Psychology of stress Reflection

2

The goal of reflective writing is to realize personal growth. In this assignment you will pursue this goal, interacting with and integrating the information introduced in the course and applying it to your existing experiences.

The  Reflection Paper supports the three learning outcomes for the course:

· analyze symptoms and causes of stress in a variety of subjects and contexts, such as individuals, communities, and organizations, for a comprehensive ethical approach to the management of stress

· formulate decisions using knowledge of biological, psychological, and sociocultural consequences of stress

· apply and evaluate stress management techniques and technologies to enable self and others to remediate stressful life situations

Objective:   Write a  4 to 5-page personal Reflection Paper that communicates how specific topics, theories, and research findings covered in the course 1) shape your understanding of psychology of stress; and 2) connect to your current knowledge, experiences, and areas of interest.

Instructions Summary:  The following guidance lists the key steps for the Reflection Paper.

1. Review the topics we have covered in class, to include those covered during the week this assignment is due.

2. Choose two to three* psychology of stress topics, theories, or research studies covered within the applicable week’s content.

3. Reflect and identify personal relevance of the selected subjects.

4. Write and submit for grading a well composed, 4 to 5-page APA style formatted Reflection Paper.

*This is a minimum target, not a finite value.  To maximize the benefits of this assignment, focus on a range of subjects that capture your attention. It is appropriate to discuss and integrate related topics. Details extracted from course Learning Resources, and research findings pulled from peer-reviewed articles, can create topic depth and breadth.  Related points, when constructively used to compare, contrast, and synthesized your understanding, builds out a thoughtfully elaborated presentation on the topic.

Requirements:  The requirements for the Reflection Paper include:

Submit a single document that reflects upon how specific topics, theories, and research findings covered in the course 1) shape your understanding of the psychology of stress; and, 2) connect to your current knowledge, experiences, and areas of interest.

Within the document…

a. Introduce . Concisely introduced the reader to clearly defined topics addressed in the paper. Anchor the paper through a well-constructed thesis statement.

b. Have purpose.   Dedicate discussion and analysis to two-three (minimum*) focal topics within the body of the paper. All topics are to be discussed in clear detail.

c. Synthesize.   Demonstrate synthesis of each topic with your current understanding of, or experiences with, the topic. Support assertions made.

d. Connect.   Identify personal opportunities for application (private, professional, public contexts). Express interrelated ideas coherently and logically.

e. Use Authorial Voice.    Discuss materials in your own words and your own writing style and structure. Avoid excessive use of direct quotes. Doing so may incur a point penalty for each occurrence and will not be accepted as content towards the page count of the reflection paper.

f. Apply APA Style **.  Neatly and concisely present a 4 to 5-page APA formatted document containing

· Title Page

· Introduction

· Body (with heading levels applied when appropriate)

· Conclusions

· References Page

· Properly formatted in-text citations and references

 

*Remember this is a minimum, not a restrictive, fixed target.  See note under Instructions.

**Use APA style  headings and subheadings, double-spacing, an appropriate  serif or sans serif font  (e.g., Times Roman 12-point; Arial 11-point; Calibri 11-point), one-inch margins (left, right, top, and bottom), page numbering, and logical flow from topic to topic.  Write with clarity, paying attention to spelling, grammar, and syntax.

Materials, psychology of stress topics. HERE- 1- Nature of Stressor

2- Appraisals, Coping, and Well-Being

TOPIC 1- NATURE OF STRESSOR WEEK1

This chapter will introduce you to some basic definitions and concepts, with the goal of acquainting you with some of the key variables that influence or determine the impact of stressful events. This will entail:

· a description of what a stressor comprises, and that stressors come in various forms. These include challenges that are of a purely psychological nature, those that have direct physical effects, and those that cause a dysregulation of internal processes, but nonetheless act as stressors, even if we aren't consciously aware of them;

· analyses of the attributes of a stressor that result in it having greater or lesser effects. In this regard, we will discuss the contribution of the stressor's severity, controllability, predictability, uncertainty, ambiguity, and chronicity;

· how stressors are assessed in a laboratory context or in community samples, including analyses of those stressors that appear as nothing more than minor inconveniences, and stressors that represent major life events, as well as traumatic experiences that are endured;

· the individual factors that influence vulnerability to the effects of stressors as well as variables that imbue us with resilience so that we can overcome the potential adverse consequences of stressful experiences. To this end, we'll consider the individual and interactive influences of genetic, environmental, experience-related, personality variables, early experiences, and age-related factors on well-being.

Some Basic Definitions and Concepts

It's a good idea to begin by defining some key terms so that we're all on the same page. For starters, what do we mean when we use the terms ‘stress’ and ‘stressor’? This sounds fairly mundane, doesn't it? Nevertheless, just humor me, and assume that differentiation of these terms might be useful. A ‘stressor’ is a stimulus or event that is appraised or perceived as being aversive and causes a ‘stress response’ that comprises a series of behavioral, emotional, and biological changes aimed at maintaining an organism's well-being. Among other things, these stress responses involve biological changes that occur so that energy resources are directed towards the places they are needed, and away from processes that are not essential at the moment (e.g., reproduction, eating, digestion). Simultaneously, multiple brain regions are activated to help us appraise and then deal with the stressful event.

So what exactly are these stressors? In fact, there is no easy definition of ‘stressor', since appraisals of events may vary with contextual factors and change yet again over time, and they are also interpreted differently across individuals. In response to a similar definitional problem of pornography, US Supreme Court Justice Potter Stewart famously observed ‘I can't define it, but I know it when I see it’ (Jacobellis vs. Ohio, 1964). In much the same way, what constitutes a stressor may be highly subjective, and it needs to be acknowledged that individual differences that exist can be fairly pronounced. In effect, one person's poison is another person's meat.

There is enormous variability regarding the degree to which stressors can affect different people. Events or stimuli that are stressful to one individual might not be similarly appraised by a second individual. For example, jumping out of a plane (with a parachute, of course) might be exciting for some individuals, whereas it might be exceptionally distressing for others. Even if two individuals appraise a stressor similarly, they might display different emotional reactions. As well, even if their emotional reactions were the same, they might display different methods of coping with the stressor. Finally, the fact that individuals’ appraisals, coping, and emotional responses are comparable does not mean that their biological responses will necessarily be the same, and hence different psychological outcomes (including pathologies) might evolve over time. These individual differences in stress responses might come about as a result of several factors, some of which are listed in Table 1.1. We'll go through each of these systematically, and revisit them in ensuing chapters, as they have important implications for the development of stressor-induced biological and pathological outcomes. Obviously, assessing the link between stressor encounters and the emergence of psychological or physical disturbances isn't easy, but the progress that has been made is significant and has resulted in the development of several effective strategies for preventing illness and treating pathology once it has emerged.

Characterizing Stressors

Even at this very early point you've learned something important about stressors. First, not all stressors have the same impact, and second, individuals differ remarkably with respect to how they appraise stressful events and how they respond to them. You've also learned that there are multiple factors responsible for these individual differences. Some of these differences might be related to the stressor, whereas others might be related to characteristics of the individual and their varied experiences. We'll now move to a more detailed analysis concerning why we respond to certain stressors as we do, beginning with a discussion of their features.

Types of Stressors

Stressors generally come in multiple flavors, and we'll start by distinguishing between these as they don't necessarily result in identical outcomes. A stressor that involves information processing (e.g., asking ourselves ‘Is that dog drooling and does that glare and posture mean it's dangerous?', or ‘Does this guy with the mask covering his face seem like a mugger?') is referred to as a processive stressor. Understanding the threat (stressor) involves several complex cognitive processes that engage numerous brain regions. These include neural circuits responsible for executive functioning that involves appraisal and decision making (e.g., frontal cortex; anterior cingulate cortex), memory processes (e.g., hippocampus and several cortical brain regions), and those involved in anxiety and/or fear responses (e.g., prefrontal cortex, amygdala, and hippocampus). Broadly speaking, processive stressors can be of a purely psychological (psychogenic) nature, or of a physical nature (termed ‘neurogenic’ stressors), such as those associated with certain illnesses or painful stimuli (e.g., burns). Not surprisingly, psychogenic and neurogenic stressors may elicit similar outcomes in some respects, but as we will see, they can also have several very different consequences.

Another type of challenge, referred to as a ‘systemic’ stressor, does not involve the same type of information processing, as it entails an insult to our biological systems. Systemic challenges include, but are not limited to, marked changes of glucose concentrations in our blood (as occur in diabetes), the presence of inflammation or the production of certain proteins evoked by inflammation (as occurs with heart problems), and numerous other biological changes. In these instances, we might not be processing the information with the question ‘Is this a threat to my well-being?', as we do when confronted by some processive stressors, but our body might be interpreting these challenges as threats, and sending messages to the brain so that certain actions are taken to meet the immediate needs. For instance, the pain associated with a broken bone (a processive stressor) might make us more cautious and protective of the injured area, and thus will increase the likelihood that it will heal without being perturbed. Likewise, the fatigue and achiness associated with influenza (a systemic stressor) pushes us into bed so that we can rest and thus recuperate more readily. The behavioral changes that occur in response to processive or systemic insults involve the integration of several biological and cognitive systems. It seems that multidirectional communication occurs between various facets of our brain, peripheral nervous system, hormonal systems and the immune system so that coordinated responses occur.

Psychogenic Stressors

Different types of stressors (psychogenic vs neurogenic vs systemic) do not necessarily lead to identical outcomes. For example, in rodents, a purely psychogenic stressor, such as being exposed to predator odors, gives rise to neurochemical changes within the brain (e.g., the release of chemicals from brain neurons) that are different in several respects from those elicited by a neurogenic stressor (a painful stimulus). In fact, even among psychogenic stressors, marked differences occur as a function of the specific stressor encountered. Those psychological stressors that reflect innate challenges (e.g., predator odors) instigate neurobiological changes that are distinguishable from those elicited by conditioned or learned stressors, such as cues that had previously been associated with a neurogenic stressor. In light of the specific neural circuits activated by these stressful events, it might be expected that they would also be associated with the emergence of different behavioral outputs or even pathophysiological processes, and might require different strategies to attenuate the negative reactions that might occur.

At one time scientists had thought that we had a ‘stress center’ in our brain, just as it was mistakenly thought that there was a ‘pleasure center'. The neural circuitry associated with stressors is much more complex; we do not have ‘a’ stress system, but instead there appear to be multiple pathways that respond preferentially to different types of stressors (Merali et al., 2004). When we examine these systems from a perspective relevant to humans, their importance takes on more tangible meaning and significance. For example, some stress responses reflect outcomes associated with something that has already happened (the loss of a loved one, a business failure, a hurricane, or being ostracized by your friends), and not surprisingly, these stressors might be associated with different psychological outcomes.

One can intuitively appreciate that certain conditions, particularly those that involve interpersonal events (e.g., the death of a loved one), might favor certain types of responses and lead to depression, but these processes might be distinct from those involving adverse achievement-related events (work-related stress), although these too can favor depressive affect (Mazure et al., 2000). Moreover, gender differences appear to exist with respect to the types of stressors that lead to pathological outcomes. In this regard, it has been suggested that psychosocial stressors may have more dramatic effects in females than in males, whereas those related to job strain/competition may have more profound effects in males (Kendler et al., 2001; Mazure et al., 2000). Other stress responses, especially those that are of an anticipatory nature (e.g., imminent surgery, anticipation of an upcoming exam or public speaking, taking a plane flight if you have a plane phobia, an imminent tax audit, the chance of seeing the bully in the schoolyard), are likely to be accompanied by anxiety (Harkness, 2008). Still other types of stressors, notably those that are ambiguous in nature (e.g., the ‘possibility’ of a terrorist attack, or a pilot announcing that ‘we have to return to the airport’ without further explanation) might be accompanied by disorganized cognitions while the situation plays out.

Some stressors involve an evaluative component (e.g., public speaking or asking questions in class, activities in front of an audience, a job interview), a social component (e.g., a fight with your best friend), one that involves a degree of embarrassment (e.g., certain visits to the doctor if you're a 50+ year-old male), and some that instigate particularly aversive emotional responses (e.g., shame, humiliation). Some psychological stressors may have profound effects, but their actions are fairly transient, whereas others may be remarkably powerful, so much so that they can have life-long effects (Robinaugh & McNally, 2010).

Neurogenic Stressors

Physical stressors can be brief (stubbing your toe), moderate in duration (e.g., a slight burn, a back strain, or a slightly sprained ankle), they can be persistent (e.g., rheumatoid arthritis, sustained or recurrent migraine headaches), or they can be both persistent and severe (severe burns, injuries sustained from accidents, or the pain associated with certain diseases such as cancer). There's little question that the more intense stressors call upon an incredible portion of a person's psychological and physiological resources. As well, these neurogenic stressors typically don't appear in isolation from psychogenic stressors. Whether these entail financial difficulties brought about owing to physical illness, repeated trips to doctors or hospitals, having to rely on others when one would prefer not to, or the anticipation that the distress will continue, it seems that complex multidimensional processes are often at work. As a result, diverse psychological processes might be necessary to cope with these multipronged insults. Often, our abilities may simply be insufficient to deal with events, and external mechanisms that enable us to withstand these challenges (e.g., our social support resources) may become essential.

Systemic Stressors

Psychogenic and neurogenic stressors are all in some sense tangible (i.e., we can see or feel them), but we can encounter stressors that we might not be conscious of, and hence we might not be aware that we are experiencing any strain. Thus, we typically wouldn't think of them as stressors. Nevertheless, it has been suggested that challenges, such as immune activation, should be considered as stressors given that they elicit a cascade of biological changes that in many ways are akin to those associated with psychogenic and neurogenic insults. Among other things, systemic stressors may affect our neuroendocrine functioning, our brain neurochemical processes, and elicit several depression-like behavioral changes (Anisman & Merali, 1999). However, because we might be unaware that something is happening in our body that might adversely affect us (certainly this is the case soon after infection), there is seemingly no opportunity to take steps that might facilitate coping with the challenge. From this perspective, systemic stressors reflect silent, insidious attackers that can have negative repercussions for well-being beyond their potential direct effects. We'll be dealing with this in considerable detail later (see Chapter 5), but for the moment just keep in mind that stressors aren't always obvious, but may nevertheless have pernicious repercussions.

Stressor Characteristics

Every stressor that we encounter may have unique elements about it and thus may have very different repercussions. By example, let's consider one broad stressor category, that of being ill, and examine the various elements that make up this type of challenge. An illness can be a brief one (a bad case of the flu, or appendicitis requiring surgery), or one that is less intense, but can still wreak havoc on a person's general well-being owing to the fact that the condition lasts for some time, and there are some illnesses that are chronic and/or progressive (gets worse over time). Some illnesses might allow individuals to function more or less normally despite the symptoms being exceptionally disturbing (e.g., tinnitus), whereas in other instances (e.g., arthritis, lupus erythematosus, Parkinson's disease) the features of the illness might interfere with multiple aspects of daily life. There are also illnesses, such as Type 2 diabetes, that necessitate changes in lifestyle, and can have drastic long-term implications for further diseases, but early on might have few discernible negative effects. Worst of all, for the patient and the family members, are disturbances that rob you of yourself (Alzheimer's Disease), illnesses that might or might not lead to death (cancer, heart disease, HIV), or those that are physically incapacitating (e.g., ALS, paralysis). Some illnesses ‘just show up’ without any apparent cause, whereas others occur as a result of traumatic events (a head injury, paralysis) stemming from one's own behaviors (engaging in certain sports), those of others (drunk or incompetent drivers), or acts of nature (flood, hurricane, earthquake). In each instance the illness trajectory may vary over months and years, and the needs of the affected individuals might differ accordingly. The psychological aspects related to the illness, the attributions regarding the cause of the illness, as well as the extent to which the illness allows the engagement of effective coping, differs with the individual's condition.

Severity

Because each stressor we encounter might have numerous unique characteristics, it is difficult to compare whether one stressor is more severe than another. This is made still more difficult as our perception of stressors may be influenced by the context in which they occur and may vary over time. Furthermore, there are stressors that simply can't be compared to one another in terms of their relative severity (e.g., the death of a child vs dealing with a severe incapacitating illness) as they are on entirely different dimensions, and are often so severe that comparisons become meaningless. Nevertheless, most people would agree that certain stressors are more profound than others (e.g., the loss of a loved one vs getting a parking ticket), and thus most of us could guess that some stressors are apt to have greater pathophysiological consequences than others.

Controllability

The notion that control over one's destiny is important in determining psychological health has been around for a long time. The classic studies in the 1950s by Brady (1958) indicated that a monkey that was responsible for making certain responses in order to avoid an aversive stimulus developed ulcers more readily than a monkey that received an identical amount of unpleasant stimulation over which it had no control. Termed the Executive Monkey Studies, this research suggested that having control (and responsibility) was a daunting stressor that could lead to stress-related pathology. These studies had obvious implications for business leaders and they became an important talking point for psychologists working with executives in large organizations, essentially telling them that being an executive has its hardships. In essence, being in control also means being responsible, and with this comes considerable psychological strain that could lead to pathological outcomes. This view held considerable intuitive appeal, but later studies contradicted these findings, and it is now commonly accepted that having control over both stressor occurrence and its termination is psychologically and physically advantageous.

Nasty Little Creatures

For some time it was thought that ulcers arose as a result of stressful experiences. However, it seems that the bacterium Helicobacter pylori is responsible for ulcers (Marshall & Warren, 1984), and in recent scientific discussions the contribution of stressful experiences has taken a back seat. Nevertheless, it does appear that stressors may affect gastrointestinal ulcers, and that stressful events and Helicobacter pylori may act synergistically to promote ulceration.

For their work in identifying Helicobacter pylori as the main culprit responsible for peptic ulcer disease, Marshall and Warren received the Nobel Prize in Physiology or Medicine (2005). To make the point concerning their hypothesis, which most scientists had dismissed, Marshall drank a brew of Helicobacter pylori to demonstrate that this bacterium would, indeed, cause ulcers. It would, after all, have been tough to get experimental participants for this study or even to get the study through an ethics review panel.

Experiments conducted almost a decade after the Brady studies, using a similar paradigm, documented one of the best-known phenomena in stress research. In particular, these studies demonstrated a phenomenon known as the ‘learned helplessness’ effect, whereby stressors over which the animal had no control provoked marked behavioral impairments in animals. It was shown that animals exposed to an escapable stressor (a shock to their feet), or that had not been stressed at all, subsequently displayed proficient performance in a test where they were required to escape from a stressor. However, animals that had been exposed to an uncontrollable stressor (a footshock that they could not escape) later exhibited profound behavioral impairments in an escape test where an active response would have terminated the footshock stressor. In these studies, the animal in the ‘uncontrollable’ stressor condition received the stressor at exactly the same time and for the same duration as the animal in the escapable shock condition. However, unlike the animals that were exposed to an escapable stressor, those in the uncontrollable condition were unable to control stressor termination. Instead, stressor offset occurred whenever animals in the escape condition made an appropriate response. Thus, animals received the same duration of the stressor, but differed with respect to the psychological dimension of having control over the stressor termination (this is referred to as a ‘yoked’ paradigm). As only animals in the uncontrollable condition later showed impaired performance, it was concluded that it was not the stressor itself that was responsible for the behavioral impairments. Rather, it was the animal's inability to exert control over stressor termination that was crucial in determining whether or not the adverse effects of the treatment would become apparent (Seligman & Maier, 1967).

In describing the results of these experiments, it was indicated that those animals who confronted an uncontrollable stressor subsequently did not make overt attempts to avoid or escape the footshock, even though they could now escape if they made a simple response of moving from one side of the test chamber to the other. Instead, they seemed to passively accept the stressor. Indeed, when an animal made an occasional escape response, this was not predictive of further escape attempts. The investigators suggested that these animals had learned to become helpless. Cognitive processes were thought to occur whereby they learned that their responses were unrelated to outcomes (‘nothing I do matters’), and as they had no control over the situation they stopped trying to escape. Indeed, if animals were initially trained to make an appropriate response and then exposed to the uncontrollable situation, they did not display behavioral disturbances when subsequently exposed to a controllable stressor. These animals, having first learned that they control their destiny, were essentially immunized against the effects of the uncontrollable stressor.

The behavioral disturbances elicited by uncontrollable stressors have been seen across a variety of species, but in rodents it is typically seen only in certain situations. It seems that when the stressor is administered to rodents, the high degree of reactivity that is elicited favors an appropriate escape response being emitted (i.e., running from one chamber in which the stressor is administered to an adjacent ‘safe’ chamber) and thus potential behavioral deficits are obfuscated. Eventually, it was observed that if the response required of the animal to escape entailed a motor response that was relatively difficult to accomplish or where an active response had to be maintained for several seconds before successful escape was possible, then performance deficits could be elicited. Such findings gave rise to the suggestion that performance disruption was not a reflection of a cognitive disturbance, such as helplessness, but instead stemmed from brain biochemical changes that hindered the rodents’ ability to maintain prolonged or complex active responses (Anisman et al., 1978; Glazer & Weiss, 1976).

Failure experiences in humans may have effects vaguely reminiscent of those associated with uncontrollable stressors in animals. For instance, university students exposed to unsolvable problems subsequently displayed impaired performance in a problem-solving task, as did depressed students who had not been exposed to the unsolvable task. Although these outcomes have often been attributed to learned helplessness, there are other explanations that might have little to do with helplessness. For instance, there might be a mismatch between the participant's expectancy regarding their performance, and their failure to meet this expectancy might have induced frustration that was responsible for the subsequent impaired performance. These differing positions notwithstanding, since these early studies, much has been made of the importance of stressor controllability in determining later psychological and physical disturbances.

Stressor Predictability, Uncertainty, Ambiguity, and Black Swans

The impact of stressors on psychological and physical well-being is influenced by their predictability, uncertainty, and ambiguity. There are occasions on which the occurrence of stressors is very predictable, but there are also those where stressors are entirely unpredictable, and our responses in these situations are likely to be quite different. Who among us would have predicted 9/11, or that an earthquake or tsunami would hit a particular region, causing the deaths of thousands upon thousands? In contrast, tax time is a stressor, particularly for accountants or those who owe the government a lot of money, and its occurrence is predictable (the behavior of governments may not always be predictable, but you can count on them being systematic when it comes to taxes).

Uncertainty is related to unpredictability, but they can be distinguished from one another. We all will die eventually (that is a certainty), but when this will happen is often unpredictable. Essentially, when we talk about predictability, it is usually in the context of events that will happen; it is simply a matter of knowing when they might happen, whether there will be a warning of their occurrence, and on what schedule they might occur (e.g., a single event, repeated events, events that occur intermittently). Uncertainty, in contrast, deals with events that might or might not occur (e.g., it is uncertain whether this new flu virus will end up as a pandemic). When there is uncertainty about the occurrence of a stressor, individuals may take on a cavalier attitude that essentially comprises ‘whatever happens, happens’. Others, however, seem to have great difficulty dealing with uncertain situations, and for these individuals their stress reactions could potentially be pathogenic.

Another similar construct is that of ambiguity. We say that a situation is ambiguous when the stimulus context does not provide sufficient information, or provides multiple but inconsistent bits of information, so that it becomes difficult to determine whether and when the event might occur. By example, ambiguity exists when one has a set of symptoms, but they do not form a coherent pattern that allows for a firm diagnosis. Likewise, when government agencies are trying to determine the imminence of a terrorist attack they might encounter a set of stimuli that suggests that something is up (e.g., increased internet chatter, certain individuals or groups have suddenly dropped off the grid), but otherwise things seem much the same as they usually are. The situation here is thus an ambiguous one.

An old proverb has it that ‘ mann tracht unt got lacht’, literally translated as ‘man thinks (plans) and god laughs’. On a daily basis, most individuals typically behave as if the events in their lives are predictable and that they can reasonably anticipate what the future holds for them, and that they even have some control over their lives. Even though most of us know that this sense of control is an illusion, many of us operate as if we have some say regarding what happens to us: we have expectations for the future, and planning is viewed as necessary given our apparent need for order and predictability. Thus, it shouldn't be surprising that adverse events that are unpredictable are generally viewed as being more unpleasant than predictable events (Baker & Stephenson, 2000), and are more likely to be associated with disturbed brain neuronal functioning, the excessive activation of some stress hormones, and altered immune functioning (Pitman et al., 1995).

So, what is it about the unpredictability and uncertainty regarding bad events that makes them so aversive? What differentiates the aversiveness of predictable vs unpredictable events is, to a significant extent, related to the anticipatory period. When we know that an event will happen at a particular time, there may be great anxiety about the impending event, and waiting itself, coupled with the probability of events occurring during specified periods, may be stressful (Osuna, 1985). Yet knowing that the event will or is about to happen gives us the opportunity to prepare or adjust our behaviors and expectancies. Unpredictable events, however, don't allow us to prepare in a similar manner, and we may be on edge for extended periods of time. Most people are familiar with the first part of Franklin D. Roosevelt's statement in relation to the Great Depression, but less familiar with the second part; ‘the only thing we have to fear is fear itself – nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance’. This very well describes the response to unpredictable, ambiguous, but potentially very stressful situations: irrational, inappropriate and immobilizing behaviors that reflect our inability to appraise and cope with situations, so that our ability to strategize becomes entirely ineffective.

As with unpredictability, in most situations uncertainty is also seen as being more aversive than is certainty. However, there are instances where this isn't the case. For instance, some people who are at risk for a genetic disorder, such as Huntington's Disease, want to know whether they carry the gene for this illness, and hence will invariably be affected. These individuals don't want to live in suspense, essentially with a sword hanging over their heads, and choose to know whether or not they carry the gene. Others, however, would rather not know and appear to be able to vanquish their thoughts so that their daily routine is not affected. It seems that individuals differ in their intolerance for uncertainty. The level of uncertainty that can be tolerated is a trait that individuals bring into situations that involve an ambiguous or uncertain component (Rosen et al., 2007). High intolerance for uncertainty has been found to exacerbate the anxiety associated with daily stressors, and increased intolerance for uncertainty, as well as the desire to reduce uncertainty, was found to predict increased information seeking (Rosen et al., 2007), which could potentially increase the adverse effects of stressors. Unpredictable events obviously have the potential for turning our lives upside down. The death of loved ones, sudden illness, catastrophic natural disasters, are all events that we know are possibilities, but we really don't expect them to happen to us. Yet the probability of dying of heart disease is about 34% and that of cancer is about 16–17% (although survival rates have been increasing for several cancers), Type II diabetes occurs in about 3.5% of individuals and is climbing, autoimmune disorders occur at 3.1%, and then there's kidney, pancreatic or liver disease, and serious automobile accidents that lead to severe disability or death at a rate of about 1.7% each year. There is also a chance of being hit by lightning or a brick falling off a building and onto your head (events that are admittedly rare), or the possibility of being in a plane crash (although for the people on the plane or the person hit by the brick, such probabilities simply don't count). The point of all of this is simple. We might not know how we'll fare in the future, but given the number of bad things that can happen to us, and the additive probabilities of these events, we can pretty much count on not getting away untouched. We don't know whether, how, or when we'll encounter these nightmares, but it's almost a certainty that we'll encounter some bad dreams.

Uncertainty and ambiguity are frequent in our experiences and they are known to promote anxiety. For example, consider what your own reactions to symptoms of an illness might be (e.g., ‘Is this lump I feel something I should worry about?’ ‘This feeling in my chest seems like indigestion, but it might also be a heart attack. What do I do now?’). This, in turn, might lead to further uncertainties pertaining to the illness and its prognosis (‘What are the odds that the treatment will work?’), and the availability of a competent and experienced medical practitioner (‘Does this doctor have the experience and skill that will be needed?’).

From what has been said to this point, it's fairly clear that unpredictability, uncertainty and ambiguity can be exceedingly stressful. But there is also a different spin that has been applied regarding the role uncertainty might play in the context of serious illnesses (Mishel, 1999). From this perspective uncertainty involves two distinct appraisal processes, namely inference and illusion. If uncertainty exists, then individuals can reconstrue a largely negative situation (inference) to extract a glimmer of hope despite the odds (illusion). Because uncertain situations are vague and changeable, in the context of events that are spiraling downward (e.g., when all treatment efforts to stall the progress of a cancer have failed), individuals can capitalize on uncertainty so that their appraisals take on a positive hue, no matter how limited this might be. Uncertainty, essentially, allows a person to expect the worst, but still hope for the best.

Dumbass Gamblers

It seems that for many of us, there is a need to maintain a semblance of control over our own destinies. Even when a situation is entirely unpredictable and individuals have absolutely no control over the outcome, those who are self-assured are more likely to choose to exercise their own judgment in determining that outcome, despite this semblance of control being illusory. The fact is that when situations are unpredictable and where outcomes are entirely out of our control, our participation in decision making (e.g., how to treat an illness) is not that far removed from that of engaging in a game of chance (gambling).

We see this desire or need for control across various domains. For example, when given the opportunity to play a game of chance (say roulette) where individuals either have absolutely no control over outcomes, or are allowed to ‘pay’ a premium to press a button to stop the wheel (in this instance they have a semblance of control insofar as the wheel will stop, but they have no control with respect to where the ball lands), they will more often pick the latter. Similarly, when people buy lottery tickets, they will often prefer to choose their own numbers rather than have a series of numbers generated through a computer (as if they have a divine connection with the odds maker in the sky, which the computer, of course, doesn't). It also seems that some people feel that they (or others) are endowed with a trait characteristic of being lucky (‘I'm a lucky person’, as opposed to ‘This was my lucky day’), and so might get involved in events that involve high risk (e.g., gambling), which they believe doesn't apply to them since they are, after all, lucky. If that isn't dopey enough, there are others who develop an ‘illusion of control by proxy’ wherein they find a ‘lucky person’ to buy their lottery tickets for them (Wohl & Enzle, 2009). One wonders whether stock market players, at least to some extent, are affected by some of these characteristics.

I was recently introduced to the ‘Black Swan theory’ advanced by Taleb (2007) to explain irrational behaviors that people often endorse in the context of making decisions. The implications of this perspective for the stress field are enormous, and so I figured it should be brought up fairly early in this volume. Essentially, from Taleb's position there are events that occur very infrequently and are essentially unpredictable, have a major impact on the individual (or society, or the economy), and often have people rationalizing, in hindsight, that the event might have been predictable if only the right data had been available. For instance, could we have predicted 9/11 and the ensuing stock market debacle, or in Japan the earthquake and resulting tsunami and the potential for a nuclear meltdown? Probably not, but it can be argued that even though any single event is an outlier (a black swan), there are so many possible things that could go wrong, one or more of these will eventually occur. Black swans don't simply refer to ‘major’ events like a 9/11, a crash in the housing market, or the possibility of another war breaking out somewhere (the latter aren't really black swans, but more like albino squirrels, which I've seen several times). There are individual tragedies that can also occur, such as being diagnosed with a rare disease, sitting at lunch and having part of a building suddenly collapse with you as collateral damage, or a piece of space junk reentering the atmosphere and taking direct aim at your house. We can't know what will befall us, as there are simply too many ‘unknown unknowns'; so many that the odds of dodging all of them are slight. However, they can and do occur, and their ramifications can be enormous.

The Brain's Response to Knowing and the Unknowable

Given that we often find ourselves in situations where the information available is ambiguous and making decisions entails a degree of risk (e.g., the behavior of stock markets), there has been increasing interest in determining which brain regions might be engaged for decision making under such conditions. For instance, which brain regions are activated under conditions that involve risk (i.e., where the outcome probabilities are known), ambiguity (a situation where there is a lack information about outcome probabilities), or ignorance (a condition wherein the outcomes were completely unknown and even unknowable)? It was observed that relative to the risk situation, ambiguous information provoked a greater activation of certain brain regions (inferior frontal gyrus and posterior parietal cortex), and this same outcome was apparent when participants were presented with non-useful information (the ignorance context) (Bach et al., 2009). Perhaps these regions are activated in an effort to make sense of this situation. It might simply be the case that the brain doesn't like uncertainty and tries to set things in order. It has been suggested that the individual differences observed in these situations might be related to differences in intolerance for uncertainty, and it is important to consider this variable in assessing neural systems that are involved in the decision-making process.

Chronicity

There are stressors that, unfortunately, must be endured on a chronic basis: these can be psychosocial or family-related issues, financial impositions, health problems, discrimination or stigma, or a combination of different factors. When stressors are chronic and occur on a predictable basis, we are often able to adapt and perhaps even take charge of our situation. Studies of animals suggested that the neurochemical changes that occur in response to acute stressors will diminish with chronic predictable, invariable stressor experiences (stressors that are chronic but don't change are termed ‘homotypic’ stressors). Sometimes, however, the stressors we experience might be chronic, intermittent, unpredictable, ambiguous and uncontrollable, and vary across days (the latter are referred to as ‘heterotypic’ stressors), making it difficult to establish adequate coping methods, or even to take preparatory steps to enable effective coping. Under such conditions, the usual adaptation that occurs in response to homotypic stressors might be less likely to develop (Anisman et al., 2008). Thus persistent stressors, such as acting as a caretaker (e.g., for a parent with Alzheimer's or a child with exceptional needs), or dealing with chronic illness or financial problems, each of which involves multiple challenges that might change from day-to-day, might strain our ability to cope effectively and lead to psychological or physical disturbances.

Chronic unpredictable stressors needn't be severe in order to elicit pathophysiological outcomes. Several studies in animals showed that a regimen that comprised a series of mild uncontrollable stressors was effective in this regard (Willner et al., 1992), although this outcome was not universally observed, tending to appear more readily with somewhat stronger stressors. The chronic mild stress model, perhaps because it has a degree of intuitive appeal (i.e., it ‘sounds’ right), has received wide recognition and attention, but it seems the effects of stressor treatments depend on a number of other factors, such as the individual's previous stressor experiences, the way stressors are appraised, and the coping methods used.

Allostatic Overload

In recent years, the concepts of stasis and allostatic overload have evolved to explain the impact of severe or chronic stressors. Under normal conditions biological changes occur to meet the ebb and flow of environmental demands, thus maintaining stability within the organism. This essentially describes homeostasis. In response to strong or sudden stressful challenges, and to severe chronic events, greater and more rapid biological changes are instigated to restore and maintain stability, and we refer to this as allostasis (Sterling & Eyer, 1988). As adaptable as humans and animals might be, when a strain on the system is excessive, our adaptive biological systems might eventually become overly taxed, resulting in allostatic overload. Under these conditions the organism may become ill or more vulnerable to the negative impact of new stressors that might be encountered (McEwen, 2000; Schulkin, 2003).

In addition, allostatic overload may occur through a more insidious process. In particular, ‘Type 2’ allostatic overload occurs as a result of social conflict or other forms of social disturbances. These threats do not necessarily elicit strong coping responses as do severe or traumatic stressors, but over time their toll might become enormous, unless measures are taken to modify the social structure that imposes itself adversely on the individual (McEwen & Wingfield, 2003). This is especially the case as the social challenges that affect us (e.g., in the workplace) might be insidious, essentially creeping up on us without our conscious awareness.

Measuring Stressors

We all seem to know what we mean by a stressor, but for experimental purposes we need to be able to distinguish between different types of stressors and how intense these stressors are perceived to be. Later, we'll be discussing individual differences in how stressors are appraised and perceived, but for the moment we'll examine how stressor experiences are measured, and a few of the limitations of these procedures.

Major Life Events

Stressful events are known to promote psychological disturbances, and severe stressors are more likely to do so than are relatively mild stressors. In an effort to analyze the impact of stressors, several variants of major life events scales have been developed, which have been used to predict the relations between stressors and the occurrence of illness or disturbed quality of life. One approach was based on the notion that a stressor ought to be considered in terms of the social adjustment that is required to deal with it (e.g., the Social Readjustment Scale: Holmes & Rahe, 1967). Others simply focus on major life stressors that had been encountered over a set period of time (e.g., six months or one year), basing their severity on responses from a normative group of participants (Paykel et al., 1971). Other questionnaires are available that focus on particular types of events, such as traumatic experiences that might have occurred at some specific time over the course of the life span (e.g., the Traumatic Life Events Questionnaire; Kubany et al., 2000), or particular stress-related pathological conditions, such as posttraumatic stress disorder (PTSD; Weiss & Marmar, 1997). There are also scales that deal with specific types of events ranging from psychological abuse to breast cancer and other types of challenges.

These scales share certain essential attributes (they do, after all, give us an idea of what an individual has experienced), but they also share several deficiencies. First, an evaluation of the distress experienced by an individual over some set period of time is often based on scaled scores. For instance, in the Social Readjustment Scale, ‘death of a child’ receives a score of 100, ‘trouble with in-laws’ gets a score of 29, ‘changes in work hours’ a score of 20, ‘revisions of personal habits’ 24, and ‘pregnancy’ 40. So getting pregnant, changing our personal habits, altering our work hours, and having issues with our in-laws are worse than having our own child die. Doesn't make a lot of sense, does it? Furthermore, certain items on the list seem to have a positive valence (e.g., an outstanding personal achievement), others a negative valence (e.g., the death of a close friend), and still others depend on an individual's perspective (e.g., a major change in responsibilities at work, e.g. a promotion, demotion, lateral transfer). So the scale doesn't necessarily reflect adverse events, but instead deals with ‘life changes’ that might or might not be interpreted as stressors. Of course, the scales don't consider the context in which a stressor had occurred. For instance, the death of a loved one is typically a severe stressor, but it might vary as a function of whether the person had been going through a severe illness or had died suddenly in an accident. Likewise, as we'll see, even apparently minor stressors can have relatively pronounced consequences when these occur within the background of a series of other, more distressing events.

A further problem with each of these approaches is that they ask individuals to report on events that had previously occurred, and hence are subject to ‘retrospective bias’. That is, the way individuals interpret or even remember the past may be colored by how they feel at the moment. If an individual is feeling really great, then past negative events might not seem so bad and they might not even recall that certain adverse events had ever occurred. In contrast, if the individual is currently dejected, then all events in their past may be perceived as the slings and arrows of outrageous (mis)fortune and they might even dredge up events that were insignificant. Further to this point, when individuals are ill they often want to know why this occurred. Is it something they did, or something that somebody else did? Or is it just bad luck? In the case of people who are depressed they might be looking for causes and might attribute their depression, sometimes inappropriately, to particular past events. In short, as most defense and prosecution lawyers know, we can't be trusted to recollect our past experiences accurately.

Daily Hassles versus Major Life Events

One typically presumes that the more intense the stressor the more profound the consequences. To a certain degree this is certainly the case. But what are the consequences of those day-to-day annoyances that can really bug you, especially when they appear repeatedly or are superimposed on the backdrop of other ongoing stressors (it's not from nowhere that we have expressions such as ‘the straw that broke the camel's back’)? Most of us know the experience of having to deal with a new stressor when were in the midst of dealing with an earlier challenge; our immediate response when this occurs is something like ‘Oh no! Not now’. It's hard enough to deal with one event, but when coping resources have to be redirected to a second stressor, even if it's a fairly trivial one, our abilities to deal with these situations may become stretched. Most of us certainly have to deal with multiple concurrent challenges at some time or other. For some, juggling different tasks is so much part of their repertoire that they can't see how anyone would ever have a problem in this respect. For others, however, juggling multiple demands is exceptionally difficult, taxing their resources, and ultimately leading to illness.

Hassles can certainly be a pain and even small increases in these experiences may result in individuals being more prone to illness and mood disturbances. The relations between such ‘daily hassles’ and pathology have been evident across a range of illnesses, including depression, irritable bowel syndrome and diabetes (Blanchard et al., 2008; Ravindran et al., 1999), although this doesn't necessarily mean that the hassles caused the pathology, as those who are already ill may be more sensitive to day-to-day annoyances. Nevertheless, these seemingly inconsequential stressors, when they continue for long enough, can have a cumulative effect.

The formal publication of the Hassles and Uplifts Scale (Kanner et al., 1981) provided an instrument to show that hassles are related to poor well-being. Since the initial publication of this scale, other similar instruments have been developed for particular groups (e.g., caregivers) or circumstances (e.g., transition to university). Investigations using daily hassles scales typically report an overall score, but it may well be that specific types of hassles are more germane to some individuals than to others. Thus, analyses might be considered in terms of the different types of challenges experienced (e.g., partner, friends and family hassles, as well as those that are related to home, work, health, and financial strains). This hasn't been widely done, but if it were, then it might be observed that illness varies as a function of both the severity and type of the stressor encountered, and that certain illnesses are more closely related to particular types of hassles.

A Taxonomy of Hassles – Changing Times

In their original report, Kanner et al. outlined the 10 most frequent hassles and uplifts reported. These hassles comprised: (1) Concerns about weight; (2) Health of family member; (3) Rising prices of common goods; (4) Home maintenance; (5) Too many things to do; (6) Misplacing or losing things; (7) Yard work or outside home maintenance; (8) Property, investment, or taxes; (9) Crime; and (10) Physical appearance. This paper was published thirty years ago, but some of those same hassles are still pertinent. Today, however, we might find that frustration with our computer, loud people talking on cell phones, emails from work when you're at home, junk emails (including word that a long-lost cousin in Nicaragua has left you $12.5M) might break into the top 10. Importantly, these were the top 10 items for the population at large, but might not be the top 10 for those dealing with particular issues experienced by some individuals, such as caregivers who deal with illness or any of numerous other major problems. Again, when hassles are superimposed on major life stressors, then we're dealing with exponentially greater problems.

Given that hassles can be draining, you might be asking what can be done about these stressors. Causal observation suggests that having people to whom you can vent and who can help you with minor problems is useful, as social support usually is. However, there are limits to what your social support network is willing to put up with. Using them excessively for the purpose of venting, and putting upon them for very minor reasons (and not giving anything in return), may end up being counterproductive, as friends might abandon you or offer unsupportive reactions and you might get to be known as a whiner. Of course, mutual whining might diminish this problem, and although it doesn't eliminate stressors, it is a way of coping.

Most of us probably already know the key element that needs to be considered in relation to hassles, namely, don't have a meltdown. It's not productive, and excessive reactions to mild events can act as stress generators, causing further problems that need to be dealt with (like fixing the broken laptop that you whacked when you forgot to save the data). Second, put things in perspective; losing your keys or having a minor skin blemish doesn't rate as all that terrible in comparison to some serious events that can be encountered. Heart disease, cancer, and paralysis are all horrible experiences, and are difficult to deal with. Day-to-day hassles aren't, and usually can be dealt with readily. In Chapter 12 we'll be talking about various stress management procedures and treatments. One that is currently in vogue is mindful meditation (mindfulness). A key precept of this procedure is ‘think in the moment’. In part, this means appraise the present situation properly, without worrying about secondary issues, and don't go into an automatic negative response mood. Once appropriate appraisals have been made (i.e., ‘this is just a minor hassle’), then with proper deliberation, effective coping strategies can be used. Of course for some people (especially the perfectionist types and likely the Type A personalities) those little things left undone sit there sneering at them annoyingly, to the extent that they are incapable of focusing on important issues. Basically, the best advice that can be offered is what my kids (annoyingly) say to me when I'm on the verge of a meltdown over something minor, ‘Chill, Dad’.

Enough is Enough

A newspaper headline had a story about a Dalhousie University professor who, after standing in line for about an hour to get a rare on-campus parking pass (even though he'd been teaching at the university for thirty years), walked up to the administration offices and handed in his resignation. I can visualize his frustration when he was likely already very busy with classes about to start, and at a certain point he just said ‘Screw it’. A small part of me wondered whether he was a flake, but a larger part was in admiration, given that as a university professor, I know some of the administrative aggravations that are often experienced (like completing form after form after form). Still, the event described had occurred yesterday, and today he's out of work. It may be that he won't miss the job (he was near retirement) and/or has other options. Alternatively, this might be an instance of stress generation. (Incidentally, as a result of such frustration I've developed a ‘request a request form’ so that when I'm asked to fill out a form, I ask them to complete my form so that I can determine whether they have the authority and justification to request that I complete their form – I'll be happy to share this form if you email me, and you won't have to complete a form to get it.)

Stressor Interviews and Diaries

To overcome some of the limitations associated with retrospective analyses, several researchers have attempted to obtain confirmation of stressful experiences by interviewing friends and family members. Although, at first blush, this might seem reasonable, the fact is that such reports can reflect the observers’ own spin or bias, and hence can be just as flawed. Besides this, stress, like beauty, is ultimately in the eye of the beholder, and it's hard to know what a particular person feels by asking someone else. Judicial courts don't allow witnesses to testify about what was happening in the mind of someone else, and researchers are equally skeptical of this approach.

Ultimately, the best way to evaluate the relations between stressful events and later outcomes is by prospectively assessing stressor experiences and then relating them to particular outcomes, such as aspects of health. Not unexpectedly, this can be an onerous task that takes an awfully long time to complete, and participant loss (referred to as subject attrition) can be very high. Thus, one might end up with only those participants who are most dedicated to the project, so that the data collected might not be representative of individuals at large. If the study is relatively short term, say for a matter of weeks or even a couple of months, a diary approach can be used (e.g., Holtzman et al., 2004). This can be conducted using a format in which participants answer a brief set of questions at the end of each day (or week) indicating what they've experienced. This requires that the investigator meet with participants and form some sort of relationship with them so that they will be motivated to engage in the study on a daily basis. As useful as this approach might be, its use in long-term studies is obviously limited by logistical considerations.

Individual Difference Factors

Vulnerability and Resilience

Up until this point, we've focused on the different characteristics of stressors that could potentially influence behavioral or physiological outcomes. Of course, these features are only a few of the many factors that influence how stressors affect us. To a considerable extent, previous life experiences, characteristics of the organism (animal or human), and personality variables determine the nature of the stress responses that occur. In the next section we'll focus on the influence of these variables. In assessing these factors, we will not only think about what makes us vulnerable to pathological outcomes related to stressful experiences, but also what goes into an individual being more or less resilient in the face of different challenges. Some of the factors that seem to make individuals resilient in fending off or preventing the adverse effects of stressors have been identified (see Figure 1.1), but it's certainly the case that there are enormous differences across individuals in this regard.

Figure 1.1 Numerous Factors might be Important in Preventing the Development of Stress-related Pathology. These Range from Personality Characteristics, Genetic Factors, and a Variety of Experiences. Some, but Certainly not All, of the Important Ingredients are Provided in Figure 1.1. The Effectiveness of these Resilience Factors is Likely Dependent on the Stressor Situation, will Vary over Time as the Stressor is Experienced, and will Also Vary across Individuals.

Vulnerability vs Resilience

In the context of illness, vulnerability refers to the susceptibility of a person (or a group, or even a whole society) to increased psychological or physical poor health as might occur in response to particular environmental or social challenges. Resilience, by contrast, refers to factors that limit or prevent these events from having adverse effects or, more often, resilience refers to the ability to recover from illness. The two aren't necessarily at opposite ends of a continuum. Moreover, the absence of factors that increase vulnerability doesn't necessarily imbue resilience. A person can, theoretically, have many factors that engender stressor resilience, but a single catastrophic vulnerability factor might be sufficient to undo all that fitness. By example, how often have you heard of a person being perfectly healthy who suddenly dies? It took only one malfunction, an aneurysm or a pulmonary embolism, for instance, to undo all that was ‘healthy’ about that individual. In this regard, one could take the view that stressors act on weak links within a system. A person may have all sorts of strong links, but when stressors come along, they have the most profound impact on the weakest link, causing damage at that point.

For an individual to be resilient, numerous ingredients might have to come together in exactly the right amounts. Charney (2004) suggested that neural mechanisms related to reward and motivation (hedonia, optimism), responsiveness to fear and fear-related situations, and adaptive social behaviors (altruism, bonding, and teamwork) all acted to influence character traits that affected resilience to severely traumatic events. Another perspective has it that resilience increases with increased tenacity, trust in one's instincts, acceptance of change, control, and spirituality. Still another perspective attributes resilience to the ability to adapt and be flexible to changes, the ability to problem solve, and possessing a positive outlook on life. No doubt, other resiliency factors, including early experiences and genetic factors, contribute to the ability to withstand the potential for stressors to harm us. Moreover, it is possible that certain characteristics exist that might enhance well-being even in the presence of factors that would otherwise increase vulnerability to pathology. For instance, an individual with many factors that make him or her vulnerable to stress-related pathology may overcome challenges by having an excellent social support network or perhaps by espousing a religious belief that allows them to endure the worst challenges. This is not to suggest that religiosity is the way to go, but it seems to work for some people.

Most studies that assessed the relationship between stressful events and pathology have addressed questions related to what makes us ill and what the characteristics are of individuals who are most likely to become ill. Much less information is available regarding what makes us resilient. Where we most often encounter this topic is in considering the resilience of some individuals in coping with illness, and the findings from such studies have been especially constructive. There are some individuals who, in the context of serious illnesses, are particularly resilient and are able to maintain, or regain, their mental health readily. Among individuals who have previously encountered a severe illness, the cognitive restructuring that might have occurred previously (e.g., finding meaning in their illness, which we'll come back to in Chapter 2) may have facilitated their ability to appraise and cope with a further stressor. In other instances, however, the previous stressful experiences might not have served in this capacity, but instead acted against well-being. Having gone through a traumatic experience, individuals might simply be too worn down or they may be sensitized so that later stressors in the form of severe illness might simply be too difficult to handle.

Resilience in relation to illness can be influenced by several personality characteristics, such as self-efficacy, self-esteem, internal locus of control, optimism, mastery, hardiness, hope, self-empowerment, determination, and acceptance of illness. Knowing this, unfortunately, isn't going to be of much help in advising anyone how to deal with illness as we can't easily get people to develop better self-esteem or greater hardiness. However, the way individuals appraise and cope with their illness may have profound repercussions for their well-being. Specifically, positive cognitive appraisal, spirituality, and active coping, which are considered in Chapter 2, were associated with resilience, and these attributes can be promoted with proper training (e.g., using cognitive behavioral therapy or mindfulness training as described in Chapter 12).

Genetic Factors

When I was an undergraduate and first introduced to genetics, it was described in the form of Mendelian inheritance (that stuff about pea plants), and most of us came to believe that we inherited certain genotypes (specific genes we received from our parents) which then affected our phenotype (what we looked like), although it was acknowledged that inheritance could be incomplete and hence we might not be exactly like either of our parents on any given domain. So, unlike pea plants, people aren't simply tall or short, green or yellow, or round or wrinkled: there are all sorts of levels in between. A second premise that was drilled into us was that whatever genes you inherited were those that you were stuck with forever, and that was that. A third premise was that for some unknown reason, genes could interact with the environment, but nobody ever explained how or why this could happen. In the last decade there has been a revolution within molecular biology and all fields of medicine and neuroscience. Scientists have not only unraveled the genome, they have also found ways of modifying genes, and identifying how and where genetic changes occur naturally or in response to environmental factors or in response to stressful events. We now know that the potential actions or effects of genes can be suppressed by environmental triggers or specific experiences and hence might promote (or limit) pathology. We also know that genes can be inserted or deleted, and thus might affect phenotypes, and we have discovered many subtle inherited mutations or variants that occur within genes (referred to as ‘polymorphisms’) that can have profound effects on pathology.

So, what's this Stuff about Genes Causing Behavior?

There is this odd notion that genes cause behavioral phenotypes. That seems pretty vague; it's as if you inherit some gene or set of genes, et voila, a behavior appears as if by magic. Moreover, it's often thought that the effects of genes are immutable. In fact, however, the job of genes is to produce proteins, including hormones, peptides, neurotransmitters, enzymes and receptors that, in turn, influence behaviors. The effects of these genes aren't immutable, but are influenced by environmental factors that moderate how these gene effects are expressed. So, you might have genes that dispose you to particular characteristics, but whether these characteristics are expressed can be influenced by day-to-day events or events that occurred way back when, even when you were just a fetus.

As you know, the chromosomes you inherit from your parents comprise a lengthy DNA strand that's made of many genes, each of which comprises a set of nucleotide bases (guanine, adenine, cytosine, and thymine; the latter is replaced by uracil in an RNA strand) that reflect the gene playbook. Using the DNA as a template, RNA is formed through a process called transcription. The messenger RNA (mRNA) produced through this process is then decoded so that a specific amino acid chain, or polypeptide, is created that will in turn produce a protein (e.g., a hormone or neurotransmitter). When the characteristics of the DNA are altered, as occurs when even a single nucleotide is changed, the message that's delivered can potentially change and have some pretty significant consequences.

The genes on a DNA strand are interspaced by a bunch of additional nucleotides, much of which we know little about. But, in this pile of ‘junk DNA’ we also find strands that precede the gene. These are known as ‘promoters’ or ‘promoter regions’ (there are other names used as well, such as ‘response elements’) that are thought to act as activators or repressors. Essentially, the promoter serves as an instruction manual for the gene that follows it. These promoter regions can tell a gene when to turn on or off, or even when to interact with other genes. Importantly, environmental events, including stressors, influence these promoters by affecting other chemicals present in cells as well as extracellularly, which can then affect the influence of the gene on hormonal and neurotransmitter processes, and all those other biological factors that come to affect behavior.

Genes, therefore, have the potential to affect behavior in one way or another (e.g., increasing certain proteins that favor a disposition towards behavioral phenotypes, such as depression or anxiety), but in most instances they don't directly cause the behaviors. Ultimately, what we do is dictated by much more than just our genes. Face it, whether it's God or Nature, neither fully transcribes our lives before we are born. That would be pretty boring. Instead, we're faced with multiple paths that can be taken, ways to deal with environmental insults and social relations, and these affect the way genes get to express themselves.

Approaches in Humans

There have been many studies showing that genetic factors might be related to various psychopathological states. These studies have included pedigree analysis in which a particular phenotype has been traced through families in an attempt to identify the presence of particular genes, and studies that compared pathology in monozygotic and dizygotic twins (identical vs fraternal twins) to determine the degree to which a particular phenotype was inherited or induced by environmental factors, and often these phenotypes were linked to inheriting certain biological substrates. In more recent years, one of the most common approaches has involved the identification of particular genes or gene polymorphisms in relation to the presence of pathological states. In some instances this has entailed finding a sample (cohort) of affected and non-affected individuals (who have, or do not have, a particular phenotype or a family history for a particular phenotype), and then doing genomic analyses to see whether there is a match between the presence of certain genes or mutations and the appearance of a pathology. The idea is that if we could identify the gene associated with an illness, then determining what proteins this gene is responsible for making (e.g., levels of hormones and neurotransmitters and their receptors, and all sorts of other essential biological factors) would facilitate the development of treatments to attenuate or prevent pathology.

It sounds simple enough to find a proper cohort and then do the genetic analysis. However, if it actually were that simple, then many of the problems in the field might already have been solved. First, the diagnosis of an illness needs to be correct, which isn't always a simple matter as different illnesses have overlapping symptoms. Second, individuals might have similar symptoms, but that doesn't necessarily mean that these stem from the same underlying biological causes (including genetic and biochemical processes). Two individuals can come to have a particular chemical modification, but this might have involved different routes (much in the same way as your bank account can be low either because you're spending too much, not earning enough, a bank error, or unknown to you someone had been removing money from your account). Finally, there are potentially millions of mutations that can occur across the genome (more than a single mutation can also appear on any given gene), and most of these will be entirely unrelated to the pathology being studied. As a result the number of participants needed to do the studies appropriately is huge. In retrospect, it is understandable that the data from studies that have been conducted, probably because so many mutations occur concurrently and due to the small numbers of participants used, have not been particularly reliable. What has been clear, however, is that for certain pathologies, as well as the underlying biological processes, the expression of genetic effects was not always evident. Instead, the contribution of genetic factors was most evident in the presence of particular challenges, such as life stressors.

Approaches in Animals

Studies conducted using rodents have made it clear that genetic factors are fundamental in determining several stress responses and the pathological outcomes associated with stressors. In this regard, several approaches can be adopted to evaluate these relationships. A good first step is the use of inbred strains that naturally differ with respect to a given phenotype (the behavior or physiological characteristics of the animal) and genotype (the animal's genetic makeup) and relating these characteristics to neurochemical or hormonal differences in response to stressors (Crawley et al., 1997). Of course, simply because a strain is high (or low) with respect to both a given behavioral outcome and particular biological change doesn't mean that these factors are connected. But as described in the insert, this observation can be followed by further analyses to determine whether a correspondence between behavioral and biological factors is evident when various crosses between the strains are assessed (e.g., within F1, F2 and backcross generations).

Genetic Analyses in past Decades

There are occasions on which it might be suspected that the effect of a stressor is determined by the genetic backdrop upon which it is superimposed; that is, having a particular gene doesn't cause the development of a particular psychological or physical illness, but it might be permissive in that it allows for stressors to have adverse effects. There are some fairly simple, if somewhat tedious, manipulations that can be conducted to evaluate these possibilities.

When two inbred strains are crossed, the offspring (referred to as the F1 generation) will all be genetically identical to one another. For example, one parent might be dominant for both components of a gene (AA), whereas the other parent may be homozygous recessive (aa). As the offspring inherit one gene from each parent, the offspring will necessarily be Aa. With respect to another gene, both parents may be BB, and so the offspring will necessarily be BB. The same will apply to every gene and hence all F1 animals will be identical to all others. When we cross two F1s, we can then begin to see differences in the genotype: the offspring of an Aa × Aa cross can potentially carry the AA, aa, or Aa combination. Within this F2 generation (also referred to as the ‘first segregating generation’) we can determine whether a particular gene and phenotype are linked to one another (either in the absence of a stressor or following exposure to a stressor). For instance, if every mouse that has inherited the ‘AA’ genotype exhibits a particular phenotype, and every mouse with the ‘aa’ genotype exhibits a different characteristic, then the two might be related. This doesn't mean they are causally related, as this is once again simply a correlation between variables. However, if those mice that exhibit a given phenotype carry the AA, Aa, or the aa combination, then we would know with a fair degree of certainty that these genotypes and the phenotype are unrelated. There are still more sophisticated variations of this approach (e.g., QTL analysis), but their description will have to be passed over for now.

There are occasions where a single gene can have more than a single phenotypic outcome. This is referred to as ‘pleiotropy’. Pleiotropy can occur because genes on a chromosome are inherited as a group (termed ‘linkage’) or because one phenotype (e.g., a biological change) may directly or indirectly lead to a second phenotypic change. Assessing genes across successive crosses also allows us to see whether certain characteristics always appear together (e.g., Does a certain chemical always end up being present in conjunction with a particular heart problem?; Does having a certain coat color predict the occurrence of epilepsy?). In effect, we could be able to develop ‘biomarkers’ that predict later disease occurrence.

As well, one could determine whether genetic influences interact with maternal factors in determining outcomes. As we have just learned, all F1s of inbred strains are identical to one another. If a particular trait is entirely due to genetic factors, then it shouldn't matter who their mom is (i.e., from one strain or the other). However, F1 mice can be produced where the dam (mom) is a member of a particular strain, whereas in another cross the dam is of the alternative strain (this is referred to as a ‘diallel cross’). In this instance the F1s will all be identical, but if they differ from one another on some phenotype, then we'd likely ascribe this to characteristics of the mom.

With the remarkable advances in our understanding of molecular biological processes and the related technologies, newer and more sophisticated methods have been developed, including those in which specific strains of mice can be engineered. Specifically, mice (and in some instances rats) have been developed in which genes can be directly manipulated (engineered). Thus, one can assess the effects of stressors on a particular outcome in the presence of a specific genotype. For instance, a gene can be deleted from (knock-out) or added to (knock-in or transgenic) the genome of a mouse, and then bred so that numerous identical mice are obtained. This allows for analysis of the role of a particular gene or small set of genes in relation to particular pathophysiological outcomes, and how stressors influence vulnerability to pathology. So, if one believes that stressors cause a rise in chemical X, which then promotes depressive-like symptoms, then strains can be developed that lack the gene responsible for producing chemical X and thus determine whether the depressive-like behaviors are prevented. Conversely, mice can be developed that overexpress the gene that determines the presence of chemical X, with the expectation that depressive-like features would be more prominent. In theory, this approach is potentially revealing and might prompt important hints for human pathology. Yet, as most complex human pathologies likely involve many genes, the effectiveness of this approach is necessarily limited, and certainly doesn't reflect the full spectrum of the disorder. Furthermore, in mice born with a particular gene deleted, there is a fair possibility that other genes may compensate for the deleted genes. With respect to the latter issue, approaches have been developed so that the gene deletion will occur at specific times in life (thereby handling the adaptations that could occur through early development) and these can be targeted at specific brain regions. The possibility of using this ‘conditional knockout’ in relation to pathology has been very exciting, and opportunities exist to assess the combined role of more than a single gene.

The key point for us here is that when these genetic approaches are coupled with the analysis of stressor effects (and other factors that may favor the provocation of behavioral disturbances) and other experiential factors (e.g., early life experiences), it may be possible to identify the array of factors that contribute to stress-related disturbances. This approach can also be used to identify the relative contribution of different biological processes to specific features (symptoms) of illness, and may ultimately provide markers that can be used to predict an individual's vulnerability to disease states.

As will be seen in ensuing sections, the data supporting genetic involvement in stress-related pathology are overwhelming, and the data derived from such studies have been critical in the development of new targets for the treatment of several illnesses. One can't say, however, to what extent genetic and environmental factors influence pathology, as among other things, their relative contributions likely vary with the specific disease being assessed. Understandably, most of the molecular genetic analyses that have been conducted have involved animals (primarily mice), and studies of the interactive effects of stressors and genes in affecting illness in humans have been limited. Nevertheless, as we'll see, when these factors were examined concurrently, the results obtained were impressive.

Endophenotypic Analyses

Before closing off this section one further issue ought to be introduced. Because of the diversity of symptoms associated with most psychiatric disturbances, the variability in the effectiveness of pharmacological treatments of such disorders, and the presumed array of neurochemical and hormonal processes that might underlie these disorders, it was suggested that analyses of these illnesses might not be best served by assessing them as syndromes. Instead, as illustrated in Figure 1.2, it might be more profitable to assess the ‘endophenotypes’ that comprise the disorder. This would involve tying specific symptoms of a disorder to specific genetic components and neurochemical processes that might be related to the efficacy of treatment responses (e.g., Gottesman & Gould, 2003). This is not an easy thing to do, but calls for this approach have become more common, and it has led to the idea that rather than treating all individuals diagnosed with a syndrome in a particular way, it would be propitious to identify the biological and behavioral characteristics of each individual, and then to apply ‘individualized’ treatments accordingly. This might be expensive in the short run, but more economically sensible over the long term.

Figure 1.2 An Endophenotypic Approach Attempts to Link the Specific Symptoms of an Illness to Specific Biological Factors, such as Genetic Markers, and then to Link these Factors to Particular Treatment Responses. There are Likely Many Factors that are Associated with Illness, but not all will be Predictive of a Treatment Response. However, Identifying those that do, Even if they are not Causally Related to the Illness, may be an Important Element in Developing Individualized Treatment Strategies.

Personality

We all know those individuals who, given the least encouragement, seem to turn into Henny-Penny shouting that the sky is falling, and others, in contrast, who seem stoic even under the worst of conditions. As we've already seen, there are several factors that make us different from one another in this regard. An important set of characteristics engendering diversity of responses to stressors concerns personality attributes. In particular, there appear to be relatively stable features of individuals that appear to be important in determining whether they will be more or less vulnerable or resilient to the impact of stressors (Suls et al., 1996). Certain personality traits might influence the stress process by affecting the way we appraise or cope with stressors, whereas others might make us more sensitive or reactive to stressors, and there seem to be characteristics that are actually instrumental in getting us into aversive situations (e.g., high risk takers are more likely to get into certain stressful situations relative to those low in this feature). Many of these factors may have evolved through the parenting individuals received, the socialization that occurred in early life, experiences that shaped particular responses, and it is probable that genetic factors also contribute in this regard.

One of the best studied views of personality has comprised the analysis of the Big Five or Five Factor Model. This conceptual framework has a lengthy history that culminated (more or less) with the model provided by Costa and McCrae (1992). The Five Factors comprise Openness, Conscientiousness, Extraversion, Agreeableness, and Neuroticism. One could argue that each of these dimensions could influence stress responses indirectly, but it is Neuroticism (or emotional stability) which largely comprises the disposition to experience unpleasant emotions readily (anger, anxiety, depression, or vulnerability), which seems most closely related to stressor reactivity. In this regard, some of the questions from the Big Five Factor inventory (‘I get stressed out easily'; ‘I worry about things'; ‘I get irritated easily’) tell us this factor is indeed targeted at stress-related reactivity (Vollrath, 2001).

Of course, the Big Five represent only one perspective concerning the personality dimensions that might influence the stress response. In fact, because of the broadness of this framework, it isn't clear that it is the best approach to evaluate predictors of stress reactivity, and numerous other factors have been proposed that are viewed as personality-based moderators of the stress response. Of these, resilience has received increasing attention, although it is not viewed as a trait. Resilience is seen as a process (or a constellation of factors) leading to changes that make individuals better able to deal with stressors or to bounce back from the adverse effects otherwise elicited by stressful experiences. Based on the many components that influence the stress response, it can be deduced that there are certain characteristics that lead to an individual being more or less resilient (e.g., early life experiences, developmental trajectory related to dealing with novel events, appraisals and coping abilities), taking into account that stress responses are governed by multiple contextual factors.

Not surprisingly, individuals who approach situations with an upbeat and optimistic outlook will have a very different view of that situation than do individuals who enter it with a pessimistic perspective. Scheier and Carver (1985) developed the Life Orientation Test (LOT), which was later revised (LOT-R), to measure the attributes of personality that make up optimism/pessimism. There are other instruments to measure this characteristic, but it seems that the LOT-R is the most widely used. Based on studies using the LOT-R it was shown that optimism/pessimism represents a personality trait that was associated with stress reactions and the ability to meet fairly severe life challenges. In this regard optimism/pessimism influenced how individuals deal with severe stressors, including breast cancer in females and radical prostatectomy in men, moderated hormonal changes and immune responses ordinarily elicited by stressors, and was related to stress reactions, such as burnout (Carver & Connor-Smith, 2010; Carver et al., 1993).

As in the case of optimism, it seems that an individual's self-efficacy (the belief that tasks can be accomplished and difficulties resolved through one's own efforts) can act as a moderator of the stress response, and thus influence well-being. Likewise, it seems that our locusof control may influence how we appraise or respond to stressful events. Specifically, those with a high internal locus of control tend to have the view that events in life arise primarily because of their own behaviors and actions, whereas individuals with a low internal locus of control generally believe that fate, chance, or powerful others determine what events they encounter. These characteristics are thought to influence how individuals interpret or appraise situations and their own abilities to deal with them, and thus will affect psychological stress responses (we'll be coming back to this in Chapter 8, when we discuss depressive illness).

There are many personality factors that play into how we deal with stressors, but only a small number of these have even been mentioned to this point. Numerous volumes have been written on this issue, and trying to cover this broad field wouldn't do it any justice, certainly not in just a few pages. As we move forward, however, the contribution of several of these many personality traits will emerge, but for the moment, the important message here is that you should not assume that the things that bother you, and the way you think stressful issues should be dealt with, necessarily apply to everyone.

Age

An individual's age has a lot to do with how they react to stressors emotionally and physically, and whether pathology will arise. Lupien et al. (2009), in their timely and thoughtful review, indicated that regardless of whether stressors occur prenatally, in infancy, childhood, adolescence, adulthood or in those who are aged, profound brain changes and mental health poroblems can emerge. These outcomes, as already mentioned, can reflect the interaction with genetic and other psychosocial factors, but the nature of the pathology that emerges may be dependent on the timing of the stressor experience. My inclination is to start this section with a discussion of older age, as this is of particular importance to me at the moment. But for the sake of a good orderly description, we'll follow a chronological order.

Prenatal Experiences

Stressors experienced by a pregnant female may have effects on the fetus that will be manifested at various times following birth. In humans, the offspring of mothers who had experienced chronic or severe stress during pregnancy subsequently exhibited cognitive, behavioral and emotional problems during both childhood and adulthood. However, studies that evaluated these relations in retrospective analyses were troubled by some of the factors typical of self-report studies. Moreover, prospective analyses of children born following natural disasters were confounded by changes in quality of life that extended well beyond the primary stressful period (e.g., earthquakes, hurricanes, and tsunami are followed by multiple financial and health repercussions). This, however, does not belie the fact that the perceived severity of natural disasters was a strong predictor of mental health problems among pregnant and postpartum women, which was related to perinatal health outcomes in the offspring.

The fetus’ intrauterine environment might profoundly influence its brain development, and hence stressful events that influence this prenatal environment may have repercussions that carry through postnatal periods. For example, stressful events will give rise to elevated levels of a stress hormone (corticotropin releasing hormone), which may appear in the placenta, ultimately affecting the fetal brain (Charil et al., 2010). In addition, among rodents, the offspring of mothers that had been stressed during pregnancy showed elevated activity of the stress hormone corticosterone when they encountered stressors postnatally, and this outcome was evident even when the pregnant dam had experienced a stressor on only a single occasion. Furthermore, these experiences influenced particular neurochemical receptors present within the hippocampus, a brain region that is fundamental in regulating biological stress responses and cognitive functioning. It might be particularly relevant that the effects of maternal stressors have especially profound effects in female offspring, and might be an important element responsible for differences between males and females in the development of stress-related pathology. In Chapter 11, which largely deals with the intergenerational transmission of trauma, a lengthier discussion of prenatal stressor effects is provided.

Stressors as Teratogens

Teratogenic agents (those that cause disturbances and malformations of the fetus) are dependent on the stage of development at which the compound is encountered. Typically, the most harmful effects occur during the first trimester, but can vary with the species, the nature of the teratogenic agent, as well as particular phases of developmental growth. In the case of stressors, it has been suggested that the mid-term period is particularly sensitive to the adverse effects of stressors, possibly because placental adaptation can be achieved early in pregnancy, thus limiting adverse outcomes. However, the data from human studies and those from non-human primates and rodents have not been entirely uniform, and this issue has yet to be fully resolved. This is particularly the case as most strong stressors encountered by humans are often chronic in nature (especially when the aftermath of the initial trauma is considered) and hence span a lengthy period of fetal development (Charil et al., 2010).

Early Postnatal Experiences

Stressors have profound effects on children, and events early in life may subsequently affect biological responses to stressors in adulthood (see Chapters 3– 5), and encourage psychological disturbances, such as depressive disorders, a variety of anxiety disorders and drug addiction ( Chapters 8, 9 and 10), and may even have effects that are manifested across generations ( Chapter 11). There are a wide range of stressors that infants and children can experience, ranging from physical, psychological, or sexual abuse, through to neglect or socioeconomic difficulties (poverty). However, children may not appraise specific challenges in the same way that adults do and therefore it is sometimes difficult to discern how they are being affected by adverse events (e.g., Compas et al., 2001). As well, the social, cognitive,emotional, and tangible resources to deal with stressors are not as well developed in children as they are in adults. Thus, it can reasonably be expected that stressful events might have marked immediate effects on children's well-being, and the notion is intuitively appealing that stressors experienced early in life would have profound repercussions on long-term well-being.

Early studies conducted by Harlow indeed revealed that monkeys raised in isolated environments later became asocial and had vastly deficient parenting skills. It has likewise been known for decades that raising children in deprived environments where they were not stimulated by touch or caress, as in the case of hospitals or orphanages, gave rise to frequent psychological and physical disturbances and exceptionally high levels of infant mortality. In fact, profound behavioral and biological disturbances are seen even when humans or rodents are brought up in environments that are not nearly as severe as those experienced by children in orphanages or monkeys in Harlow's studies. Early experiences, and in particular maternal care and factors related to socioeconomic status, most certainly influence developmental trajectories and ultimately adult behaviors (Shonkoff et al., 2009). Among other things, children from a nurturing early life environment were subsequently found to have a hippocampus that was larger (by about 10%) than children from a less nurturing environment (Luby et al., 2012), which could have enormous repercussions for stress responses and mental health, as well as learning and memory processes. Furthermore, stressful early life experiences have been associated with greater adult anxiety, depression, and chronic fatigue syndrome, and have also been implicated in favoring the development of a variety of diseases of aging, such as vascular disease and autoimmune disorders, and premature mortality (Shonkoff et al., 2009).

Re-Programming Biological Functions and Epigenetic Processes

To account for why early events might have repercussions many years later, it was proposed that psychological stressors result in the programming of various types of biological signals, including those that involve hormonal and immunological processes. Further, adverse early life experiences give rise to several behavioral and cognitive changes (e.g., high threat vigilance, mistrust of others, disrupted social relations, disturbed self-regulation, and unhealthy lifestyle choices) that might engender further stressors or result in these individuals being highly reactive to threats. These behavioral factors, and the stress reactions they elicit, might exacerbate already disturbed hormonal and immunological functioning associated with the early experiences, and eventually might culminate in pathology.

In considering the effects of early life experiences, one should not just focus on severe cases, such as abuse. Indeed, simply having an inattentive or neglectful parent can have profound and lasting repercussions on cognitive functioning and on vulnerability to stress-related disturbances. Studies with rodents indicated that early life neglect may engender disturbed adult behavioral and biological functioning, whereas stimulation may enhance an animal's ability to contend with later stressor experiences. In this regard, it seems that if pups had an attentive mom who cared for them well (in the case of rodents this involves lots of licking and grooming of pups), then these animals grew up to be fairly resilient in the face of stressors (Kaffman & Meaney, 2007). In contrast, extended periods of separation from the mom, or having an inattentive mom, resulted in animals being more stress reactive as adults, relatively resistant to the extinction of fear responses, and even after extinction had taken place, the fear response could readily be reinstated (Callaghan & Richardson, 2011). Essential questions that have emerged have concerned which neurobiological processes are involved in these outcomes, and whether the adverse effects of early adverse experiences can be reversed, or if there are variables that may compensate for poor parenting.

In their influential review and commentary, Shonkoff et al. (2009) indicated that numerous diseases that appear in adulthood, including psychiatric disorders, diabetes, heart disease, and various immune-related disorders, might have their roots in childhood stressor experiences. They suggested that the cumulative effects of life stresses contribute to allostatic overload that might eventually lead to pathology, or alternatively, that stressful experiences in childhood may become biologically ‘embedded’ (either through epigenetic processes or via sensitized biological responses) so that their consequences might appear years later. These investigators distinguished between ‘positive’ or ‘tolerable’ stressors that, with appropriate social support, might allow individuals to learn how to cope with such events, from those described as ‘toxic’ stressors (extreme poverty, psychological or physical abuse, neglect, maternal depression, parental substance abuse, and family violence) that are more likely to lead to pathology. In effect, there are challenges that are basically part of growing up, that have positive effects as they allow individuals to learn how to appraise and cope with events properly. However, there are also ‘toxic’ challenges that no one should have to endure. Shonkoff et al. didn't simply indicate that there were problems, rather they called for changes in public policy to attenuate these problems. They suggested that an increased focus be placed on: (a) reducing toxic childhood environments; (b) greater provision of early care and education programs that might not only serve as appropriate learning environments, but could also foster ‘safe, stable and responsive environments; (c) evidence-informed interventions and treatments to deal with family mental health problems; and (d) expanding the role of child welfare services so that they undertake comprehensive developmental assessments in order that professionals be able to apply appropriate interventions. To what extent these straightforward suggestions will be endorsed by policy makers will be seen.

Epigenetic Processes

A fairly hot topic in recent years has been the possibility that stressful events (as well as other factors) may affect the expression of genes, without altering the sequence of amino acids that make up these genes. This has been termed ‘epigenetics’, which essentially refers to the study of heritable changes in gene expression that result in a phenotypic change, but without fundamentally altering changes in the underlying DNA sequence (Bird, 2007). Some event, say one that had been experienced early in life, may have caused a series of changes within cells, so that the expression of the gene is suppressed. This gene suppression could affect whether or not certain neurochemical processes, including the neurochemical receptors, are operating appropriately, and hence could have effects with respect to how individuals deal with stressors, or they could have effects directly on processes that lead to illness. Importantly, these changes could persist over the course of an organism's life, and could also be transmitted across successive generations (if the epigenetic change occurred within the germ line, i.e., the sperm or ovum), hence affecting the biological and behavioral processes of the children and grandchildren of the individual that had initially been affected. Epigenetic changes have been shown to contribute to some forms of cancer, as well as autoimmune disorders, such as rheumatoid arthritis. Although epigenetic mechanisms have been linked to stressful experiences encountered at any time in life, there has been considerable interest in determining to what extent early life events (abuse or neglect) might have long-term consequences owing to epigenetic changes. In this regard, analyses of the brain tissue of depressed individuals who died by suicide revealed epigenetic changes in the genes associated with stress-relevant neurochemical responses among those individuals that had experienced early life parental neglect (McGowan & Szyf, 2010; Poulter et al., 2008).

Transitional Periods

In addition to the impact of prenatal and early postnatal periods, there are other developmental times during which an organism might be especially sensitive to stressors. These include those phases of life that are referred to as transitional periods. We all go through events in life that involve change or transitions that call upon our adaptive resources. Entering kindergarten, for instance, is one of these life transitions. You're suddenly a big boy or big girl, having graduated from day care, but you also suddenly find yourself in a new social context, where it's not just you, mom and dad anymore. Likewise, entering high school, college, university, or the workforce is also an exciting major life transition during which we might experience insecurities and may be particularly vulnerable to the adverse effects of stressors. Leaving home, living with someone else, getting married (or divorced), moving cities and retirement, represent life transitions, and at these times the responses to stressors might be altered.

Most animal studies that assessed the effects of early life events on later stressor vulnerability have focused on events experienced during the early postnatal period (postnatal days 1–10), and as we've seen, stressors experienced at this time alter the developmental trajectory of stress relevant processes. However, it also seems that the juvenile (early adolescent) period, spanning postnatal days 28–35 in rodents, is exquisitely sensitive to stressors and has protracted ramifications on vulnerability to the stressor-provoked neurochemical and behavioral changes that occur in adulthood (Jacobson-Pick et al., 2008; Spear, 2009). The sensitivity of this developmental phase may be related to reorganization of many neurotransmitter systems that occur at this time. As well, it is a developmental phase during which rodents display increased socialization (play) with conspecifics and increased independence from the dam. In fact, stressors in the form of social instability encountered at this age may influence brain development, particularly the hippocampus, and thus may affect some forms of memory in adulthood, including those associated with fear (McCormick et al., 2011). Moreover, as adults, these rats exhibited elevated levels of the stress hormone corticosterone and reduced numbers of receptors in the hippocampus that are sensitive to corticoids. Interestingly, in both rodents and humans, the adolescent period is one during which fear responses are especially difficult to overcome relative to those seen in younger or older individuals. Once an anxiety or fear response is established it may persist even after the danger is no longer present, and among adults with fear-related disorders, about 75% of cases have their roots in anxiety that developed at earlier ages. These fear responses are not immutable, as they could be attenuated with appropriate treatment; however, this was more difficult to achieve in adolescent rodents and humans (Uys et al., 2006).

Adolescence in humans is a period in which individuals are highly focused on ‘fitting in’, developing an adult-like identity, finding a peer group that will accept them and with whom they feel comfortable, showing interest in a sexual partner, and even concerns about events that they will be facing some time down the road. These issues become particularly acute as young people move from secondary school to university, as this transition requires considerable adaptation in the face of psychosocial and environmental changes. During this stage of life, many individuals leave behind long-standing social networks and form new ones, including changes in their romantic relationships, and efforts to gain social, economic, and emotional independence. In effect, just when young people are expected to establish their independence, they encounter a transition replete with factors that destabilize their support systems, and individuals may struggle with a collision between expectations of autonomy and contending with a series of novel and stressful experiences that would be best met with the support of others.

Given the distress associated with transitions into adulthood, a considerable number of young people experience clinical levels of major depression, dysthymia (i.e., chronic low-grade depression), and anxiety disorders that were estimated to be as high as 25% (Mackenzie et al., 2011). Moreover, many may have undiagnosed or subsyndromal symptoms of depression and anxiety that could reflect the antecedent conditions of major depression (Offer & Spiro, 1987). Thus, although the transition into adulthood can be seamless and exciting for some, for many others it is a challenging process that seems to last forever, and every day is filled with hardships.

Older Age

Before starting a discussion of stress and aging, we need to distinguish what we mean by aged or aging. When I was young, and the mean life span was somewhere around 75 for females and 70 for males, someone at retirement age (65) was considered to be fairly old. With changes in lifestyle (diet, exercise) and medical treatments, life expectancy has increased appreciably, and 65 is hardly seen as ‘old’, and certainly not by others who are about that age (am I sounding a bit defensive?). Still, being old is no picnic, and getting old also has significant down-sides. With age comes a decaying system; young guys no longer want to play tennis as they ‘want a good game’, and flirting is interpreted as coming from an ‘old lech’. Worse still, disease states generally become more common: neurodegenerative and cardiovascular diseases appear; kidney, liver, and lung diseases are on the horizon; and prostate problems, even those of a minor sort, can cause social distress (if this is too ambiguous, think of ‘Depends’). Aging also influences the extent to which stressors affect well-being. Whether an individual ages ‘successfully’ or not depends (there's that word again) on, among other things, complex interactions that involve genetic factors, environmental influences, concurrent morbidities, and the ability to cope with stressors.

Studies in rats have pointed to yet another age-related factor that interferes with well-being in association with stressors. In older rats, the release of several brain neurotransmitters, such as norepinephrine, as well as the stress hormone corticosterone, is elevated under basal conditions (as it is in humans), and increases appreciably in response to acute stressors. However, normalization (the return to basal levels) may take longer to occur than it does in younger animals. It is thought that hormonal and neurochemical responses elicited by stressors are of adaptive value, but once the stressor terminates, things ought to return to normal relatively quickly. The sluggish normalization of neurotransmitter release and corticosterone levels, as we'll see in Chapters 3– 5, in older individuals might have some fairly unfavorable repercussions.

A good conceptual framework to use in regard to stress and aging is that of allostasis and allostatic overload (Goldstein, 2011). Let's face it, the wear and tear on a 70 year-old person (like a 70 year-old car), will be much greater than the load that has been put on a much younger model. The greater the strain an individual had encountered previously, and the greater the challenge they are currently undergoing, the more likely it is that the bumper will fall off. However, as individuals age, vulnerability to pathology might not only stem from decaying biological processes, but might also be a result of the dwindling availability of resources that lend themselves to effective coping, including the reduced availability of social support from family and from friends who might not be able to help (or who might have predeceased them).

Who would Scam Old People?

Of the many illnesses faced by older people, one of the most dreaded is dementia. The loss of self and the indignities that can be experienced in relation to many diseases are often beyond what anyone envisions for themselves. Significantly, among the elderly, cognitive decline is linked to stressful experiences. A prospective study among elderly individuals conducted over just 2.5 years revealed that protracted, highly stressful experiences were associated with increased conversion from individuals exhibiting mild cognitive impairments to moderate levels of dementia. Studies in rats also suggested that cognitive deficits and ‘tau pathology’ (a substance implicated in Alzheimer's disease) are influenced by cumulative stressor experiences (Sotiropoulos et al., 2011).

There are all sorts of scams being perpetrated, particularly through the internet. Over the course of two days I learned that my long-lost cousin in Italy, Giorgio Anisman, and my similarly lost cousin in Russia, Yvegeny Anisman, had died suddenly and I was their only known living relative. I stood to inherit millions! Who falls for these transparent and patently ridiculous efforts? Apparently there are some people who do, but it's a subset of older folks that are the most frequent victims of telephone and internet scams. It could potentially be that an age-related loss of neurons has made them ‘less smart’, or it might be that they're more trusting or, phrased differently, that they are deficient in their ability to ‘doubt’ information that would ordinarily appear suspicious. It seems that with age, a region in the brain associated with appraisals and decision making, the prefrontal cortex, may undergo changes for the worse. In this regard, even among otherwise intelligent people, when the dysfunctionality occurred in one aspect of this region, namely the ventral medial prefrontal cortex, individuals experienced difficulty in the effortful process necessary for disbelief, and hence they were more likely to be the victims of fraud. Being scammed is embarrassing and stressful for pretty well anyone, but for the elderly it's yet another slap in the face that highlights their limitations.

For some ‘seniors’, particularly those who've aged successfully (healthy in body and mind), this time of life can be wonderful. For many others, however, aging is the pits, and they certainly don't refer to it as ‘the golden years’. Besides being accompanied by health problems and repeated visits to different doctors, aging is associated with difficulties getting around, the loss of friends (through death or translocation), the dispersal of family members as children find employment or other opportunities elsewhere, and diminished coping resources, including a progressively smaller social support network. In fact, loneliness, which is stressful for individuals of any age, is often notable in the elderly as their social network might have dissipated, and certain types of stressors produce especially marked physiological changes (e.g., cardiovascular responses) relative to those apparent at earlier ages (Ong et al., 2011). Beyond these stressors, aged individuals might suffer multiple indignities, including unsupportive interactions (often being patronised, talked down to, dismissed, made to feel invisible, or made to feel like a burden) and stigmatization. In light of these factors, it seems that the coping strategies endorsed by older individuals might shift away from ones that reflect a sense of control over their own lives, to those that are reliant on others. Is there any wonder that depression rates in older people are as high as they are?

Sex

It's hardly news that women in much of the world have it much harder than do men. Whether it involves issues related to the job front, taking care of the home or children, or illness, women seem to carry a greater load than do men. Certain illnesses, such as mood disorders and autoimmune disorders (those in which the immune system turns on the individual, as in the case of multiple sclerosis, lupus erythematosus, arthritis) also occur more frequently in women than in men. In the case of major depression the ratio is about 2:1, and this increases to 3:1 in the case of atypical depression (i.e., where symptoms comprise increased sleep, increased eating, and mood reactivity). Likewise, posttraumatic stress disorder (PTSD) that develops in response to traumatic events occurs more frequently among females than males. These sex differences might occur for any number of reasons, including differences in the stressors actually experienced, greater stress-relevant neurochemical disturbances in females, the influence of particular sex hormones, socialization processes that promote certain behavioral styles being adopted, the endorsement of less adaptive coping strategies to deal with stressors, or psychosocial or personality factors that favor the development of illness. To the extent that sensitivity or reactivity to stressors differs between sexes, one might expect to find that the treatment of stress-related disorders would likewise differ in this regard.

In animal studies sexual dimorphisms (differences in phenotypes as a function of gender) are also apparent in neurobiological responses to stressors. In rodents, females are generally more behaviorally reactive to stressors than males, typically being associated with greater stressor-related neuroendocrine changes, such as variations of the stress hormone corticosterone (Rivier, 1999). Moreover, neuronal activity is increased in numerous brain regions that govern behavioral and cognitive responses to stressors (e.g., frontal, cingulate, and piriform cortices, and the hippocampus, hypothalamic paraventricular nucleus, medial amygdala, and lateral septum), and the extent of the activation varies over the estrous cycle, implicating a role for sex hormones in determining these outcomes (Figueiredo et al., 2002).

In humans, however, the effects of stressors on cortisol (the equivalent of corticosterone in rodents) were greater in males than in females, or were found not to differ as a function of gender (Kajantie & Phillips, 2006). It seems that these effects might vary with the estrous cycle, with greatest cortisol responses in women occurring during the luteal phase (the later part of the menstrual cycle during which the hormone progesterone is very high). It was also reported that the effects of social stressors on cortisol levels in women are blunted among those using oral contraceptives, indicating interactions between stressors and estrogen in provoking the stress response. No doubt there are numerous factors that could account for the difference between cortisol responses in human males and females, including those related to the nature of the stressor (intrapersonal stressors might have greater effects in females, whereas performance pressures have greater effects in males) and the appraisal/coping that might be instigated by the stressor in particular situations.

As we cover successive topics, it will become clear that the greater stress-vulnerability of females regarding depressive and anxiety disorders is also apparent with respect to autoimmune disorders and some types of heart disease. Despite these health inequities, it seems that on average, women still outlive men just as they did fifty years ago, although the gap has been closing. This is not simply due to a bias regarding who is in the workforce, as the same statistics are apparent in both industrialized and non-industrialized countries.

If They're the Weaker Sex, How Come Women Live Longer than Men?

The greater life span of women doesn't seem to simply be a result of estrogen levels, although it can't readily be ruled out that estrogen can interact with other factors to increase well-being. It could be related to women having two XX chromosomes, whereas men have an X chromosome replaced by a puny Y. Tom Persl had an interesting perspective on this (Lauara Blue, Time Magazine, 6 August 2006; www.time.com/time/health/article/0,8599,1827162,00.html He suggested that several factors converge to produce the gap. First, men smoke a lot more than women (or at least they used to); second, they eat more food that promotes elevated cholesterol levels; third, men generally are not as effective in coping with stressors, tending to internalize rather than letting go and externalizing. This said, I've heard from women that men complain vociferously about every little thing, and if, God forbid, they get a cold you'd think the world was coming to an end (incidentally, these women even referred to this as a ‘man cold’). There is another factor that should be considered: it is possible that testosterone may somehow come to affect longevity. It has, in fact, been reported that eunuchs in Korea between the fourteenth and nineteenth centuries lived about fifteen years longer than other people. Doesn't sound like a great method for extending life, does it?

Previous Experiences and Sensitization

There is no question, as we've seen in our discussion of early life experiences, that an individual's previous experiences may influence the response to later stressor encounters. It's not simply a matter of our memories of previous experiences influencing our responses to stressors. The characteristics of the neurons themselves may have changed, so that the response to later stimulation is enhanced (this is known as ‘sensitization’).

Studies in animals indicated that stressor encounters influence the neurochemical responses elicited by subsequent insults. For instance, the brain's neurochemical changes exerted by acute stressors can be induced more readily if mice had previously encountered stressful experiences (Anisman et al., 2008). It's still a bit early in the book to explain how stressful events might come to change the characteristics of neurons so that they would become more responsive (or conversely, less responsive, which is termed ‘desensitized’ or ‘down-regulated’) to later challenges. In fact, there are several ways in which these sensitized responses can develop, but what must be recognized at this point is that many biological systems are subject to this sort of effect. You might come across the concept of plasticity in regard to neuronal processes. This refers to the ability of the synapses to change, or the connection between neurons to change in strength as a result of experiences (use) or lack of use. Plasticity is a fundamental feature of the brain that is required for, among other things, learning and memory, and sensitization is an instance of this neural plasticity. However, when we deal with sensitization it should be considered that processes responsible for the sensitization of a given neurotransmitter system may differ from those associated with the sensitization of a second transmitter system. For instance, it is possible that sensitization of some systems may involve altered expression or sensitivity of relevant receptors, whereas sensitization of other systems may involve the synergistic (multiplicative) effects of two or more biological substrates. Finally, the effects of stressors on sensitized neuronal responses may persist for many months following a stressor event, and it is possible that sensitization processes contribute to the long-term influence of stressors on psychological states.

Based on such findings, it was suggested (Post, 1992) that the biological substrates of depressive illness may evolve over time with repeated stressor experiences and recurrent depressive episodes. With each stressor experience, or with each episode of depression, the stressor severity needed to elicit the depressive mood becomes smaller, until eventually, very little is needed to encourage a depressive state. There have, indeed, been numerous reports showing that although the first episode of depression is preceded by fairly strong stressors, the severity of the stressor necessary to cause illness recurrence is smaller (Kendler et al., 1995). In fact, among individuals who experienced recurrent episodes of depression, very mild stressors were needed to re-induce the depressive state, and even reminders of stressful experiences were sufficient to produce this outcome (Monroe & Harkness, 2005).

In addition to sensitization of biological systems, how we appraise (evaluate) the world around us can be influenced by our previous stressor experiences. By example, it isn't hard to imagine that if individuals encounter a stressor that traumatized them, later reminders of these same experiences will have profound psychological and physical repercussions. This also applies to adverse experiences that occurred in early childhood. Children who experience a trauma will, as adults, be much more likely to develop depressive illness (Kendler et al., 2004), and importantly, this is apparent even when statistically controlling for the family and contextual factors that have been associated with depressive illness. This effect of early life adversity is not limited to young children, having similarly been observed in women that had experienced physical or sexual abuse in adolescence (Harkness et al., 2006). It might be the case that when certain stressors are encountered, they cause changes in numerous aspects of an individual's life, altering the trajectory of life experiences (friendships and other support networks, coping processes, lifestyles, general world view, and even the propensity for further stress encounters), and culminating in a greater vulnerability to psychological and physical illness.

Stress Generation

Stress generation refers to occasions on which individuals, because of their circumstances, may bring stress onto themselves. This doesn't mean that we should blame the victim for finding themselves in adverse situations. Instead, it means that sometimes, through any number of factors, people are disposed to doing the wrong thing at the wrong time, and they might even do this repeatedly. Depressed individuals, by their behaviors, are thought to be a particularly vulnerable group for stress generation (Liu & Alloy, 2010). For instance, one partner in a romantic relationship may tire of always having to deal with the other person's depressive state (poor mood, negativity, lethargy, and aggressive behaviors that might occur), hence leading to the dissolution of the relationship. Essentially, the depressed partner, by not altering their negative behaviors (typically these involve behaviors of a dependent nature),contributed to the break-up and the loss of an important relationship that might have served as a stress buffer. Likewise, the depressed individual, who tends to be inactive and withdrawn, may also alienate their co-workers, and ultimately find themselves out of a job. Stress generation is also more common among those high in neuroticism (emotional instability), which is not surprising as their emotional sensitivity might favor interpersonal conflicts (Poulton & Andrews, 1992). It has also been reported that perfectionism contributed to interpersonal stressors (Flett et al., 1996), as did sociotropy (a personality trait in which individuals exhibit high levels of dependence and an excessive need to please others; Daley et al., 1997). This is in line with the perspective that individuals whose self-esteem is based largely on their relationship with others place themselves in a situation where interpersonal conflicts will be tied to depression and thus will contribute to further stress generation.

In a sense, it seems that stress breeds stress. In fact, in some instances, by their behaviors and attitudes individuals are able to make their worst fears turn into reality. Let's have a look at one example where this appears, namely that of dating abuse, which occurs in about 20% of dating relationships among university-aged individuals (the abuse, incidentally, goes in both directions, as males when asked are as likely to report psychological abuse as are women). Significantly, however, women who had previously been abused were reported to be at increased risk of being in further abusive relationships. In our research conducted with undergraduate women, 70.4% of those who encountered dating abuse reported a previous assaultive experience (childhood assault, assault by a previous partner), whereas only 24.6% of those in non-abusive relationships had such a history (Matheson et al., 2007). It was not a matter of women who experienced abuse generally being more likely to encounter traumatic experiences, as other forms of trauma (e.g., accidents, witnessing violent events, and the death of someone close to them) were not more common among abused women. Instead, it seemed as if an experience of abuse that occurred earlier in life effectively set in motion a cascade of changes that favored increased vulnerability to later stressors, which provoked depression and PTSD. What exactly this process entails isn't known, but it is possible that the initial abusive experience engendered a set of beliefs and learned coping responses that facilitated women's ability to endure or tolerate their abusive situations, or alternatively, the experience may have limited their capability to leave a bad relationship. Additionally, early abuse experiences may limit the development of social and emotional intelligence skills, and such skill deficits undermined the ability to appraise and respond appropriately to emotionally charged stressor situations (Terrance & Matheson, 2003). In view of the relations between dating abuse and earlier abusive experiences, increased incidence of stress generation, diminished self-esteem and self-worth, depression and PTSD, it would be inappropriate to consider an adult experience in isolation from other factors that might be tied to stress generation.

Conclusion

Stressful events are common life experiences whose effects can be negligible and brushed off readily, or they can be extremely severe, affecting individuals for years. Numerous factors can contribute to our vulnerability to stressor-elicited illnesses, and likewise being resilient in the face of severe stressors and pathology involves complex interactions between a constellation of variables. To a significant extent, however, the impact of stressors will be determined by how these stressors are viewed or appraised and how individuals cope with them. In Chapter 2 we'll be covering these topics in the hope that this will give us a better perspective of what to do when we encounter adverse events. However, if there's a single take-home message from Chapter 1, it's that stressful events and their effects are not only complex, but also that there are marked interindividual differences in their effects. What might be stressful to you might be a walk in the park for someone else, and conversely someone else's greatest distress may be a mild annoyance for others. Without considerable experience (and perhaps not even then), don't presume to understand another person's stress responses.

Summary

· Stressors come in multiple flavors and vary across numerous dimensions. The extent to which stressors affect our well-being is related to the nature of the stressor and the psychological attributes of that stressor, such as the controllability, predictability uncertainty, and ambiguity of stressors or threats of impending stressors.

· The impact of stressors may be governed by the chronicity of stressor experiences as well as stressors that had previously been encountered (e.g., early in life).

· Individual difference factors are fundamental in determining to what extent a stressor might have severe adverse consequences. In this regard, genetic make-up, age, gender, and personality factors all are effective in moderating stress responses.

· Factors that contribute to these individual differences, including the phenotypic expression of genes, can be influenced by previous stressor experiences that can potentially shape the way in which individuals respond to psychological, physical, or even systemic challenges.

TOPIC 2- Appraisals, Coping, and Well-Being

In Chapter 1 we learned that stressor features as well as our individual characteristics, regardless of whether they're due to genetic contributions, previous experiences, personality or age, will influence the extent to which negative experiences affect our well-being. To a significant extent, these variables influence how potential stressors are appraised or viewed, and the methods that are used to minimize or eliminate their impact (Lazarus & Folkman, 1984). In this chapter we'll consider appraisal and coping processes and how they might come to promote negative outcomes. The reader ought to come away with an understanding of:

· what's meant by stressor appraisal, and how to identify the factors that influence the appraisal process and decision making, as well as how misappraisals of events might occur and how illogical thinking might play into these;

· how appraisals influence emotions, and how emotions might affect appraisals;

· the various ways in which individuals cope with stressors, and some of the moderators of a coping response. They should also be able to identify how coping styles and strategies (styles refer to a dispositional or trait characteristic; strategies are viewed as a state characteristic that may be dependent on situational factors) might influence the emergence or exacerbation of pathological states;

· the extent to which some coping methods can be used to deal with stressors more effectively than others, and the circumstances under which this might be the case;

· how social support resources can be used to deal with stressors, and what happens when instead of obtaining support one ends up with unsupportive interactions.

Appraisals and Coping Skills

How we perceive potentially threatening events, and which methods we use to cope with them, have been linked to both psychological and physical pathologies. Indeed there has been a deluge of studies showing that the impacts of stressors were modified by both personal and coping resources, thus influencing whether or not particular disturbances would emerge. Likewise, the occurrence of depression in the context of particular illnesses (e.g., HIV, cancer, renal transplants, and cardiac problems) has been related to the individual's coping ability (Tennen et al., 2000), and it seems that aspects of coping may be fundamental in dealing with specific stressors, such as caregiving, the loss of a child, stigma and discrimination, as well as in response to severe trauma (Branscombe & Ellemers, 1998). As depicted in Figure 2.1, how we perceive or cognitively appraise (interpret) stressors has a lot to do with the coping strategies we invoke to deal with them (Lazarus & Folkman, 1984), which in turn might contribute to whether or not pathological outcomes will emerge. Conversely, the coping styles or strategies we use to deal with stressors might also come to influence how we appraise stressors.

Figure 2.1 The Triad above Indicates that our Appraisals Influence the Coping Strategies that we use to Deal with Stressful Experiences. Once a Stressful Event Occurs we make an Appraisal of this Event, which, in Turn, Leads to Coping Strategies being Engaged in an Effort to Attenuate or Diminish the Impact of the Stressor. If the Event is Seen as Aversive, and Especially One that is out of our Control, then the Event will be Perceived as Stressful and a Stress Reaction will be Engendered, which might Provoke or Exacerbate a Pathological Condition.

Appraisals of Stressors

Appraisals refer to the evaluations that individuals make in response to a potential stressor. These appraisals comprise the threat or risk associated with the event (i.e., the potential for harm or loss, and the degree of challenge the event represents), as well as an assessment of the severity, controllability, predictability, ambiguity, and the meaning associated with this potential threat. When faced with a potentially stressful event, appraisals ought to be adaptive, as they should enable individuals to distinguish those situations that require action from those that do not, along with the type of action that will most effectively address the stressor. To a considerable extent, appraisals are based on the individual's specific abilities, beliefs, previous experiences in dealing with similar and dissimilar events, and the resources available to contend with the challenge. Thus, appraisals define the extent of the threat that an event imposes, and influence the coping methods that are selected to deal with the stressor. For example, although threat and challenge are similar in so far as they both might promote action, they also have important distinguishing features. Specifically, an appraisal of threat is often associated with negative emotions (e.g., fear, anxiety, or anger) as it signifies the potential for harm or loss. Challenge, in contrast, might signify the potential for growth or gain and hence might be associated with positive emotions (e.g., exhilaration, eagerness, excitement). However, this might not be the case for all individuals encountering a given event: for one individual the event might reflect a challenge, but for another, the same event might be viewed as a threat.

Primary and Secondary Appraisals

Potentially stressful events are thought to give rise to two interpretive processes, termed ‘primary’ and ‘secondary’ appraisal. Primary appraisal comprises perceptions associated with the impact of a potentially stressful event or stimulus: for example, the impact of an event may be perceived as benign (or even positive), and hence no immediate action might be deemed necessary. Alternatively, the event or stimulus might be construed as a threat, and as such, additional interpretations concerning the event might be evoked: these include the potential for the event to induce harm, whether it threatens the individual, and to what extent it is a challenge (Lazarus & Folkman, 1984).

Threat might not always be identified easily in some situations, but individuals will infer that a threat is present based on experience and previously acquired knowledge (Lazarus, 1966). Moreover, the positive or negative outcomes associated with earlier experiences might provide individuals with information relevant to threat appraisals (Gallagher, 1990). Having identified a threat, individuals ought to engage in behaviors to limit the threat or its impact. Needless to say, remaining in a heightened or repeated state of arousal owing to perceptions of impending threats is hardly adaptive, and might confer increased vulnerability to illness. Indeed, individuals who tend to appraise events as threatening may be at increased risk for greater long-term health problems relative to those who make more positive appraisals (Hemenover & Dienstbier, 1996).

Figure 2.2 This Differentiates between Possible Appraisals that can be Made with Respect to a Given Situation. For Instance, an Individual being Sent on a Training Course to Upgrade their Skills can see this as being Either a Challenge (‘This will be Super. I've Always Wanted to be Able to Get the Maximum out of the Internet and here's my Chance to Learn.’) or a Chore (‘Oh Brother. Now I have to Leave the Comforts of Home for Two Weeks to Take a Dippy Course that I could do on my Own.’). They can Also see it as a Cost (‘I've Got a Ton to do and when I Get Back the Pile will have become that much Higher’) or an Investment (‘Once I Get this under my Belt, I'll be Able to do Searches Twice as Fast and that'll Increase my Productivity and Give me yet more Leisure Time’).

As indicated in Chapter 1, the response to stressors is governed by numerous factors (e.g., previous experiences, age), and true to this, appraisals of stressful events may be influenced by several antecedent experiences as well as numerous dispositional factors (e.g., Power & Hill, 2010; Roesch & Rowley, 2005). In this regard, general appraisal styles have been associated with several global personality constructs, including hardiness, optimism, hope, hostility, trait negative/positive affectivity, and extraversion and neuroticism. Given the large number of factors that can influence how individuals might appraise a potential threat, it's perfectly predictable that unanimity is often lacking as to how certain stressors are appraised. Certainly there are stressors that virtually all people will perceive in a similar fashion (e.g. war, natural disasters). However, there are many less intense stressors that are somewhat ambiguous, which will be associated with diverse appraisals.

Whereas primary appraisals are mainly concerned with the perceived impact of a stressful event, secondary appraisals encompass those perceptions related to the resources available for successfully eliminating or attenuating a stressor. Essentially, the secondary appraisal poses the question ‘Can I cope with this threat?’. For example, when confronted with potential unemployment (an occurrence likely to be perceived as threatening or distressing), a secondary appraisal would comprise an assessment of the financial resources available to deal with the stressor (e.g., employment insurance) relative to the demands that will be placed on the individual (e.g., mortgage payments, tuition for kids, gasoline, food; along with other stressors that accompany being ‘let go’, including diminished self-esteem, anger, or shame). Thus, the apparent stressfulness of the event will depend, in part, on the degree to which that individual's resources are perceived to enable them to meet these demands. Of course, the appraisals that individuals make regarding a threat are influenced by a variety of contextual or experiential factors. For instance, in the case of potential job loss the appraisals might be affected by whether the individual is supporting others, whether they're near retirement and would have left the job soon, as well as the extent to which their identity was tied to the job.

Secondary Appraisals and Control Dimensions

One of the most fundamental aspects of secondary appraisals concerns our perceived control over the situation. Control can involve several different components or subtypes. Behavioral control comprises the ability to influence a stressful situation through the initiation of some sort of action, whereas cognitive control can be conceptualized as the ability to influence the situation by using some sort of mental strategy (Cohen et al., 1986). Another aspect of control comprises decisional control, which entails having a choice over the coping strategies available to deal with a stressor, provided that the situation allows for such choices to be made. Another element of control is concerned with informational control, which reflects the degree to which the individual is able to predict and prepare for stressful events. Although each type of control appears to be important in determining strategies to reduce distress, cognitive control likely promotes the most beneficial effects on well-being.

Appraisals, Decision Making, and Fast and Slow Thinking

As described in Figure 2.2, the way we appraise stressors goes a long way in determining the way in which we choose to cope with challenges. The model described by Lazarus is, in several respects, very reminiscent of a framework that has been adopted in decision-making theory, and it has much to offer theorizing related to stress processes and the development of stress-related psychopathological conditions. To a significant extent we make decisions or attributions based on what Tversky and Kahneman (1974) termed the ‘representative heuristic’ (Kahneman, by the way, won a Nobel Prize in economics for his work, but sadly Tversky died before he could be a recipient of this award). Generally, heuristics refer to strategies (or shortcuts) that are made on the basis of information that is easily accessed. These shortcuts might be based on an individual's experiences or rules that had previously been established. Thus, rather than going through lengthy processes to make decisions, individuals might simply resort to past practices, educated guesses, or rules of thumb. The representative heuristic is employed when individuals consider whether their current hypothesis regarding the occurrence of an event is consistent with everyday experiences instead of strict probabilistic considerations. When individuals are in stressful situations new learning is often difficult, but well-entrenched performance, memory, and decision making are not usually impaired. Evidently, in a problem-solving situation that occurs soon after being exposed to a stressor, problem-solving abilities may be compromised, and individuals are more likely to fall back on using a representative heuristic. Another heuristic comprises attribute substitution, which essentially means that when a situation is fairly complex, individuals will make decisions based on a simpler question, but without necessarily being aware that they are doing so. In this instance, they might choose certain attributes of a complex situation or a person, and apply these attributes more broadly. It also seems, as we'll see shortly, that certain emotions and personality variables might influence the way we appraise events and the decisions we make. Fearful individuals tend to exhibit pessimistic risk assessments and are risk averse, whereas angry people are more optimistic in their assessments and less risk adverse. Unfortunately, anger may also be associated with a heuristic in which individuals might not select from all the options available to them in a decision-making situation (Lerner & Tiedens, 2006).

In discussing the cognitive processes related to decision making, it was suggested that dual systems are in operation: an automatic operations system (dubbed System 1 or Fast Thinking) and a more cognitively-based system, termed System 2 or Slow Thinking. Kahneman (2011) explained that System 1, the automatic, fast thinking system, is highly influenced by our experiences, so that it is primed to react in a particular way in response to environmental events, whereas the cognitively-oriented slow thinking System 2 might kick in when more complex decisions need to be made.

Deciding on the Fly

Some decisions that we make are based on lots of thought and reasoning, but sometimes we need to make decisions rapidly and there might not be much time to do so. It seems that although the prefrontal cortex is generally involved in decision making, some aspects of this cortical region might be responsible for decision making that occurs on the spur of the moment, whereas others are based on experience and habits that had been formed earlier (Jones et al., 2012). It has been thought that ‘value-based’ decisions, such as those that occur when an individual appraises options and potential consequences, involve the functioning of the orbital frontal cortex. Based on studies among individuals that had sustained damage to this region, it was concluded that the orbital cortex is necessary when decisions must be computed quickly or that must be inferred. However, other cortical regions likely are involved when the decisions are based on ‘cached’ values that were determined by previous experiences. It will be recognized that this is not far removed from the Fast and Slow Thinking described by Kahneman, but anchors the notion to particular brain regions. Essentially, when the orbital frontal cortex is disturbed, decision making ‘on the fly’ suffers from an impaired ability to base decisions on prior experiences that allow options to be weighed appropriately. This has obvious implications for an individual's ability to learn from their mistakes, and may be relevant for the propensity to make bad decisions related to repeated drug abuse, especially as drugs such as cocaine markedly influence the orbital frontal cortex.

To a considerable extent our experiences and memories of experiences might prime our responses to particular events (Morewedge & Kahneman, 2010). In this regard, three factors will largely govern our response biases; associative coherence, attribute substitution, and processing fluency. Associative coherence refers to a particular stimulus eliciting a coherent and self-reinforcing pattern of associative processes; what this means is that the stimulus or event is consistent with our preconceived or primed ‘intuitions’. The second component, attribute substitution, means that when we have made a judgment about a particular stimulus, we might form further unconscious attributes about this stimulus, based on what we had learned previously in similar situations. So if we are primed to believe that Sarah is a charitable person, we might make further attributions about that person, such as Sarah is also kind, warm, and even a kindred spirit. Even though we know virtually nothing about Sarah, except for one characteristic (she is charitable), it primes us to readily believe or accept other features of her personality. Finally, processing fluency, or our subjective experience concerning the relative ease/difficulty involved in a given cognitive task, is influential in determining whether particular judgments will be made. There are a variety of factors that influence processing fluency in addition to previous experiences and priming, including the clarity and ease with which the information is obtained.

Turning back to primary appraisals in the context of stress responses, it seems that when we make an initial decision or appraisal about an event, this involves a semi-automatic process that might be enacted on the basis of the very same principles described by Kahneman in regard to decision making. Essentially, associative coherence, stimulus substitution, and processing fluency may be fundamental in defining our initial appraisals of a potentially threatening situation. Consider for a moment a sudden stressful occurrence that you experienced. If it was one that you had previously experienced or one that was similar to other events, then you might engage in responses that are ‘second nature’ to you and the resulting actions seem well rehearsed (hence, when going into some situations, a realistic practice run, even cognitively, is well advised). However, if the stressful situation is entirely out of the range of your expectations or experiences, then it may give rise to a confused response (or even an ‘out of body experience’) and it takes a few seconds or even milliseconds for you to ‘understand’ what is actually happening. It is then that System 2, or secondary appraisals, come into the picture so that appropriate decisions can be made.

There are situations that we get into where decision making is not clear cut. Indeed, we might find ourselves in circumstances where the conditions seem ambiguous because we don't have the knowledge or background to see it for what it is. By example, most of us won't have a clue concerning the value of a car or a house when we start out looking to make a purchase. Instead, we look at ‘anchors’ that help us make a decision (Kahneman, 2011). In this case, the anchor is the asking price (or what other houses in the area have sold for, or advice from an agent who is actually not on our side, but simply wants to make a sale), and after some negotiation we might come up with a number that is reasonable both to ourselves and from the perspective of the vendor. However, the seller could have asked for an amount that was 10 or 20% higher (or lower) and we would have gone through the very same process, simply because we have no idea what the actual value of the house or car might be. Of course, in some instances the starting point might be so far off the mark that we wouldn't even consider the purchase, but if it is ‘in the ball park’ then we might proceed with our negotiations none the wiser.

The very same thing holds true when it comes to making appraisals regarding threats to our well-being. We need an anchor to tell us what the threat means. When a government agency pronounces that the risk of a pandemic is high, we might ask ‘what's meant by high?’. Does ‘high’ mean that 99% of people will be affected, or is ‘high’ 30%, and what does this mean when it comes to the risk for me or those close to me? Furthermore, given the past track record of the agencies that inform us about all sorts of events (e.g., the media, government, or even some celebrity who holds forth on a subject in which s/he hasn't any expertise), to what extent should these anchors be discounted? After all, we've had numerous warnings from government agencies of things that simply haven't materialized. Even though we are able to process a fair amount of information, and we're able to appraise its value, it is often the case that our appraisals aren't at all sophisticated and might actually be tied to anchors that comprise nothing more than ‘what some guy said’ or list prices on a sign.

Appraisals and Misappraisals

Before we go any further, an important caveat needs to be introduced. We often assume that our appraisals of situations are, in fact, accurate. In part, this is likely correct. This also means that, in part, this conclusion is wrong. How accurate are our appraisals of situations? You probably know that when you're in a slump everything looks bad (this is your appraisal), and when you're riding high, then just about everything looks good, and even the obviously bad things look manageable. Essentially, when a person comes into a situation in a poor state of mind, then in dealing with stressors they might not see the world the way it really is, but instead see it from a narrow, dark, and gloomy place. It's under these conditions that we might want to look to our friends to get their reaction to events, as it's often easier for an outside observer to see things ‘in perspective’.

Just as we might make appraisals based on our own previous experiences, we also do so based on what others tell us or on the basis of what we believe that others think. Individuals frequently make social comparisons, and then form their appraisals accordingly. Experiments from decades ago illustrated that we tend to conform to what others do when making certain types of appraisals, and it seems that social comparisons are also made when it comes to some fairly stressful situations. Obviously, when you need to rely on the judgment of others over a certain issue, make sure that they're in the right state of mind for properly assessing a situation. At times, a person might find themselves asking for advice from a group of friends. However, as you have heard at some time or another, the appraisals and actions made by groups might be very different from those that any single individual might make. Specifically, when appraisals and decisions are made by a group, it is more likely that they will engage in greater risk taking than might be the case if they do so as individuals. This phenomenon, known as the ‘risky shift’, can come about owing to a diffusion of responsibility (‘we're all in this together, and we'll share the blame if things don't work out well’). Alternatively, it might be that individuals follow the example of others who are seen as more inclined to take on a risky position. Regardless of the source of the risky shift, this tells us that when we, as individuals, make appraisals of situations, the perspectives we come up with might differ from those made by a group.

There are also numerous situations in which individuals don't make evaluations of events on the basis of their own intuitions, but on the basis of what norms they believe exist. In a recent study we recruited college-aged women who were in psychologically abusive dating relationships and in whom symptoms of depression were elevated. When these women were shown a nine-minute video clip of a young woman describing her steadily increasing abusive relationship (escalating from mild criticism through to verbal and psychological abuse, and finally to clear physical harm), our abused participants, who we had expected would be upset by what they heard, were for the most part not at all upset. Indeed, some were upbeat, and even giddy. Our experimental probing suggested that these women seemed to be making social comparisons to justify the fact that they were staying in their current relationship, and the film clip served to validate their view that their relationship was actually normal. Essentially, some of these women indicated that ‘My relationship isn't all that great. But if my boyfriend treated me that way [referring to the video clip] I'd leave him’. Remarkably, however, when we measured the stress hormone (cortisol) that is detectable in saliva, their hormone levels were elevated in comparison to those of women who were in non-abusive relationships. So although their stated appraisal of the situation was that it did not distress them, their biological stress system seemed to tell us otherwise, and just witnessing the video and answering questions related to their own lives were sufficient to produce this outcome. Their verbal statements might have reflected a social comparison process, but we don't discount the possibility that their statements concerning their relationship might well have been a cover to avoid admitting that their situation was actually as abusive as it was (Matheson & Anisman, 2012).

Seemed like a Good Idea at the Time

Most of us have misappraised situations. Sometimes we make commitments to do things which at the time ‘didn't seem like bad idea'; however, our sense of dread increases as the time for action approaches. Ask any plane phobic about a holiday planned six months earlier, or the person with a fear of public speaking who agreed, many months earlier, to talk to a large group, and they'll say that it didn't seem like a bad idea at the time. When things are far off, there is an ‘illusion of courage’ that makes us less fearful of an event even though we've had lots of experience knowing that we won't deal with this well when the time comes (Van Boven et al., 2012). We're just not very good at appraising the distress of distal events. Clearly, what we need to do at the time of the invitation is perceive how we will actually react when the moment of truth comes along, and importantly, act on these feeling, rather than fool ourselves into thinking that things will be different next time.

Related to the fact that experiences influence how we appraise events is the notion that even subtle cues can prime us to perceive events around us in a particular way. We know, for example, that eye witness testimonies are frequently unreliable, and that our memories of events can be altered through subtle suggestions (Loftus, 2003). Priming, as Kahneman (2011) has indicated, can likewise be based on subtle factors as well as comments made by individuals in regard to a person or situation. If my best friend thinks someone is two-faced, and he tells me this, then when I meet this person I might well be very cautious or even negative. Related to this, stereotypes about certain groups or cultures can influence our appraisals, even if we are not consciously aware that this is occurring. Likewise, if an individual is primed to believe that a certain drug will reduce the pain that they're experiencing, they will report diminished pain after consuming the drug, even if it was only a placebo (see more on this in Chapter 12). A person in a ‘uniform’ or a relatively tall person is viewed as more authoritative than others, even if there's not a hint that this person is in the least competent. Our appraisals, and our misappraisals, intrude on a huge number of things that we do on a day-to-day basis, and often we might not have a clue concerning the subtle effects of such priming.

As mentioned earlier, our appraisals concerning the controllability of a stressor may have considerable importance in defining the coping strategies that we use and the behavioral and psychological outcomes that ensue. If we believe that we can influence a situation, then appraisals of that situation obviously ought to differ from those evident when we believe a situation is beyond our control. However, individuals frequently overestimate the degree to which they are able to exert control over otherwise chance events, and might be motivated to perceive control over their environment. It goes without saying that these misappraisals might produce difficulties that hadn't been anticipated, but this illusion of control might also have some positive attributes. When we perceive events as controllable, we are generally better able to deal with stressors through the adoption of problem-focused coping strategies (trying to diminish or eliminate stressors or somehow dealing with them in thoughtful systematic ways), which is usually considered a good way of coping. In a sense, the illusory sense of control may actually reflect an adaptive process for dealing with challenges. For instances, cancer patients who had the perception that they had some control over their illness exhibited lower levels of distress than did individuals who did not have these control perceptions (Ranchor et al., 2010). Illusory control in this instance might not affect disease progression, but at the very least, it allows for lower daily distress.

Finally, there are many instances in which situations, especially those of a social nature, are relatively unclear, as the messages we receive are subtle or may have multiple meanings. What does a slight frown by my colleague mean, and was it actually directed at me or was it a frown that wasn't directed at anybody in particular? If a situation is uncertain or ambiguous, it's fairly difficult to make proper appraisals. Often, this is compounded by the fact that appraisals regarding stressors are made at the very time when we might be least well prepared to make accurate appraisals – that is, while we are in a threatening situation our judgment may be influenced by our emotions or our inability to see things objectively.

Appraisals and Irrational Thinking

There is yet another aspect of uncertainty/ambiguity that is central to our analysis of appraisal processes. This issue also falls into the category of decision making rather than appraisals, but appraisals of choices and making decisions are (obviously) intricately linked. Kahneman and Tversky have made the point that individuals often behave in apparently odd ways, often making seemingly irrational decisions. In one interesting study, students were placed in a situation where they were told to imagine that they had sat a very important exam that would determine their future. They were then asked to imagine that the grades would be posted in two days’ time. Some students were told they had passed the exam, whereas others were told they had failed. At this point they were also told that they had the opportunity to take a nice holiday trip, and were asked whether they would take this trip. Those students who had passed and those who failed frequently indicated that they would take the trip – presumably those who passed saw it as a reward for their hard efforts, and those who failed saw it as a chance to diminish their despair. Essentially, all the students indicated that they would indeed take the trip, although they would do so for different reasons. Now comes the really interesting part. In a second study, students were told that the exams would be posted in two days’ time, but this time they were given the option of either (a) going on the trip immediately (before the results of exam were released), (b) foregoing the trip, or (c) paying a $5 fee to hold their ticket (delay the trip) until they had received their grades. The students did what you would probably do – they paid the $5 to have the ticket held. Does this decision make any sense at all? In the first experiment students indicated that they would be taking the trip regardless of whether they passed or failed! Yet when offered the option of waiting (and paying $5) they tended to choose this, despite the fact that they would likely opt to take the trip irrespective of their grade. So what might have motivated this behavior? It seems that uncertainty gives rise to some interesting ways of coping that are understandable, even if they are irrational.

Too Many Choices

Retailers know that giving the consumer too many choices isn't always the best idea; when faced with too many choices, with varying attributes and prices and confusing information, the potential consumer goes away to ‘think’ about it. My friend, a retailer, tells me that when she hears this she wants to scream ‘Think about it? What's there to freakin think about? We're talking about a toaster. A toaster! Not whether you should go for chemo vs. mastectomy!’.

We can go on with numerous examples of the irrational decisions that people make, but the main topic of this book is about stress, and in this context we often witness people make bad decisions that then have negative repercussions. You might recall from our earlier discussion of stress generation that stressed individuals seem to get themselves into increasingly distressing situations. They make poor appraisals and then choose the wrong methods of coping, and they do this repeatedly. Let's use a very simple example of this. At the end of this chapter there is a questionnaire to measure how individuals cope with stressors. In our research we use this coping inventory a fair bit. In some experiments we ask participants to indicate, on a 5-point rating scale, to what extent they use each of the coping responses to deal with particular stressors. In some of our experiments we also asked participants to indicate how effective they thought these coping strategies would be in dealing with a given stressor. For many people, particularly those who seemed fairly well adjusted, there was a match between the coping method they chose and how effective they thought it might be. However, others, particularly individuals with high levels of depressive symptoms, favored particular coping styles, despite their belief that this coping method wouldn't be effective. I can almost hear them saying ‘I know my coping responses weren't good, but I just didn't know what else to do’. You might want to complete the questionnaire in relation to a recent stressor you experienced, and then go through it a second time to determine whether you think the coping behaviors you selected were effective.

There are, of course, many factors that go into the irrational behaviors that individuals display. For some, their personality characteristics don't allow them to do what's necessary. There are individuals who are so afraid of making wrong decisions, or who can't abide with feelings of regret, that they end up not making any decisions. For others, too many choices are daunting and they too end up making no selection at all. In still other situations procrastination might be a way of dealing with the anxiety associated with making decisions (putting off seeing a doctor regarding certain suspicious symptoms), and they continue with these clearly maladaptive behaviors in the full knowledge that their procrastination might have negative consequences (Steel, 2007). (I'm told this is a ‘guy thing’, but I'm not so certain of that.) Not surprisingly, perhaps, the greater the stakes the more difficult it might be for decisions to be made. For instance, decision making by parents regarding pediatric medical procedures can be an enormous strain (Lipstein et al., 2012), especially when once the decision is made, it can't be unmade. Sometimes the decisions individuals have to make are at an entirely different level, such as moral decision making. In an experimental setting, individuals might be presented with a scenario that entails choices that are difficult to resolve (e.g., in experimental paradigms in which the participant is given the choice of actively sacrificing one person in order to save the lives of several others). You'd think that such decisions would be based on logic or empathy, but there are actually a large number of factors that influence outcomes. Not unexpectedly, perhaps, the decisions made in these situations are very much influenced by the recent stressors that individuals had encountered (Youssef et al., 2011).

Human behaviors in response to stressors are, in several respects, not all that far removed from the responses that rodents show under adverse conditions. When animals are in stressful situations, their defensive repertoire may narrow to those responses that are highest in their repertoire, and other response strategies will emerge only as the predominant strategies are rejected; however, there are occasions where animals might persist in emitting these incorrect responses despite the fact that they are never reinforced. In a sense, this is not unlike human behavior under the conditions of strong challenges, wherein individuals fall back on those strategies that are highest in their repertoires (resorting to the tried and true), even if this approach isn't the most logical or effective. However, humans have a System 2 that kicks in when the reactions of System 1 are clearly not productive, and this serves us well in decision making even when we find ourselves in some very stressful situations.

Trusting your Brain and Trusting your Gut

As we learn new things and retain this information, millions of neurons within the prefrontal cortex are firing, and the repeated activation of these neurons is necessary to keep short-term memories in place. Should these neurons stop their systematic vollies, the memory will quickly be lost (think of how quickly you forget a phone number when you're interrupted). Understandably, when stressful events occur, our short-term memory will be disrupted, possibly because some of the neurons that were working to maintain that memory were now engaged with some other task. As memory processes are integral to problem solving and decision making, in the face of stressors it's efficient and practical to rely on heuristics that are well entrenched. People working in high-pressure situations (surgeons, air-traffic controllers, soldiers), need to be well trained so that when stressors erupt, as they invariably do, they have the short-cuts available to them that allow for rapid and appropriate decision making.

There are situations that are somewhat ambiguous and making decisions is understandably difficult. In these situations we might make decisions based on our intuitions (or trusting our gut). Perhaps not surprisingly, even though the situation was ambiguous, those with expertise fared better with respect to their decisions even though they relied on gut responses compared to those without the same level of expertise. Interestingly, however, when told to ignore their gut instincts and rely on a strict analytical basis, the experts and non-experts performed equally. It may be that there are heuristics here that kick in when making gut decisions that can take us some way if the gut instincts are based on brain processes (Dane et al., 2012).

Most students, at one time or another, have been faced with the dilemma of whether they should accept their first response in a multiple choice exam, or rethink it and perhaps change their initial answer. From the research described here, it seems that if you know your stuff, then go with your first instinct. If you don't know your stuff, then an analytical process won't help you much, so you might as well go with your gut. However, if you fail the exam don't blame me for giving bad advice. Maybe you should have been attending classes more often …

Appraisals and Personality Factors

The meaning that a person constructs about any given situation, as well as their own capabilities in dealing with these events, might not only be related to events that involved similar experiences, but can vary with the individual's global self-constructs that emanate from a lifetime of experiences, including those that occurred during childhood (Carver & Connor-Smith, 2010). In this respect, uncontrollable adverse events during childhood (e.g., abuse, neglect, or parental loss) may lead to the emergence of dysfunctional beliefs that can distort the individual's evaluation of their own coping capabilities or competency. These evaluations might influence the individual's self-efficacy and the way the individual appraises the specific characteristics of stressful encounters. Unfortunately, once these negative self-referential attitudes are well entrenched they're not easily dislodged, and misappraisals of situations might be more common than we'd imagine. It also seems that highly extraverted individuals tend to appraise situations as challenges, whereas individuals high in neuroticism are apt to appraise situations as more threatening (Gallagher, 1990; Hemenover & Dienstbier, 1996). We won't go through the numerous personality factors that affect stressor appraisals, but we can readily understand that several other global personality constructs, including hardiness, optimism, hope, hostility, trait negative/positive and affectivity, would influence our appraisals of potentially stressful events.

Of the methods used to diminish distress and the illnesses that stem from stressful experiences, several include attempts to change the way individuals appraise events. Rather than engaging in negative thinking, individuals are taught to appraise events in a more positive or more realistic manner, and then to deal with stressors based on these appraisals, even though this might be a personality feature that is difficult to modify. Fundamental to these approaches is the avoidance of entering situations with a negative perspective. Thus, while some aspects of stress management entail proper ways of getting rid of or coping with distress, an important aspect involves changing an individual's appraisals of events around them. A whole school of thought, now termed ‘positive psychology’, has formed around the concept that positive perspectives and expressions of particular personal characteristics can be essential to foster well-being (Seligman & Csikszentmihalyi, 2000). What this means is that rather than follow the medical model in which attempts are made to diminish the symptoms of illness, the aim of positive psychology is to promote well-being by acting prophylactically to prevent the development of stress-related pathology (Schueller & Seligman, 2008). In this regard, a treatment referred to as positive psychotherapy (or PPT), which essentially comprises a series of exercises to instill positivity, reduces signs of depression in a subclinical population as well as in clinically depressed individuals, and this procedure was superior to antidepressant medication (Schueller & Seligman, 2008).

The Forecast

… how many will pass from the earth and how many will be created; who will live and who will die; who will die at his predestined time and who before his time; who by water and who by fire, who by sword, who by beast, who by famine, who by thirst, who by upheaval, who by plague, who by strangling, and who by stoning.

Who will rest and who will wander, who will live in harmony and who will be harried, who will enjoy tranquility and who will suffer, who will be impoverished and who will be enriched, who will be degraded and who will be exalted.

Fans of Leonard Cohen might recognize that this Rosh Hashana prayer of atonement might be at the root of his poem/song, ‘Who by Fire’. Our take-home message might be that while life isn't all that predictable, most of us don't spend our time worrying about all the ‘ifs’ and ‘maybes’. Although we know we're eventually going to get hammered in some form or other, we manage not to think about it. Illnesses are a long way off, and might even happen to someone else and not me. Perhaps this is an excellent strategy to deal with uncertainty, since focusing on potential catastrophes likely isn't profitable. What we can do, however, is recognize that there are certain behaviors (or lifestyle factors) that can affect the risk of bad outcomes and we're probably better off dealing with those.

Appraisals in Relation to Learning, Memory, Automaticity, and Habit

Years ago, Hebb (1955) formulated the view that as we learn new information the connections between neurons are strengthened, and the assembly of cells involved in recognizing objects and responding to them appropriately is both strengthened and widened. Complex learning and memory involve still broader cell assemblies or networks, and once the connections are sufficiently strengthened, stimulating one aspect of the network will result in the entire cell assembly being triggered. So, for example, if I tell you that a word in this sentance (the one you are reading at this moment) is actually spelled incorrectly, you might have to go back again to find the error. Likewise, you won't have any trouble understanding the statement ‘a frnd in ned is a frnd indd’. This is because your cell assemblies are in place, and once a component of the cell assembly is activated, you can interpret the sentence appropriately.

According to this formulation, learning occurs via a top–down approach; we learn through a trial-and-error process, through associations being made, by being rewarded for certain responses, and generalization (a grizzly bear is a grizzly bear regardless of whether we see it from the front or from the side) and discrimination (grizzly bears are dangerous, but not when they're in an enclosed area within a zoo). As topics become more difficult, the networks involved become more complex, but we take advantage of already developed networks so we can build on these. Some perceptions and responses are so deeply ingrained that we will respond reflexively to particularly stimuli, essentially working on auto-pilot or using automatic thoughts (Kahneman's Fast Thinking or Negative Thinking biases displayed by some individuals). Related to this, some of our behaviors are so exceptionally well entrenched that we can engage in them repeatedly (habits), which essentially reflects a bottom–up approach. When we try to solve problems we often use methods that were successful in the past, with the attitude that if the wheel has already been invented, why should we try to build something new? This axiom has been around for a long time, but it isn't always a correct perspective (for that matter, I can see somebody, somewhere, having said that if we already have a perfectly useful abacus, why try something new?). Sometimes, we simply need novel approaches to old problems.

These same processes are pertinent to how we appraise and cope with stressors. To a certain extent we are hard-wired to respond to environmental stimuli in a standard manner (fixed action patterns). Young birds, for instance, respond in a stereotypic fashion to a visual image of a hawk moving across their visual field, and animals often respond to warning signals from other animals without having had previous relevant experiences. These automatic responses are essential; an antelope might not get a second chance to discover that a lion running at it is, in fact, a threat. In other cases, factors related to learning (attention, memory) are fundamental in stress processes being established. Essentially, we are equipped with both top–down (experience– dependent) circuits, and those that develop through a bottom–up approach (prewired).

There is considerable evidence that our cognitive functioning, particularly in relation to appraisals of stressors, may be warped by previous experiences. In the preceding sections we saw this repeatedly, but what is particularly noteworthy is that certain appraisals may come to occur in an automatic fashion. For some individuals, depending on their personality attributes and previous experiences, these automatic thoughts involve a negative bias. Thus, for example, when we ask depressed individuals to recall previous experiences, they tend to recall more negative than positive events (Ingram et al., 1995), and also tend to recall a greater number of negative emotional words than those that have a positive valence (Taylor & John, 2004). Essentially, by experiencing and learning about events in a particular way, automatic response sequences (or habits) may be established so that we will appraise these events in a stereotyped negative way when we later encounter them. Unfortunately, habits are hard to break, and getting ourselves out of negative mind sets takes some doing.

Emotional Responses

Just about everyone realizes that positive and negative events will give rise to different emotional responses. The nature of these emotional responses will depend on how an individual appraises an event (conversely, emotional responses can also influence appraisals), and the context in which the event occurs, as well as previous experiences, personality factors, and motivation. In this brief section we'll discuss emotions associated with stressful experiences, but I have to admit here that one can hardly do justice to such a complex and fascinating topic in only a few pages, particularly given the vast literature that exists (see for example the work of Damasio, 1999).

A given event might elicit different emotional responses across individuals owing to particular experiences, various developmental factors and other related socialization processes. As well, damage to certain parts of the brain owing to a stroke or lesions may profoundly influence emotionality, ranging from a loss of emotion and affect through to excessive responses to certain types of stimuli. Moreover, just as individuals may differ in their intellectual capacity and social intelligence, there are individual differences concerning emotional intelligence (Salovey & Mayer, 1990). Essentially, emotional intelligence is thought of as an ability that involves multiple skills related to emotional perception and expression, the emotional facilitation of thinking, emotional understanding and emotional regulation, as well as personality characteristics and other traits (e.g., optimism, motivation). Some people are adept in this regard, whereas others seem to express their emotions in odd ways and also seem unable to read the emotions of others. An extreme form of this inability to understand emotions is alexithymia, a trait in which individuals seem to have difficulty in identifying their own feelings, describing their feelings, or understanding the feelings of others, and in fact, they might look to others in emotional situations to see how they ought to react.

Distinguishing between Emotions

There are subtle differences that exist in emotional responses to stressors and, as seen in Table 2.1, our vocabulary is replete with descriptors that reflect these differences. In addition to these individual emotions, several emotions can also occur concurrently in response to a single event (seeing a certain person can elicit jealousy, hatred, and anger concurrently), and sometimes it's difficult for us to even understand the emotion that we are feeling. Likewise, a particular event can instigate one emotion in a given context, but a very different one in a second situation. By example, a racial or religious epithet can cause an individual to feel anger when it occurs, but if this occurs in front of others, and the individual thinks that these other people believe the slur, then it might cause feelings of shame. Some emotions differ from one another in ways that might be related to the context in which certain events occur. For instance, fear and angst are very similar, but fear is thought to be directed to a specific stimulus, whereas angst is sometimes thought of as a non-directed emotion. Likewise, shame and embarrassment/humiliation are very similar in that they each occur in response to one's own socially or professionally unacceptable behavior that comes to the attention or is witnessed by others. Each also involves the loss of honor (dignity). However, whereas embarrassment and humiliation are emotions that occur in front of others, shame can also occur as a result of an unacceptable behavior that only the individual knows about.

The emotions mentioned up until this point have been largely those of a negative nature, but there are also many positive emotions that can alter the way we appraise stressful events: desire, ecstasy, excitement, enthusiasm, euphoria, hope, joy, love, lust, passion, pleasure, pride, trust, and zest are just a few of these. They're as complicated as the negative emotions,and obviously appear under different conditions. Sometimes these emotions can combine with those of a negative nature to elicit ‘mixed emotions’ or those that are ‘bittersweet’. Watching adult kids leave home can leave an individual feeling both pride and loss/loneliness, and having a loved one pass after a lengthy illness can similarly result in both relief and sadness. Of particular relevance to the present discussion is that if positive emotions can alter the way we appraise and hence respond to stressful events, then the positive psychology mentioned earlier can potentially be an effective way of precluding the despair and depression that might otherwise be endured in negative situations.

Stress-Related Emotions

Clearly, emotions can involve multiple mechanisms, and because more than a single emotion can occur at the same time, they are often difficult to study, certainly in the context of identifying biological correlates of emotions. Further, we often resort to animal studies to analyze the biological responses associated with certain emotions (e.g., fear, anxiety), but there are limitations to what can actually be evaluated in animals (Do mice feel emotions such as shame or guilt, and if they do, how can we tell?). What does seem to be the case is that while there are wide arrays of emotions that emerge under diverse conditions, these all serve several common or interrelated functions. Among other things, they provide us with information about events around us. They also let others know how we're feeling (unless we can successfully hide our emotions), allowing them to take measures that are corrective (apologize), supportive (sympathy), or defensive (aggressive, indignant). However, there are nuances to these emotions that give us more detailed information than simply ‘things are bad’ or ‘everything seems to be okay’.

You're probably aware that there are different types of pain, and they have different meanings and implications (e.g., to a physician). There are sharp pains and dull pains, those that continue or are intermittent, pain that throbs and that which is steady, pain that is localized or that which is widespread or radiates. Likewise, different emotions can tell us about the situation we're in and whether defensive actions should be taken, and what these actions should comprise. By example, anger is an activating emotion, so that in response to some transgression (e.g., a slur against one's group), an individual might want to take an angry or aggressive stance toward the perpetrator. Concurrently, that person may feel shame/embarrassment, which is an emotion associated with withdrawal or suppression, and as a result they might be less likely to act on their anger. This decision might potentially save them from the ill-feelings of a group of bystanders who might view aggression as socially unacceptable, although the individual might later experience a period of pervasive rumination about the event and what they should have or could have done differently. Yet it is exactly this experience that provides individuals with critical information, namely that they can't deal with this issue on their own and that collective action by group members will be needed instead (Matheson & Anisman, 2012).

Just as emotions can influence cognitive processes, cognitions can influence emotions or the way emotions are expressed. For instance, an aggrieved party ordinarily might become aggressive towards the person who angered them. However, the expression of that aggression might be more likely if the potential victim of this aggression was appraised to be smaller and weaker, and less likely when that person looks strong and able. The ‘aggrieved’ person may be angry, but in some instances they seem to have executive control regarding behavioral outputs. We often hear the statement ‘I just lost control’. This might be true in some instances, but it may also be the case that individuals ‘allow’ themselves the luxury of losing control when the opponent is viewed as weaker.

As we've already seen, positive or negative moods have a lot to do with how we appraise or interpret events around us. Likewise, being angry or envious will alter appraisals of events related to the person who we are angry with or of whom we are envious. More than that, however, our emotions can alter our general disposition to react in particular ways to unrelated events. There's nothing very surprising in this, but even though we all seem to know it, it is remarkable how often we ignore this basic bit of knowledge. We've all heard of the boss who, when in a bad mood, might pick on an employee, or the parent who, having had a rough day, then takes it out on a partner/child. These individuals can't seem to compartmentalize their responses, and their mood increases their own stress reactions, giving rise to stress in others, and concurrently they lose potential sources of support that might otherwise have helped them deal with their own distress. Most of us also know that our emotional responses will affect our decision-making ability, particularly if this entails complex and/or stressful aspects. By example, in his (1993) book on negotiating, Getting Past No, Ury offers the sound advice that when stress levels are high and emotions are peaking, it's best to ‘go to the balcony’ (meaning, remove yourself from the situation and see what's going on as an observer, rather than being enmeshed in the turmoil). In this way we can see the scene for what it is, unhampered by our emotional responses.

We've known for a long time that the limbic portion of the brain plays an integral role in emotional outputs. For instance, fear and anxiety are associated with the central portion of the amygdala and the extended amygdala (a region referred to as the bed nucleus of the stria terminalis), whereas the ventral tegmentum and nucleus accumbens (midbrain regions that we'll talk much more about later) seem to be involved in reward/motivational processes. However, these brain regions do not operate in isolation from other regions, but cooperate with one another to produce organized outputs. Connections exist between the prefrontal cortex and the amygdala, so the brain regions involved in decision making (the cingulate cortex, prefrontal cortex) can influence those involved in anxiety (the amygdala). It also seems that some brain regions, such as the nucleus accumbens, may contribute to more than a single type of stimulus, being activated in stressful as well as rewarding situations. Presumably, complex emotions that entail an amalgam of primary emotions involve multiple brain regions interacting with one another.

It might be expected that different emotions may also be tied to diverse peripheral physiological changes. Just as specific events can give rise to different emotional responses, distinct patterns of cardiac and respiratory activity have been associated with fear, anger, sadness and happiness (Rainville et al., 2006). Likewise, the release of the classic stress hormone cortisol occurs preferentially if the stressful event elicits shame (Dickerson & Kemeny, 2004) or anger (Moons et al., 2010), and the immune responses elicited by stressors similarly depend on the specific emotions elicited (Danielson et al., 2011).

Coping with Stressors

Appraising stressors appropriately is only half the story regarding how stressors can influence well-being. The other half is concerned with how individuals cope with stressors. Some theorists have viewed coping as a style (i.e., a dispositional feature that is relatively stable), whereas others have seen this as a strategy that varies in response to situational factors and varies over time as the stressor and its ramifications unfold (Tennen et al., 2000). There is also a middle ground in which it is supposed that the coping methods used vary as a function of the particular situation encountered, but these methods are guided by the particular coping styles that individuals bring with them to the situation. This hardly seems surprising, but it had at one time been a topic of some debate. In the section that follows we'll go into a fair bit of detail regarding coping processes, but as we do, keep in mind that coping may stem from the way individuals appraise events, but it also may affect appraisals. We're dealing with dynamic processes that are subject to feedback and frequent adjustments.

The Stress–Appraisal–Coping Triad

There are numerous coping methods that can be used to deal with stressful experiences. These can be in the order of a couple of hundred actions or behaviors, but they are usually classified into about a dozen different subtypes that fall into two or three general types that comprise problem-focused, emotion-focused, and avoidant strategies (disengagement). There have been other names for these strategies, and other classification systems described, but these categories are probably the most widely used. Emotional coping subsumes multiple strategies (e.g., emotional expression, emotional containment, rumination, self- or other-blame, withdrawal,denial, and passive resignation) as does avoidant coping (avoidance, denial). Problem-focused coping, as the name implies, primarily involves coping through problem solving, or through other cognitive processes that can be used to deal with stressors, such as cognitive restructuring (re-evaluating the threat, or finding meaning in a bad event). In addition, there are methods of coping that don't fall comfortably into any single class as they can be used in multiple capacities. For instance, one can use social support in an emotion-focused capacity (a shoulder to cry on), in problem-focused coping (‘Help me find a way out of this jam’), or in an avoidant capacity (e.g., through distraction). Likewise, active distraction (e.g., going to the gym to ‘work off’ anxiety) and humor can fit into each of the categories, but more often they align most closely with problem-focused coping. Both wishful thinking and rumination are usually viewed as emotion-focused coping methods, but this may depend on what other coping methods are used concurrently. Thus, if individuals ruminate and feel sorry for themselves, then this is clearly emotion-focused coping, but some individuals use rumination together with problem solving, in which case it is not part of an emotion-focused strategy. Finally, religion doesn't fit well within any of these categories; it may represent an avoidant strategy, but it can also be used as a problem-oriented strategy or one that involves obtaining social support from like-minded people (Ysseldyk et al., 2010).

Coping through Religion

Religion is potentially a very effective coping strategy, even if it doesn't (necessarily) have healing powers that some have attributed to it. For religious individuals, it may provide comfort when all else fails. Religion can provide a system of beliefs that allows individuals to find meaning in an experience, and to appraise events as predictable and at the very least ‘under God's control’. In addition, it often provides a social support network that enables problem-oriented coping, or even emotion-focused strategies that bring about solace and peace of mind.

Marx disparagingly stated that ‘Religion is the sigh of the oppressed creature, the heart of a heartless world, just as it is the spirit of a spiritless situation. It is the opium of the people’. The response to this might be ‘Whatever gets you through the night’ (Lennon, 1974; this should of course be distinguished from the other Lenin), provided, of course, that this is not used as an alternative to potentially more effective coping strategies. Indeed, rather than seeing religion as the opium of the people (masses), it can be argued that among some groups it serves as the SSRI (or the CBT) of the masses.

How to Cope

It is often thought that when appraisals and coping strategies are ineffective, then the development of pathology might ensue, whereas effective coping will limit such outcomes. If only it were this simple. Trying to analyze the relations between stressful events, coping strategies, and the emergence of pathological states isn't as straightforward as simply correlating individual coping strategies with particular outcomes. Appraisals and coping strategies not only vary across situations, they also do so with the passage of time (DeLongis & Holtzman, 2005; Tennen et al., 2000) and the subjective construal of the stressor. Added to this, individuals won't use a single strategy at a time, but may use several strategies concurrently, or flip from one to another as the situation demands, as well as on the basis of the opportunities and resources available.

The specific coping strategies that individuals endorse might serve different functions as a stressor evolves over time. By example, when an individual first learns that they have a potentially fatal illness, one of their first reactions (once the shock has worn off) might be one of seeking support from their relatives (spouse, children) or close friends. The function of this might simply be to use the support as an emotional-coping method. This might be followed soon after by the use of this support group to obtain information (e.g., to find out whether alternative treatment strategies are available). Later still, the support may become one of an instrumental nature (taking the person to treatment sessions, supplying food), and finally, in a worst case scenario, social support may be used to provide social comfort, distraction, and finding peace.

It is often taken as axiomatic that in situations in which the individual has control, problem-focused strategies (e.g., problem solving, cognitive restructuring or positive growth) that are seen to be adaptive will predominate, whereas those strategies that encourage an undue focus on emotions (e.g., rumination, emotional venting, self-blame) are viewed as counterproductive and maladaptive. This simple view is intuitively appealing. Yet it is also a bit simplistic, especially as emotion-focused coping ought to be viewed as comprising either emotion-approach or emotion-avoidant features. In certain situations the latter coping method (e.g., using avoidance/denial) might be an optimum strategy (e.g., when learning that one has a terminal illness). Likewise, although avoidance often works against individuals’ well-being in the long run, it may provide temporary relief from an ongoing stressor, giving someone the opportunity to adopt (or develop) more effective strategies. As well, emotional approach strategies that allow the individual to modify or regulate negative emotional responses can have positive effects in several stressful situations. This coping method can generally be subdivided into emotional processing (e.g., attempts aimed at acknowledging, exploring, and understanding emotional responses to challenges) and emotional expression (reflecting verbal and non-verbal messages concerning the emotions felt). In emotionally-charged situations, emotion-focused coping might be particularly beneficial as it facilitates the individual's ability to come to terms with their feelings, and in so doing distress may be reduced (Stanton et al., 1994). To be sure, emotional expression without coming to an understanding of these emotions can be disruptive, especially when this coping method involves inappropriate rumination or gives rise to negative affect and appraisals.

Table 2.2 provides a description of several coping strategies that individuals might use in dealing with distressing events. As we've seen, any given coping strategy may serve different functions, or operate to facilitate or inhibit other strategies. Despite the frequent discussion of which coping strategies are good and which are bad, keep in mind that individuals do not endorse coping strategies in isolation of one another, and different coping strategies are used concurrently and/or sequentially. Individuals can ruminate and problem solve concurrently,and they can ruminate and blame at the same time. And in addition to this, they can shift from one strategy to another and then to yet another all within a short time-span.

One would think that if a particular strategy proves ineffective in attenuating the impact of a stressor, then it would be advantageous for an alternative strategy to be adopted. Yet, under certain conditions, cognitive functioning may be impaired, limiting the adoption of new responses. In times of distress our repertoire of responses may be narrowed so that only our prepotent (or well-entrenched) responses will be used, whereas other coping methods, as effective as they might potentially be, will fall by the wayside. In still other situations, particularly those that involve a high degree of ambiguity (e.g., ‘Will the biopsy show the tumor to be malignant or benign?’, ‘Can we expect biological terrorism?’), individuals may find themselves uncertain about what to do, and end up taking few coping initiatives on their own. In these instances, a good role model or leader can be especially worthwhile.

So, what differentiates individuals who are good at dealing with stressors from those who are not? As already indicated, how we appraise situations is fundamental in this regard. However, assuming that an appropriate appraisal is made, it seems that those individuals who are adept at using a relatively broad range of coping strategies, and prepared to be flexible in their use (i.e., able to shift from one strategy to another as necessary), may be best suited to deal with stressors. In contrast, stressors will most negatively affect those individuals with a restricted range of coping methods, or rigidity in turning away from ineffective coping strategies. Further to this same point, the functional effectiveness of coping is not simply determined by which strategy is used, but also by how various strategies are used in conjunction with one another (Matheson & Anisman, 2003). As a case in point, although rumination is frequently associated with depressive illness (Nolen-Hoeksema, 1998), it typically occurs together with other coping strategies. In fact, in non-depressed individuals rumination co-occurred with a broad constellation of problem- and emotion-focused strategies, as well as cognitive disengagement (e.g., ‘I'm going through some pretty bad times, but if I talk to the guys at work they might have some ideas about what I can do’). In contrast, among dysthymic patients (those with chronic, low grade depression), rumination was primarily associated with emotion-focused coping, and inversely related to efforts to disengage (e.g., ‘I'm going through some pretty bad times, and it's because I'm just a failure at everything I do or ever will do; I just want to lie here and never see the world again’) (Kelly et al., 2007). We don't know what came first; the depression might have preceded the narrowed coping methods, but it is often thought that poor coping favors the emergence of depression. In either event, poor coping seems to involve the use of rumination in conjunction with emotion-focused coping strategies rather than with an array of other strategies.

There is yet another oddity in the way individuals cope or problem solve that varies as function depending on whether they had previously been stressed. When placed in a problem-solving situation, individuals who had not been stressed tended to consciously take the simplest approach to figure out how things worked, and concurrently their hippocampal activity was high (the hippocampus is involved in memory and its activation serves participants well in this problem solving situation). Stressed participants, in contrast, tended to use excessively complex strategies, even if they could not verbally express why they chose the strategy that they did (i.e., it seemed to be a subconscious undertaking). In this instance, brain imaging revealed that the problem-solving effort was accompanied by activation of the striatum that might be more aligned with unconscious learning. In effect, stressful events may influence the way we deal with situations, moving us away from purposeful, conscious approaches.

The Good Fight

For as long as I can remember, there has been this notion that fighting against an illness might increase survival, whereas feelings of helplessness and hopelessness would have the opposite effect. This is epitomized in movies where the doctor says about the star that has just undergone some brutal surgery to remove a bullet or a tumor ‘Well, it's up to him/her now. But, I think Matt/Marlene is strong and has a will to live’. It's as if the patient has some control over events (does this also mean that if they were to die, then they'd be to blame?). In fact, feelings of helplessness and hopelessness have been negatively related to five- and ten-year survival following breast cancer treatment (although the strength of the relationship was only moderate). However, there have also been reports that having a ‘fighting spirit’ was unrelated to survival. So, although negative appraisals and mood might lead to poorer outcomes, having a positive spirit and the will to fight simply doesn't impress or worry cancer cells.

The advice that is commonly given to those who are critically ill is ‘don't give up’, ‘be strong’, or ‘fight against your illness’, and obituaries make reference to ‘the valiant battle’ or ‘fought bravely to the end’. Most (or maybe only some) of us also know the words from Dylan Thomas's famous poem: ‘Do not go gentle into that good night, Old age should burn and rage at close of day; Rage, rage against the dying of the light.’ There is certainly much to say for putting up the good fight, and there's no doubt that social support can help in this regard. Yet in reading Thomas's poem you might want to note the use of the term ‘good’ in referring to night in the very first line, even though there is the encouragement to ‘rage against the dying of the light’. Perhaps the night can be good, especially when raging against the dying of the light has proven to be useless and the person has suffered a long and painful illness. It is under these conditions that the social support a person receives can serve as a comfort that might help the person let go and die peacefully. In fact, I believe (although there's obviously no evidence to support this belief) that sometimes a dying person is waiting for their family to allow them to go gentle into that good night.

Assessing Appraisals and Coping

Several instruments have been developed to assess the coping styles or strategies that individuals endorse in stressful situations. In general, methods of evaluating appraisals of events are less common than those assessing coping methods. Often, participants are asked to think of an event or are provided with a depiction of an event, and then simply asked how threatening and stressful they perceived that event to be, and how much control they think they had over it. There have also been scales developed to assess stressor appraisals, with one of the most commonly used being the Stress Appraisal Measure (SAM) (Peacock & Wong, 1990). The SAM is thought to measure three aspects of primary appraisals, namely challenge, threat, and centrality, as well as secondary appraisals comprising resources available to contend with a particular event. This widely-used instrument typically has much to offer, especially when used in conjunction with an analysis of the coping methods used.

Coping methods have been assessed through various scales. One of the earliest measures in this regard was the Ways of Coping Questionnaire (WOC), which assesses the degree to which individuals endorse specific coping strategies in response to a specific stressor that the participant indicates they had recently encountered (Folkman & Lazarus, 1988). This scale comprises eight subscales, six of which assess problem-focused coping, and two which reflect emotion-focused coping. A degree of dissatisfaction with this approach has been expressed (e.g., Endler & Parker, 1994), which has prompted the development of still other scales.

The Coping Response Inventory (CRI) developed by Moos et al. (1990) assesses the individual's appraisal of a specific stressor and then divides coping into approach and avoidance responses, as well as cognitive and behavioral coping. The Coping Orientation to Problem Experience (COPE) inventory developed by Carver et al. (1989) assesses how individuals generally deal with stressful events. This measure comprises 15 strategies that are typically organized into problem-focused coping (e.g., planning), adaptive emotion-focused coping (e.g., humor), and finally, maladaptive emotion-focused coping (e.g., denial). Similarly, the Coping Inventory for Stressful Situations (CISS) developed by Endler and Parker (1994) assesses the frequency with which individuals endorse particular coping strategies for dealing with stressful events. Finally, Matheson and Anisman (2003) developed the Survey of Coping Profile Endorsement (SCOPE) to assess coping styles and strategies, and subsequently used this scale to measure appraisals of coping effectiveness (see Table 2.3). This questionnaire asks participants how they would cope with stressors in general (coping styles) or in response to specific events (strategies). The SCOPE comprises 14 subscales aligned with those described in Table 2.1.

These coping scales have a fair bit in common with one another: there is overlap in some of the items, dimensions of coping, and when factor analyzed (a statistical method to determine which of several variables link or cluster together to create distinct factors), they all provide either the two- or three-dimensional structure already described (e.g., problem-focused, emotion-focused or avoidant coping). Thus, the choice of instrument an investigator might use depends on the stressor of interest as well as the fit with the researcher's own theoretical approach to understanding the issues at hand, or with how they wish to use the data. There are also other coping scales available that focus on specific situations or variables (e.g., Quality of Social Support Scale), particular illnesses (e.g., Mental Adjustment to HIV Scale; Mental Adjustment to Cancer Scale), or coping within specific subgroups of individuals.

What follows is a sample version of the most recent rendition of the SCOPE as well as the scoring used for this instrument. If you are curious and decide to assess your own coping methods using this questionnaire, bear in mind that you can't use this to make diagnoses about yourself (e.g., ‘My profile looks like someone who is very unhappy’). The scores provided in the ensuing section are ‘group’ scores, and comparing yourself to these ‘averaged’ profiles might not mean much. Further, the scale can be used to measure coping ‘styles’ or ‘strategies’ depending on the wording of the question. If the question asks you to respond on the basis of ‘stressful events experienced over the past two weeks’, then you'll be examining coping style. If, however, the question is framed as asking about coping with a particular event (e.g., a fight with your spouse, an argument with your boss, distress over not getting things completed, etc), then you'll be looking at coping strategies. If you do each of these assessments, starting with coping styles, and then at later times assess your coping strategies in regard to particular stressors, you might find that your coping methods differ across stressor situations, but there will be some similarity to your coping disposition (style).

Coping as a Profile of Responses

In most studies that involve numerous subtypes of coping, a ‘factor analysis’ is conducted to reduce the number of variables that need to be dealt with as responses to certain questions will often cluster together. Thus, although a given coping inventory might comprise many subscales, the factor analysis might group these into two or three more manageable units. As indicated earlier, emotion-focused coping comprises several coping strategies, such as emotion-based strategies, self- and other-blame, rumination, and so forth, and hence these are essentially pooled to represent a single factor. Likewise, problem-focused coping might comprise problem solving and cognitive restructuring, and these are combined as a single unit for purposes of analysis.

Factor analyzing the data and combining categories may be fine in many situations, but there are occasions where this might not be desirable, and to a certain extent might even be counterproductive. The factor structure evident under one set of conditions (e.g., in a group of individuals who are healthy or non-stressed) might not match up with that evident under certain stressor conditions or among individuals dealing with a particular experience. For instance, in a non-stressed group of individuals, social support may fall into a factor that is aligned with emotion-focused coping. However, in response to a certain illness, it might more comfortably fall into the category of problem solving, as social support would be used in this capacity (e.g., ‘help me find out if there is an alternative treatment strategy available’). Still later, if the illness progresses, social support might fall into an emotion-focused framework. Obviously, across these circumstances social support would appear as part of a different factor (as a source of problem solving or instrumental support vs one that involves emotional support), and hence they would not be statistically comparable to one another.

A second issue concerns the fact that although having a factor structure simplifies analysis, coping processes entail complex interactions that cannot be deduced using simple methods. In fact, creating broad categories that involve multiple coping strategies might not allow for the identification of subtle factors that could distinguish groups from one another. It is ironic, parenthetically, that while social psychologists have focused on reducing the number of variables into broad factors (although some, such as Carver, have made the point that the researcher might feel more comfortable not factor analyzing the data and assessing strategies individually), those involved in the creation of tests and measurements of other characteristics have not done so, and have recognized the value of treating categories distinctly. For instance, an IQ score provides an overall index of intelligence/ability or separate indices for verbal and performance measures. However, most tests are not limited to these broad categories. Instead, these tests involve multiple categories that allow the identification of more subtle problems that might be present. For instance, Johnny can score comparably across all components of the IQ test, or he might score low in those dealing with language, but high in those that involve creativity. In both instances he might have an average overall IQ score, but these different profiles might have very different implications. Likewise, the profile of coping responses endorsed may provide important clues as to the subtle differences that exist between groups or between individuals, which might otherwise be obfuscated by pooling data across the several strategies that make up a factor.

Figure 2.3 Coping Profiles among University Students who Exhibited Dysphoria (Moderate Depression), Anxiety, both Dysphoria and Anxiety, or Low Levels of Both.

Figure 2.3 shows the coping strategies adopted in a normative sample of university students. In general, those coping methods that are often considered to be adaptive, including problem solving (PSV), cognitive restructuring (CR), active distraction (ADIS), cognitive distraction (CDIS), and social support seeking (SS), were found to be more highly endorsed than the emotion-focused strategies comprising emotional expression (EE), other-blame (OB), self-blame (SB), emotional containment (EC), passive resignation (PR). An exception to this was that rumination, which is not usually thought of as an effective strategy (but consider the comments made earlier about its conjoint use with other strategies), was also found to be used frequently. For the most part, the coping strategies were comparable between men and women, although women tended to exhibit higher levels of cognitive distraction and rumination, as well as social support seeking and emotional expression.

When coping styles were assessed among individuals who differed with respect to depressed mood, the differences in coping profiles were pronounced ( Figure 2.3). The Beck Depression Inventory (BDI), a self-report questionnaire that asks individuals about various aspects of their mood, was used to divide participants into groups. Among individuals with some degree of depressive symptoms (a moderate BDI score >9, termed ‘dysphoric’ in the figure), the coping profile could readily be distinguished from those of individuals who were not at all depressed (a low BDI score <4). The dysphoric individuals used less problem-focused coping and social support seeking than individuals with low or mild symptoms of depression. They also used more rumination, emotional expression, other-blame, self-blame, and emotional containment than non-depressed individuals. Evidently, even in the face of mild depressive symptoms (nowhere near clinical levels), some coping methods were very much like those of individuals with higher levels of depression that we had seen in earlier analyses.

As anxiety often appears in conjunction with depression (anxiety is often comorbid with depression), we wondered whether the coping profiles of those with anxiety or dysphoria alone could be distinguished from that evident among individuals with both sets of features. Figure 2.3 shows that the coping profile of individuals in these categories differed from one another in several respects. Specifically, anxious participants displayed problem-focused coping just like that of the controls, whereas those with dysphoria or dysphoria plus anxiety showed much lower problem-solving efforts. A similar pattern was evident with respect to active distraction. However, all three of the symptomatic groups reported greater rumination than that of the controls. Moreover, the degree of emotional expression, other-blame, self-blame, and emotional containment varied as a function of the symptoms presented. Individuals with a combination of anxiety and dysphoria reported higher levels of these coping methods than did those with only one class of symptoms. It seems that the profiles of coping responses effectively distinguished between individuals with different psychological symptoms, which might not have been detected as readily if the coping methods had been grouped into broad categories.

The point of these various examples is that psychological illness, and even mental health characteristics below the clinical threshold, might be accompanied by distinct coping profiles. Using this profile approach may also provide clinicians with information regarding where their focus should lie in helping patients deal with their stressors or illnesses. Specifically, if a clinician believes a patient is not coping well, it might be useful to identify which specific aspects of their coping methods deviate most from the norm, and then focus therapy on these particular aspects of coping as well as on particular appraisals.

A Twenty-First-Century Coping Response

In response to severe stressors, as in the case of severe depression, food consumption typically declines. However, in response to moderate stressors there are a fair number of people who display increased eating, particularly in the form of junk food rich in carbohydrates (Dallman, 2010). Negative emotions among ‘emotional eaters’ might elicit this outcome owing to particular hormonal changes (Raspopow et al., 2010). Alternatively, emotional eaters might not accurately recognize bodily sensations when under duress, essentially mistaking arousal for hunger. Yet another view is that distress results in disinhibition which ‘allows’ for increased eating to occur, and that eating acts as a coping mechanism to alleviate the negative emotions otherwise evoked by stressful events. With respect to the latter view, eating might actually be a way of coping with adverse events (as either a disengagement strategy or in an effort to ‘self medicate’ through increased glucose availability).

Long ago, when human-like critters spent a large portion of their time hunting (a dangerous pastime as the prey could easily become the predator), the increased release of the stress hormone cortisol might have been essential for proper defensive actions, and this cortisol also prompted the consumption of food. This increased consumption was necessary, especially for the strength and endurance to partake in the next hunt, when it would readily be burned off. As my friend and associate Sonia Lupien has indicated, today, when the hunt comprises a visit to the supermarket and stressors consist of sitting on our butts while being stuck in traffic, the cortisol release that leads to eating might turn out to be counterproductive. Therefore eating may be a vestigial response associated with cortisol release, but its value in relation to stressors in Western society (which often comprises eating comfort foods high in calories) is less apparent.

Finding Meaning and Personal Growth

In some situations, cognitive restructuring may be a particularly effective problem-oriented method of dealing with severe stressors. A common form of this coping method has comprised changes in the meaning and importance of the aversive event. It has been suggested that living through traumatic circumstances may result in two independent processes occurring, namely trying to make sense of the event and finding some benefit from the experience (Davis et al., 1998). For instance, although cancer occurrence can take an enormous physical, psychological, and social toll on individuals, cancer survivors might use their experience as an opportunity to improve their physical and mental health. Indeed, individuals report gaining benefits from living through a cancer experience; they might recognize the positive implications or experience post-traumatic growth following their experience of cancer (Cohen & Numa, 2011; Sherman et al., 2010). Beyond the positive effects of this coping method, it also limits negative post-traumatic stress outcomes and the adverse effects of intrusive thoughts on positive affect, life satisfaction, and spiritual well-being (Park et al., 2010).

Not unexpectedly, the positive effects associated with finding meaning or benefit finding (‘meaning making’ is a related concept that will be treated together with finding meaning and benefit finding) occur in a variety of other venues, such as caregiving for spouses with dementia, family members with cancer, and among parents with severely ill children. The fact is that benefit finding stemming from a severe adverse experience is not at all uncommon. Women treated for breast cancer frequently become engaged in ‘walks’ to support breast cancer research, and other groups have similarly made heroic efforts to raise funds for certain charities (e.g., the Terry Fox Foundation; Rick Hansen's Man in Motion campaign; the Michael J. Fox Foundation; the Milken Family Foundation).

It is vital to distinguish between two subtle characteristics regarding meaning making, namely those of searching for meaning (‘meaning-making efforts’) and arriving at a meaning (‘meaning made’) (Park, 2010). Perhaps not unexpectedly, simply searching for meaning doesn't necessarily result in appreciable benefits, whereas finding or arriving at some meaning might. In fact, seeking meaning can in some instances have adverse effects or might be indicative of a persistent preoccupation with an adverse event (Park, 2010). Later, when we deal with methods of stress management, a theme that will be repeated is that there aren't any treatments that work for everyone. So, too, it seems that finding meaning might be an effective coping method for some individuals but not for others, and it might also vary with the situation that culminated in the severe trauma. It is one thing to find meaning in the death of a loved one that can be ascribed to the negligence of others (e.g., legally taking on an automobile company when death was caused by cars bursting into flames upon a moderate back-end collision), it's quite another to find meaning from a person tripping over their coffee table, hitting their head, and subsequently dying (although these cases are often chalked up to being ‘God's will’).

There are several factors that predict which individuals adjust (sometimes referred to as acceptance of the diagnosis and the treatment) to their condition. These comprise the sustained use of proper coping methods, the ability to manage non-illness related stressors, and a belief system that resulted in an altered meaning of the cancer experience. Thus, the well-being of women in this situation would be well served by providing resources to reduce distress, providing effective support systems, which include the opportunity to talk about their experiences, and helping women in reframing their beliefs about the illness. As powerful as finding meaning or post-traumatic growth might be as a coping method, its effectiveness in dealing with some disorders might be better than with others. For instance, post-traumatic growth is a cogent factor in dealing with cancer, cardiac disease, multiple sclerosis, and rheumatoid arthritis, and has been reported to be a prominent coping method among parents dealing with a child with a severe illness. However, the jury is still out regarding the efficacy of this coping method in dealing with HIV/AIDS. As effective as finding meaning might be, it doesn't cover every situation, nor is it for everyone. Some people simply won't find any meaning in their illness, which might simply be seen as something that they must endure.

Social Support

There has been a vast amount of research concerned with the benefits of social support in dealing with day-to-day stressors and those of a traumatic nature. As indicated earlier, social support has many functions, serving as a shoulder to cry on and a source of information, guidance, instrumental help, reliable alliances, social integration, attachment, reassurance of worth, and an opportunity to provide nurturance. The value of these components of social support varies across situations as the needs of individuals differ under various circumstances, and may also vary over time in relation to a given stressor (e.g., in response to a serious illness).

Social Support as a Buffer

Social support might not be effective in getting rid of every stressor (e.g., getting the tax department off your back, unless you're really well connected), but it could serve as a buffer against some of the adverse effects of stressors, thereby preventing the psychological disturbances that might otherwise occur (depression, anxiety; Lakey & Cronin, 2008), improving physical health, and promoting recovery from illness (Carod-Artal & Egido, 2009). For instance, elevated depressive symptoms were highly related to having poor social support, and obtaining social support may limit the development of depression. These studies, which included retrospective and prospective analyses, have involved a wide range of stressful situations and taken in several age groups. Of course, the positive actions of social support may vary with a great number of factors, and so blanket statements concerning the value of social support need to be somewhat tempered.

Positivity and Social Support

There are many physicians and scientists who believe that social support, along with other aspects of ‘positive psychology’, may have great benefits in the healing process, even for some diseases that don't seem to respond well to drugs (e.g., some types of cancer). There are, however, others who believe that positive psychology and social support are all well and good, but they don't cure illnesses. The data provide a degree of support for the view that positive outcomes may come about in relation to social support, but are the magnitude of the effects meaningful with respect to illness attenuation? For instance, a 10 or 20% rise in immune functioning may be statistically significant, but does this translate into a greater ability to fight infection or cancer? Regardless of whether it does or doesn't, social support will lessen the psychological burden of those in distress.

The beneficial effects of social support aren't new. In the Talmud, which preceded modern psychology by a fair bit, there is the statement that ‘whoever visits the sick takes away 1/60th of their illness’. I don't know where they got this number, and I suspect that it's not evidence-based. That aside, this statement doesn't necessarily mean that you acquire 1/60th of the other person's illness (although I've seen this argument actually made), nor does it mean that a tumor will have shrunk by 1.66% with each visitor. I guess it also doesn't mean that if 60 people visit you simultaneously, then you'll be entirely cured. What the statement is intended to mean is that social support lightens the burden (even temporarily) carried by the sick person.

The mechanism through which social support has its positive actions is not fully understood. Support can act as a distraction, or a way of limiting the psychic damage that might otherwise be provoked by stressors, and it also limits many of the stressor-elicited biological changes (hormonal, neurochemical, and immunological) that might have adverse consequences. For instance, social support availability was inversely related to levels of stress hormones (e.g., cortisol), both in laboratory stress tests and in natural settings (Heinrichs et al., 2003). For instance, women with metastatic breast cancer with a high quality of social support showed lower cortisol levels than those with a lower quality of support. In fact, based on a meta-analyses (see the box below as to what is meant by ‘meta-analysis’) it was concluded that social support diminished the cortisol response elicited by laboratory stressors (Heinrichs et al., 2003). Further, it was reported that in a stress test where psychosocial support resources were available, brain activity changes occurred (comprising right prefrontal cortex activation and diminished amygdala activity) that were associated with appraisal and fear/anxiety processes (Taylor et al., 2008). Further, individuals who had received social support over several days displayed a blunted cortisol response and elevated neuronal activity within the anterior cingulate cortex in response to a social stressor (Eisenberger et al., 2007).

Meta-Analysis

The use of meta-analyses has become increasingly popular to identify the key variables that determine the processes associated with various pathologies and stressor effects. A meta-analysis is a statistical procedure in which the results of many studies already published in peer-reviewed outlets are combined in order to evaluate a particular research question. The aim of this type of analysis is not simply to say that a significant effect was associated with a particular condition or treatment, instead it assesses the effect size in each study (effect size is an index of the strength of associations that exist between two variables) taking into account the number of participants included in that study. Hence it is thought that this sort of analysis provides a more realistic estimate of how variables are related to one another. In some reports, the meta-analysis is also accompanied by a thorough review of the literature, pointing out some of the variables that might not have been included in the primary analysis, and which variables might either mediate or moderate relations that were uncovered by the meta-analysis.

It is likely that actually having support may not count nearly as much as the perception that social support is available. Indeed, when individuals perceived support as being available, their well-being improved irrespective of whether and to what extent the support was actually proffered (Wills & Shinar, 2000). Moreover, it is likely that the quality of the support available, rather than simply having support, may be essential in determining changes in psychological symptoms. In some instances social support groups are particularly effective in buffering stressor effects, especially if members of the group are all encountering similar problems (say a suicide support group, or one that involves the parents of children with particular illnesses). It seems that support coming from someone ‘who understands my pain’ is better than that coming from someone, no matter how well intentioned they might be, who seems less able to ‘put themselves in my shoes’.

Social Support in Relation to Identity

The benefits that might be derived from social support depend on the motives and goals of the individuals (or groups) that provide the support, how the recipient of the support perceives and interprets the motives of the supportive individual or group, and the broad context associated with the conditions where the support was offered (Haslam et al., 2012). If the support provider and recipient are both part of the same ingroup (i.e., they share an identity, meaning that they see themselves as being part of the same religion or culture, and in this case it can also mean individuals who share similar problems), then the positive effects of the support in a stressful situation may be more beneficial than those obtained from someone who does not share the same identity (Haslam et al., 2005). Thus, social support that comes from a parent who has a child with a heart problem similar to one experienced by the child of the support recipient might be more valued and effective than support obtained from someone who does not have a sick child. However, there are also cases where support from an outgroup member can be exceptionally well received (e.g., support in relation to a political stance), as this reinforces the idea that ‘my cause is just, and is widely recognized’.

Typically, when the influence of support is assessed, this is considered within the context of the benefits obtained by the support recipient, and not in the context of benefits to the support provider. As we'll see, for some individuals acting as a support provider (a care-giver) can be meaningful and rewarding, and it seems that charitable giving and working for charitable causes can have a similar impact. Prosocial behaviors, such as the provision of support, have indeed been associated with specific brain activity changes, including increased neuronal activity in the ventral striatum, a brain region involved in reward processes. Evidently, giving support elicits positive outcomes in the support giver, and in some instances diminishes their own distress.

Forgiveness and Trust

Among the most common stressors experienced are those that entail interpersonal relations. These can take the form of disputes, let-downs, or transgressions between family members, close friends, traditional enemies, authority figures, or between groups of individuals. There are many instances in which a victimized individual or group is asked to forgive (or voluntarily might choose to forgive) the behaviors of the transgressor. Apologies can be offered by one party in the hope that forgiveness can be obtained from the other. In a best-case scenario one individual sees that they were in the wrong and values the relationship, and hence apologizes. The recipient of the apology then views this as sincere, and forgives the other person. It is not uncommon for transgressions within our intimate relationships to be the greatest challenge regarding our ability to forgive. Depending on the severity and chronicity of the conflict (e.g., abuse or partner dissolution or betrayal), such transgressions may engender shame and/or anger, anxiety, depression, and considerable rumination that can be exceedingly damaging, and often these transgressions are hard to forgive. In other instances, the transgression might be perceived as being just too great, the hurt too strong, and forgiveness is virtually impossible. Of course, there are numerous other factors that might also come into play that could undermine a reconciliation (e.g., ego, trust, self-righteousness, financial concerns).

So who benefits from forgiveness? Both parties, I suppose, but it may be particularly beneficial for the forgiver. The view has often been expressed that forgiveness of interpersonal transgressions might limit the adverse impact of these events on well-being, particularly by limiting the ruminations that go with them (e.g., McCullough, 2000). Essentially, rather than focusing and ruminating on the transgression, by forgiving the transgressor the victim allows themself the freedom to walk away. Of course, this doesn't mean that offering forgiveness results in forgetting, but for the moment it allows them to ‘let go’ or ‘move on’. As a result, forgiving someone else for their behaviors might actually be, as is often said, ‘a gift to the forgiver’ (Brown & Phillips, 2005; McCullough et al., 1998).

As difficult as apologies and forgiveness might be to achieve between two individuals, it is often more difficult to achieve a reconciliation between groups. However, there are notable cases in which this has happened. By example, the Australian government, and later the Canadian Government, via their respective prime ministers, apologized to Aboriginal groups for wrongdoings related to the treatment of children who had been forcibly removed from their homes and sent to ‘residential schools’ in order to socialize them. The intent of the apology was to have the Aboriginal people forgive them (and the people of the country) for past wrongs. It seems as if this should have been an easy thing to do, but it took years for this to be enacted (see Chapter 11 for a discussion regarding intergenerational trauma effects).

You might ask what sort of effect this apology could possibly have as it didn't come from those who committed the atrocities, but from others who were actually far removed from those who were responsible, and sometimes the apology came with considerable reluctance as it might have had implications for reparation for the wrongdoing. Well, if nothing else, it's a message that says ‘We don't condone the past egregious behaviors, and we would like better relations with you’. Typically, the response from groups that receive an apology is a positive one, but with caveats attached: ‘We are happy to receive your apology and it means a lot to us. Although, we can't forget the past, we would like to move forward. Thus, your apology will mean much more if it comes with actions that improve quality of life for our group.’ In effect, the apology serves as vindication for the oppressed group's experiences, and it might represent a first step for future improvement. There is a down-side to this, of course, as improvements for the aggrieved group may not occur, and they will thus see this as yet another betrayal (and in the meantime, members of the oppressor group may well say ‘Heck, we gave them an apology, now what do they want?’).

Conceptualizations of forgiveness, regardless of the framework from which a researcher comes, share the view that forgiveness influences perceptions of an interpersonal interaction so that negative thoughts, feelings, and behaviors are reduced (McCullough, 2000). It is believed that to a certain extent forgiveness (or the ability to forgive) may be a dispositional characteristic (Ysseldyk et al., 2009), but not unexpectedly, this also varies with specific transgressions. Ultimately, however, forgiveness might act to reduce vengeful and avoidant motivations and increase benevolent feelings or behaviors. In effect, forgiveness should not be viewed as an end in itself, but might be an act that influences cognitive, behavioral, and affective responses in relation to the transgression.

Although forgiveness is typically associated with positive psychological outcomes, a forgiving response can also have the opposite effect. In the case of an abusive relationship, forgiveness might serve to perpetuate women's (or men's) illusion of long-term safety and well-being, and thus reinforce the individual to stay in a clearly unhealthy relationship. For example, forgiveness of a currently abusive partner might act to diminish the perceived severity of the transgression (e.g., ‘Oh, maybe I'm being a bit too sensitive’), which might undermine an individual's well-being in the long run (e.g., through self-blame, avoidance and social isolation, and continued experiences of abuse). As a result, rather than serving as a buffer against distress, in some situations forgiveness may alter appraisals and coping efforts, culminating in a greater probability of stress-related symptoms evolving.

In order for genuine forgiveness to occur it is essential that the behavior of the protagonist can be trusted. Trust is an essential component not only in interpersonal relationships, but also in intergroup relations, and it is a fundamental component in politics and in commerce. Of course, it is also essential in conflict resolution as forgiveness requires trust that the other person or group will not subsequently repeat their objectionable behavior. When we trust another person we are essentially leaving ourselves uncloaked and unprotected, believing that no harm will come to us.

Not surprisingly, just as trust might make for good relationships, a breach of trust may have exceptionally stressful and damaging effects. We see this frequently in cases of separation/divorce where an individual may feel that ‘I trusted you, and you have gone and severed this trust in the worst possible way’. Obviously, this would be most evident if there was a third party involved. This type of situation, predictably, might be accompanied by rumination, and in particular, thoughts concerning retribution (which is the saintly way of saying revenge). As indicated earlier, however, this might be the worst possible way of coping. Rumination can have some positive attributes when it's used in combination with problem solving or cognitive restructuring. However, in the case of rumination associated with divorce/separation, the cognitive restructuring that will be evident (if indeed it is) will likely be focused on less productive issues. Revenge can be satisfying, but only transiently, particularly as it may cause the other side to escalate the battle. At the very least, it becomes a vicious circle wherein the individual ruminates more, thinks about all the wrong things, and even becomes obsessed with the idea. Sometimes it's best to just walk away, have this person out of your life, and to do so quickly and efficiently. Of course, there are occasions when the other side is unreasonable (e.g., on financial issues) and you don't want to be pushed around and have someone take advantage of you, especially when you believe that the circumstances that led to the split are not your doing. In this instance, you might have good cause to stand your ground, but at the same time you ought to appraise the down-side of the battle that will evolve, and consider how far you want to take it, before making your next move. In a game of chess lots of pawns die, and there may be sacrifices.

Trust comes into our lives in various ways, and trust in the workplace (in this case, trust in the organization and trusting other employees) influences our well-being and our satisfaction with the organization. Investigators often view ‘trustworthiness’ as reflecting the benevolence, integrity, and ability of a trustee (person or organization), and ‘trust’ as already described as comprising an intention or willingness to accept (or allow oneself) to become vulnerable with the expectation that the trustee will behave appropriately. It seems that trust has much to do with job satisfaction: Helliwell et al. (2009) indicated that one unit of trust (on a 10-point scale) has an effect on well-being that is comparable to a 30% salary increase. In effect, if you offer people the equivalent of an extra 20% of their salary (i.e., some amount less than 30%) or the opportunity to work in a trusting environment, they would likely pick the latter. To be sure, within many settings trust also needs to be accompanied by several related factors, including integrity, loyalty, consistency, and openness. And added to this, whether it's close interpersonal relationships, workplace situations, or intergroup conflicts, an essential factor concerns the view that individuals often think that talk is cheap: their trust will be dependent not on what is said, but on what is done.

Unsupportive Interactions

Social support can go a long way in helping individuals deal with stressors, and this appears to be especially true in regard to illness. One not only sees the influence of social support in relation to psychological illness, such as depression, but also in relation to adjusting to neurological illnesses, such as Huntington's disease, motor neuron disease, multiple sclerosis and Parkinson's disease. Support can come from different sources, and social support from family members may have particularly pronounced positive effects on chronic illness outcomes, especially when family cohesion is high and there is an emphasis on self-reliance and personal achievement. In contrast, negative patient outcomes were tied to critical, overprotective, controlling, and distracting family responses to illness management.

Social support is unquestionably positive for our well-being, yet there may also be a downside to receiving support. Among other things, receiving support could negatively influence self-esteem, as it might result in the individual feeling less competent in contending with the situation without assistance. In addition, individuals might feel indebted to the support provider, which may serve as an additional stressor for an already stressed individual. Finally, attempts to obtain social support may sometimes promote ineffective responses from others, or may cause inaccurate advice to be obtained as the other person might simply not have the ‘right’ answer.

This brings us to yet another potential risk related to social support; specifically, we often approach others for support, usually with a reasonable expectation that that support will be forthcoming. Typically, our friends listen and offer their support. There will be times, however, when that support isn't offered, or comments are made that are not quite in line with our expectations. Such experiences, referred to as ‘unsupportive relations’ or ‘unsupportive interactions’, might take us by surprise, and in some instances may have marked negative repercussions (Ingram et al., 2001) that far exceed those of simply not having support. Clearly, being unsupported is not the same as having a lack of support, and the ramifications can be pertinent to the evolution of pathological outcomes. Unsupportive responses may come in several forms, including minimizing (e.g., ‘felt that I was overreacting’), blame (e.g., ‘I told you so’), bumbling (e.g., ‘did not seem to know what to say, or seemed afraid of saying or doing the wrong thing’, as well as forced optimism) or distancing or disconnecting (e.g., ‘did not seem to want to hear about it’).

Sitting on the Fence

There are times when individuals might expect support, even if they don't explicitly seek it. When victims of discrimination, threats of genocide, or of harsh treatment by their government do not receive support from others (as we've seen often), then the behavior of other countries and people might be viewed as an instance of an unsupportive relationship, and the effects on later relationships can be very disturbing: ‘ In the end we will remember not the words of our enemies, but the silence of our friends’ (Martin Luther King; Nobel Laureate, 1964) and ‘… to remain silent and indifferent is the greatest sin of all’ (Elie Wiesel; Nobel Laureate, 1986).

This said, there are times when others might intervene, without sufficient understanding or knowledge, basing their behaviors on instinctive gut responses, media manipulation, well-orchestrated political campaigns, or simply in taking the side of the perceived underdog. With respect to international and national politics, ideologies become confused with realities, and discerning what is true and what reflects bias becomes exceedingly difficult. Decisions that are made in this regard likely follow the heuristics described by Kahneman and Tversky as opposed to well thought-out, reasoned decisions.

There are times when our friends fail to support us properly, but there are also times when we misinterpret what can be done or we have warped expectations concerning what our friends ought to do. For instance, some progressive, chronic illnesses can be devastating emotionally and financially, but social support might not be as forthcoming as it might be when a person has been diagnosed with cancer. Friends might not rally around as readily when a person is diagnosed with MS or lupus, and certainly not if it's a mental condition. Moreover, even if they do, there's a time-stamp on this behavior as people are able or willing to provide support for only so long before they tire or need to get on with their own lives. Unfortunately, the ill person might see this withdrawal of support as a betrayal or unsupport (‘you know who your friends are when the chips are down’), which can exacerbate the depression that might be associated with illness.

Connected to unsupport is the premise that support was expected, but wasn't obtained (or did not reach the level that was expected). Of course, there are some people who are entirely unreasonable and have expectations of others that simply can't be met. There are also those who demand loyalty to an extent that supporting them fully would be contrary to anything reasonable. In most cases, however, the support expected is not unreasonable, and often the support is sought from those to whom we are closest. Thus, when your best friend forever (BFF), partner, parent, or sib doesn't come through as expected, it's particularly distressing, and adds to the distress you were dealing with in the first place. Think of a time when you counted on your two best friends to help you out, but both had more important commitments,or said things that were just plain thoughtless (‘well, you know, there are two sides to every story’), or worse still, blamed you for the situation you found yourself in (‘well, maybe you brought it on yourself’). How long was it before you spoke to them again?

Unsupportive interactions have been linked to reduced psychological well-being, over and above the perceived unavailability of social support, or the effects of the stressor experience itself (Ingram et al., 2001; Song & Ingram, 2002). We've all heard of cases where family members distance themselves from one of their own who has been diagnosed with HIV/AIDS. The stigma of this illness is enormous and having family members turn on an individual is obviously counterproductive for the patient. But the unsupport might even come from those who are close to the affected person simply because they may feel uncertain about how to act and what to say due to a lack of experience. As a result, and despite good intentions, responses can be interpreted as unsupportive, causing further distress in those individuals living with the disease, thus exacerbating depressive symptoms and poor emotional well-being. Remarkably, the stigma associated with HIV/AIDS is so profound that even children who contracted the disease prenatally or through transfusions are victimized by unsupport. Specifically, although the families of children with HIV/AIDS and those with cancer exhibited comparable family functioning and both groups tended to seek support from family members, the parents of children with HIV/AIDS were more reluctant to seek support from outside the family. Once more, HIV/AIDS has a stigma attached to it that affects whole families regardless of how or in whom the disease appeared, and thus the benefits of support might not be sought or ever obtained.

Yet another example of how unsupport affects outcomes derives from work with young women who end up in abusive dating relationships. Dating abuse is not an uncommon circumstance, as more than 20% of college women are subjected to physical abuse and the number is still greater for psychological abuse (however, I would remind you, before you start becoming unsupportive of all males, that the incidents of abuse perpetrated by women against men are just as high). The problems for abused women may be compounded by other unsupportive relations that develop. Specifically, when abused women disclose information regarding their situation, family and friends may become frustrated and react negatively when their advice is not accepted, especially if the victim of abuse refuses to terminate the relationship. Predictably, these women may feel that that they can no longer rely on their social network for support or advice, and will stop confiding in them, thus further isolating themselves. With no one to turn to, their partner may become their sole source of support, despite the abuse (reminiscent of the child who turns to the abusive parent for support and protection).

In addition to direct effects on well-being, unsupportive relationships may undermine the use of other coping methods. In this regard, among HIV patients, perceived distancing and the disinterested responses of others predicted greater use of ineffective coping strategies, such as disengagement and denial, which in turn was associated with greater mood disturbance. Likewise, among bereaved respondents, unsupportive interactions with members of their social network were associated with diminished coping efforts and reduced perceived effectiveness of the coping strategies that were used. The net result of these unsupportive experiences is that individuals might become reluctant to seek support, and may limit or re-orient their help-seeking behaviors in an ineffective fashion. Rather than seeking help from friends or family, individuals might turn to anonymous sources of support (e.g., internet chat groups) where judgments are not tied to the individual's sense of self-worth (i.e., rejection from an anonymous stranger may be less distressing than rejection by a close other).

One final comment is in order before closing off this section. Unsupport is particularly notable in the elderly, and especially among those with severe neurological problems, such as Alzeheimer's Disease, Parkinson's, and stroke. In fact, there have been many reports of the elderly being subjected to abuse as a result of frustrations experienced by caregivers. A new position statement by the American Academy of Neurology has, in fact, called on clinical neurologists to screen patients for abusive experiences. We may as well be upfront about this. Not all caregivers are meant to do this sort of sensitive work and their frustrations might emerge inappropriately. Of course, abuse is manifested in many contexts beyond elder abuse, and when patients show up for neurological testing, it is wise to assess whether these problems are secondary to some sort of abuse, as not doing so might leave the patient open to still greater problems.

Taking Advantage of a Friend

There is a cute and interesting laboratory manipulation that has been conducted to see how individuals might (or not) deal with decisions that involve unfairness, and represent an unsupportive interaction. The ‘ultimatum game’ (or a slight variant called the ‘dictator game’) is one in which a sum of money is offered to two individuals provided that they can come to an agreement on how to split the booty. If the proposer makes an offer that is accepted then they both win, but if the proposal is not accepted then they both lose. Typically, if the offer is an unfair one (say an 80:20 split), then the second person will reject the offer. It can be imagined that if the total prize were $100 the individual offered $20 would simply say, ‘Screw this. I'd rather lose the $20 than be suckered’. But what if the total prize were $100,000, would they be as likely to walk away from $20,000?

In this paradigm the unfair offer is coupled with a neurophysiological profile in which electrical activity in the medial frontal region becomes very negative (Boksem & De Cremer, 2010). However, if the unfair offer comes from a friend, then it's less likely that it will be rejected, and the negative activity within the frontal cortex is not apparent, possibly owing to activation evident in other regions, such as in the anterior prefrontal cortex (Campanha et al., 2011). Apparently, we respond more positively to unfair offers from friends than from strangers. Frankly, I'm a bit surprised by the results. I would have thought that when one is taken advantage of by a friend the emotional and negative cognitive responses would be that much greater than when this knife in the back came from a stranger. However, events in a laboratory might not mean the same thing to an individual relative to the betrayals that occur in real life.

Social Rejection

A particularly potent stressor that social beings, like us, might encounter is one that entails social rejection. Groups of individuals can be rejected, as seen in cases of discrimination related to gender, sexual orientation, race, or religion. Rejection can occur at a group or personal level. Social rejection is, in fact, fairly common as in the case of stigmatization and discrimination against those with mental disorders, or those with illnesses such as AIDS. Social rejection can also occur in the absence of these factors, occurring either because the individual is somewhat different from the rest of their ingroup or is viewed as being an embarrassment to the group. This is often referred to as the ‘black sheep effect’, where members of the ingroup don't want their group's identity tarnished by a particular individual. When group members feel that they are a unified social entity (entitativity), outliers from the group who negatively represent them are denigrated in order to preserve the good standing of the group as a whole (Lewis & Sherman, 2010). Predictably, the stronger the ingroup cohesion (ingroup identification), the more likely a deviant member would be viewed as being atypical and hence rejected. In fact, individuals will derogate an unfavorable group member to a greater extent than they would an unsavory outgroup member. This could be a means of protecting the group, but it is equally possible that this differential derogation is an individual protection strategy as it serves to limit the threat of being associatively miscast (‘He's not one of us, and I'm not like him at all’) (Eidelman & Biernat, 2003).

Some adolescents will know the feeling of having their two best friends turn on them or simply ignore them, leaving them out of social events and generally feeling diminished by them. In general, unsupportive relationships, especially those that involve targeted rejection, can be especially damaging, and have been linked to an exacerbation of depressive feelings. No matter the age, the impact of social rejection can be intense and undermine individuals’ abilities to contend with ongoing stressors, just as unsupportive responses act in this capacity. You'd think that on-line social exclusion might not be as bad as it is when it occurs in a real social setting, but it is actually hurtful, even if you don't know the people who are excluding you. However, when excluded from an on-line forum, it might be a bit easier to say to yourself ‘It's not me, they have a problem’, and hence your self-esteem might not be as drastically affected as it may otherwise be. Then again, think about being excluded as a ‘friend’ on your erstwhile friend's Facebook page, especially when everybody under the sun is included. It's already happening that a slap to the face now occurs in the form of being ‘defriended’.

Our fear of social rejection is in itself a very powerful negative emotion that may be linked to elevations of the stress hormone cortisol, and if this fear is sufficiently persistent, the overall biological profile that is observed is not unlike that characteristic of other chronic stressors and those that accompany PTSD. Essentially, fear of social rejection reflects a trait that is accompanied by chronic distress, leading to an adaptation to limit the excessive physiological activation that might culminate in allostatic overload.

Given the powerful actions of social rejection on psychological well-being, there have been several paradigms developed to assess this in a laboratory context. One increasingly popular approach to studying this is a computer game, referred to as cyberball, in which a virtual ball is tossed between three characters (Blackhart et al., 2007). One of the icons is controlled by the participant, and the others are presumed to be controlled by other individuals. Initially, the ball is tossed evenly between the players, but shortly afterward, it is passed between the other two virtual participants and the actual participant is excluded.This has the effect of eliciting negative ruminative thoughts, an altered mood, hostility, and elevated cortisol levels. In addition to these behavioral and hormonal effects, social rejection in the cyberball paradigm markedly influences the brain processes associated with appraisals and decision making as well as with depressed mood. In particular, following rejection the self-reported distress was accompanied by increased activity (as measured by functional magnetic resonance imaging (fMRI)) in the dorsal anterior cingulate cortex, although this outcome was diminished among individuals who had experienced rich social support in the days prior to testing. Not unexpectedly, the effects of rejection on brain processes were marked in adolescents, especially in those with a higher rejection sensitivity who might be most vigilant regarding peer acceptance.

What makes these findings particularly interesting is that the very same brain activation profile has also been seen in studies assessing the effects of physical pain (Eisenberger et al., 2003). Given this similarity it was suggested that the anterior cingulate cortex is fundamental in the neural circuitry that supports physical and social pain, and may be part of a broader ‘neural alarm system’ (Eisenberger & Lieberman, 2004). Similar effects were observed in adolescents, and in this instance rejection was also accompanied by decreased neuronal activity in the ventral striatum (a region associated with reward processes), suggesting that the rewarding experience that could accompany a game with others had lost its luster. Moreover, these brain changes were most prominent in those individuals who were especially sensitive to rejection (Masten et al., 2009). Furthermore, the way in which an adolescent's anterior cingulate cortex responded to social rejection was predictive of their disposition toward later depression (Masten et al., 2011). In particular, those who showed the greatest changes of the anterior cingulate cortex activity in response to social rejection in an online social interaction subsequently showed the greatest depressive behaviors (as judged by parents) over the ensuing year. Thus, this index of social exclusion might be a marker for future depression. It is of particular significance in this regard that social support during adolescence, reflected by the time spent with friends, can serve to diminish the brain changes associated with peer rejection even when measured in the ball-tossing game two years later. In effect, reactions in a social rejection test might be a marker for later mood disturbances that accompany social interactions.

In an effort to provide a comprehensive perspective of how social rejection comes to promote depression, Slavich, O'Donovan et al. (2010) incorporated emotional, cognitive and psychobiological factors in an interesting manner. Essentially, it was suggested that social rejection may result in the activation of neurons within brain regions (e.g., the dorsal anterior cingulate cortex) involved in the processing of information related to negative events and reflection-based distress. These experiences give rise to negative self-referential cognitions (‘people just don't like me’) and emotions that are related to these feelings, especially shame and humiliation. This, in turn, would activate brain regions that are involved in regulating mood, and may affect certain aspects of the immune system (inducing inflammatory effects) that might also contribute to depressive-like states.

Aside from the informative nature of these studies with social rejection, what struck me was that the observed emotional responses and the changes of brain activity occurred even in a relatively contrived laboratory situation, where a virtual ball was being tossed around. How much stronger would the brain react to social rejection in a genuine life context that involves friends or family? As King Lear said, ‘Turn all her mother's pains and benefits to laughter and contempt; that she may feel how sharper than a serpent's tooth it is to have a thankless child!'

Conclusion

Adverse events, especially those that occurred during critical periods early in life or possibly during adolescence, result in increased vulnerability to later stressor induced pathology. However, some individuals are able to emerge less scathed than others even in the face of the most traumatic events. It is possible that this occurs owing to an inherent biological resilience, the availability of effective coping resources, a sense of mastery, or other psychosocial factors. In fact, stressful events in some cases may imbue individuals with greater resilience (e.g., by putting them in a situation that favors finding meaning or personal growth). Individuals may have learned from adverse experiences that with appropriate behaviors and coping methods it is possible to transcend current strife (Seery, 2011), indeed there might be something to the tiresome cliche ‘that which doesn't kill you makes you stronger’. From a practical research perspective, knowing which behavioral or biological factors distinguish those who succumb to illness in the face of severe trauma and those who do not might prove exceptionally valuable in defining strategies to immunize or treat individuals so that traumatic events do not have the severe repercussions that might otherwise occur.

It seems that appraisals of events and how we cope with them can be influenced by prior stressful experiences as well as our current affective state. There are some individuals who tend to put a negative spin on events, so that others often perceive them as being a negative or pessimistic person (they, in contrast, would say that they are not pessimists, they're realists). Likewise, the coping strategies they typically endorse are stereotypical (fixed), even when the situation might call for a different approach. Breaking well-entrenched behavioral styles (habits) is exceedingly difficult (e.g., emotional rumination in response to stressors), but there are times when these coping methods are entirely inappropriate and hence ineffective. In contrast, an effective way of dealing with stressors is to be flexible in using particular coping strategies, and to recognize that this flexibility needs to be maintained over time and across situations. That sounds like good advice, but it doesn't tell you how to do it, and might be about as helpful as advising me to become taller if I want to play in the NBA. However, when we come to Chapter 12 (dealing with treatment and intervention strategies) we'll discuss ways that might help individuals adopt a more flexible pattern of responses to the challenges they encounter.

Summary

· How we appraise stressors may influence the way in which we cope with them.

· Appraisals of events can influence our decision-making process that also feeds into our choice of coping methods, although individuals often behave in irrational ways, appraise events inappropriately, and make poor decisions.

· It isn't that the coping methods adopted aren't inherently good or bad, it is instead that the effectiveness of particularly coping strategies is likely situation-dependent.

· Several coping methods can be used concurrently, and the array of coping strategies used can determine their usefulness. In addition, in dealing with stressors it is important to maintain flexibility so that various strategies are available as needed.

· Social support is often one of our most potent coping strategies, but expected support that does not materialize, or is viewed as less than ideal, may be interpreted as unsupportive, and can thus have very negative repercussions.