeks (Roth & Holmes, 1985). The results revealed that individuals who reported high levels of stress had poorer subsequent health if they were not fit; stress had little impact on the health of fit subjects. Overall, the evidence is fairly strong that engaging in regular exercise can promote health by reducing stress (Edenfield & Blumenthal, 2011).

PREPARING FOR STRESSFUL EVENTS

In this and previous chapters we have discussed many types of stressful events, ranging from being stuck in traffic, to starting day care or school, being overloaded with work, going through a divorce, and experiencing a disaster. Preparing for these events can reduce the potential for stress. For instance, parents can help

prepare a child for starting day care by taking the child there in advance to see the place, meet the teacher, and play for a while (Sarafino, 1986).

Irving Janis (1958) pioneered the psychological study of the need to prepare people for stressful events, such as surgery. In general, research on preparing for surgery indicates that the higher the patients’ preoperative fear, the worse their postoperative adjustment and recovery tend to be, as reflected in the following measures (Anderson & Masur, 1983; Johnson, 1983):

The patient’s self-reported pain,

The amount of medication taken to relieve pain,

Self-reported anxiety or depression,

The length of stay in the hospital after surgery, and

Ratings by hospital staff of the patient’s recovery or adjustment.

These outcomes suggest that preparing patients to help them cope with their preoperative concerns should enhance later adjustment and recovery. The most effective methods for preparing people psychologically for the stress of surgery attempt to enhance the patients’ feelings of control (Anderson & Masur, 1983; Mathews & Ridgeway, 1984). To promote behavioral control, for example, patients learn how to reduce discomfort or promote rehabilitation through specific actions they can take, such as by doing leg exercises to improve strength or deep breathing exercises to reduce pain. For cognitive control, patients learn ways to focus their thoughts on pleasant or beneficial aspects of the surgery, rather than the unpleasant aspects. And for informational control, patients receive information about the procedures and/or sensations they will experience.

Although receiving preparatory information is usu-ally helpful, sometimes it can have the opposite effect—for instance, the Los Angeles City Council had put signs in

city elevators assuring riders that they should stay calm, since “there is little danger of the car dropping uncontrollably or running out of air.” . . . A year later the cards had to be removed because of complaints from elevator riders that the message made them anxious. (Thompson, 1981, p. 96)

Also, having too much information can be confusing and actually arouse fear. Young children often become more anxious when they receive a great deal of information about the medical procedures they will undergo (Miller & Green, 1984). With children in dental or medical settings, it is generally best not to give a lot of detail. Describing some sensory experiences to expect is especially helpful,

such as the sounds of equipment or the tingly feeling from the dental anesthetic.

In summary, we have discussed several methods that are helpful in reducing the potential for stress and, thereby, benefiting health. These methods take advantage of the stress-moderating effects of social support, social skills, personal control, exercise, being well organized, and being prepared for an impending stressor. In the next section, we consider ways to reduce the reaction to stress once it has begun.

REDUCING STRESS REACTIONS:

STRESS MANAGEMENT

People acquire coping skills through their experiences, which may involve strategies they have tried in the past or methods they have seen others use. But sometimes the skills they have learned are not adequate for a current stressor because it is so strong, novel, or unrelenting. When people cannot cope effectively, they need help in learning new and adaptive ways of managing stress. The term stress management refers to a program of behavioral and cognitive techniques that is designed to reduce psychological and physical reactions to stress (Greenberg, 2013). Sometimes people use pharmacological approaches under medical supervision to reduce emotions, such as anxiety, that accompany stress.

MEDICATION

Of the many types of drugs physicians prescribe to help patients manage stress, we will consider two: benzodiazepines and beta-blockers, both of which reduce physiological arousal and feelings of anxiety (AMA, 2003; Kring et al., 2012). Benzodiazepines, which include drugs with the trade names Valium and Xanax, activate a neurotransmitter that decreases neural transmission in the central nervous system. Beta-blockers, such as Inderal, are used to reduce anxiety and blood pressure. They block the activity stimulated by epinephrine and norepinephrine in the peripheral nervous system. Beta-blockers cause less drowsiness than benzodiazepines, probably because they act on the peripheral rather than central nervous system. Although many people use drugs for long-term control of stress and emotions, using drugs for stress should be a temporary measure. For instance, they might be used during an acute crisis, such as in the week or two following the death of a loved one, or while the patient learns new psychological methods for coping.

BEHAVIORAL AND COGNITIVE METHODS

Psychologists have developed methods they can train people to use in coping with stress. Some of these techniques focus mainly on the person’s behavior, and some emphasize the person’s thinking processes. People who use these methods usually find them helpful.

Relaxation

The opposite of arousal is relaxation—so relaxing should be a good way to reduce stress. “Perhaps so,” you say, “but when stress occurs, relaxing is easier said than done.” Actually, relaxing when under stress is not so hard to do when you know how. One way people can learn to control their feelings of tension is called progressive muscle relaxation (or just progressive relaxation), in which they focus their attention on specific muscle groups while alternately tightening and relaxing these muscles (Sarafino, 2012).

The idea of teaching people to relax their skeletal muscles to reduce psychological stress was introduced many years ago by Edmund Jacobson (1938). He found that muscle tension could be reduced much more if individuals were taught to pay attention to the sensations as they tense and relax individual groups of muscles. Although today there are various versions of the progressive muscle relaxation technique, they each outline a sequence of muscle groups for the person to follow. For example, the sequence might begin with the person relaxing the hands, then the forehead, followed by the lower face, the neck, the stomach, and, finally, the legs. For each muscle group, the person first tenses the muscles for 7–10 seconds, and then relaxes them for about 15 seconds, paying attention to how the muscles feel. This is usually repeated for the same muscle group two or three times in a relaxation session, which generally lasts 20 or 30 minutes. The tensing action is mainly important while the person is being trained, and can be eliminated after he or she has mastered the technique (Sarafino, 2012). Relaxation works best in a quiet, nondistracting setting with the person lying down or sitting on comfortable furniture.

Stress management is applied mainly with adults, but children also experience stress without being able to cope effectively. Fortunately, many behavioral and cognitive methods are easy to learn and can be adapted so that an adult can teach a young child to use them (Siegel & Peterson, 1980). Relaxation exercises provide a good example. An adult could start by showing the child what relaxing is like by lifting and then releasing the arms and legs of a rag doll, allowing them to fall

down. Then, the adult would follow a protocol, or script, giving instructions like those in Table 5.2. When children and adults first learn progressive muscle relaxation, they sometimes don’t relax their muscles when told to do so. Instead of letting their arms and legs fall down, they move them down. They may also tense more muscles than required—for example, tightening facial muscles when they are asked to tense hand muscles. These errors should be pointed out and corrected.

Often, after individuals have thoroughly mastered the relaxation procedure, they can gradually shorten the procedure so they can apply a very quick version in times of stress, such as when they are about to give a speech (Sarafino, 2011). This quick version might have the following steps: (1) taking a deep breath, and letting it out; (2) saying to oneself, “Relax, feel nice and calm”; and

thinking about a pleasant thought for a few seconds. In this way, relaxation methods can be directly applied to help people cope with everyday stressful events.

Research has demonstrated that progressive muscle relaxation is highly effective in reducing stress (Carlson & Hoyle, 1993; Jain et al., 2007; Lichstein, 1988). What’s more, people who receive training in relaxation show less cardiovascular reactivity to stressors and stronger immune function (Lucini et al., 1997; Sherman et al., 1997).

Table 5.2 Progressive Muscle Relaxation Protocol for Children