1. Stress

2. Three Views of Stress
Focus on the environment: stress as a stimulus (stressors)
Reaction to stress: stress as a response (distress)
Relationship between person and the environment: stress as an interaction (coping)

3. Stressors
Some examples?
What are some examples of stressors?

4. Stressors War Overcrowding Deadlines Dense traffic Marital conflict
Work stress
What are some examples of stressors?
War and blood pressure studies.
Air-traffic controllers
London bus drivers.

5. Acute vs. Chronic Stress
Acute stress
Sudden, typically short-lived, threatening event (e.g., robbery, giving a speech)
Chronic stress
Ongoing environmental demand (e.g., marital conflict, work stress, personality)

6. Acute Stress

7. Acute Stress – Rozanski 1988
Subjects – 39 individuals with coronary artery disease
Stress tasks (0-5 minutes each):
Mental arithmetic
Stroop-colour word conflict task
Stress speech (talk about personal fault)
Graded exercise on bicycle (until chest pain or exhaustion)
Rozanski et al., (1988). New England Journal of Medicine, 318;

8. Acute Stress – Rozanski 1988
Outcome – stress response
Myocardial ischemia determined by radionuclide ventriculography (measures wall motion abnormalities in the heart)
Rozanski et al., (1988). New England Journal of Medicine, 318;

9. Acute Stress – Rozanski 1988 Results
Cardiac wall motion abnormalities were significantly greater with stress speech than other mental stress tasks (p < .05) and was of the same order of magnitude as that with graded exercise.
Wall motion abnormalities occurred with lower heart rate during stress than during exercise (64 vs. 94 beats/min, p < .001)
Rozanski et al., (1988). New England Journal of Medicine, 318;

10. Chronic Stress – Frankenhauser, 1989
Subjects – 30 managerial and 30 clerical workers
Equal number of men and women
Outcome: blood pressure, heart rate, and catecholamines measured throughout workday and non-workday.

12. Chronic Stress – Frankenhauser, 1989
No gender differences in the effect of work on BP and HR.
In both men and women, BP and HR were higher on a workday than a non-workday.

13. Chronic Stress – Frankenhauser, 1989
Catecholamine Response
Time of Day

14. Three Views of Stress
Focus on the environment: stress as a stimulus (stressors)
Reaction to stress: stress as a response (distress)
Relationship between person and the environment: stress as an interaction (coping)
We have been talking about some of measurable outcomes of stress such as changes in blood pressure, heart rate, and the stress hormones (catecholamines). This gets us to another view of stress which is that “stress is anything that causes a stress response. What is a stress response?

15. Fight or Flight Response
Increase in
Epinephrine & norepinephrine
Cortisol
Heart rate & blood pressure
Levels & mobilization of free fatty acids, cholesterol & triglycerides
Platelet adhesiveness & aggregation
Decrease in
Blood flow to the kidneys, skin and gut
Canon’s definition of the fight or flight response. Peripheral vascular resistance increases in some vascular beds (e.g., kidneys, skin and gut) while decreasing in vascular beds feeding oxygen to essential bodily areas needed for fight or flight (e.g., brain, muscles, heart).

16. Selye’s General Adaptation Syndrome (1956, 1976, 1985)
Resistance
Arousal high
as body tries
defend and
adapt.
Exhaustion
Limited
physical
resources;
resistance
to disease
collapses;
death
Alarm
Reaction
Fight or
flight
Perceived
Stressor
During stage of resistance the body tries to adapt to the stressor with a slight decrease in arousal and heightened resistance to stress and illness, however, remains vulnerable to over-react to additional stressors. During stage of exhaustion, prolonged physiological arousal leads to changes in stress glands; weakened immune system; decreased resistance; damaged vasculature; and even death. Some truth to this theory with stress effects seen with essential hypertension, heart disease, and immune-related deficiencies.
Criticized because it assigns little role to psychological factors; not all stressors have been found to produce the same stress response; and not everyone exhibits the same stress response (genetics, diet, personality modify the stress response).
If stress continues ….

17. Cognitive Model of Stress Lazarus & Folkman
Potential stressor (external event)
Primary appraisal – is this event positive, neutral or negative; and if negative, how bad?
Secondary appraisal – do I have resources or skills to handle event?
If No, then distress.
Lazarus & Folkman

18. Cognitive Model of Stress Lazarus & Folkman
Primary appraisal – Is there a potential threat?
Outcome – Is it irrelevant, good, or stressful?
If stressful, evaluate further:
Harm-loss – amount of damage already caused.
Threat – expectation for future harm.
Challenge – opportunity to achieve growth, etc
Lazarus & Folkman

19. Cognitive Model of Stress Lazarus & Folkman
Secondary appraisal –
Do I have the resources to deal effectively with this challenge or stressor?
Lazarus & Folkman

20. Cognitive Model of Stress Lazarus & Folkman
High Threat
Low Resources
High
Demands
High Stress
High Resources
High/low demands
Moderate Stress
Low Threat
Low demands
Some stress
Low or no stress
Lazarus & Folkman

21. Personal Factors Affecting Stress Appraisal
Intellectual
Motivational
Personality
Beliefs
“Because I strongly desire to have a safe, comfortable, and satisfying life, the conditions under which I live absolutely must be easy, convenient and gratifying, and it is awful and I can’t bear it and can’t be happy at all when they are frustrating.”

22. Situational Factors Affecting Stress Appraisals
Strong demands
Imminent
Life transition
Timing
Ambiguity – role or harm ambiguity
Desirability
Controllability
Behavioural control – perform an action
Cognitive control – using a mental strategy
Point out that stress is cumulative such that a stressor may be felt as more stressful if you already have a lot of other stressors you are dealing with.
Also, point out that stressors can affect a person even without that person being aware of the stressor (e.g., London bus drivers – objective stress had impact not subjective stress; Air traffic controllers – both objective and subjective measures of stress independently affected stress levels (Repetti 1993a).).

23. Learned Helplessness – Seligman, Peterson, et al.
Dogs exposed to unavoidable shocks
Following exposure, when placed in a situation where they can now jump to avoid the shock, they fail to make the escape response.
Learned helplessness occurs when one perceives that one’s actions (e.g., working hard) does not lead to the expected outcome (e.g., high grade).
Learned helplessness – develop an expectation of uncontrollability.

24. Job Strain – Karasek et al., 1981
Demands
High
Low
Control
STRAIN

25. Job Stress – other aspects
Physical environment
Poor interpersonal relationships
Perceived inadequate recognition or advancement
Unemployment (even anticipated)
Role conflict
High responsibility for others
Example of high responsibility for others is air traffic controllers. Ask the students, even from their own experience, what they think are some of the behavioural and psychological effects of work stress: higher rates of absenteeism, job turn-over, tardiness, job dissatisfaction, sabotage, and poor job performance.

26. Biopsychosocial Aspect of Stress
How stress affects health
Via behaviour
Via physiology

27. Behavioural Aspects Increased alcohol Smoking Increased caffeine
Poor diet
Inattention leading to carelessness

28. Physiological Aspects
Cardiovascular reactivity – increased blood pressure, platelets, lipids (cholesterol)
Endocrine reactivity – increased catecholamines and corticosteroids
Immune reactivity – increased hormones impairs immune function

29. Psychophysiological Disorders
Digestive system – e.g., ulcers, irritable bowel syndrome
Respiratory system – e.g., asthma
Cardiovascular system – e.g., hypertension, lipid disorders, heart attack, angina

30. Stress-Illness Relationship
Preexisting
physiological
or psychological
vulnerability
Physiological
& psychological
wear and tear
Illness
precursors,
symptoms
Stress may have a direct effect on illness, it may interact with preexisting vulnerabilities, and it may adversely affect health habits. Let us start with focusing on how behavioural changes and coping further moderate the effect of stress on illness.
Behavioural
changes &
Coping efforts
Exposure
to stress
Illness
behaviour

31. Moderators of the Stress Experience

32. What is coping?
Process of managing the discrepancy between the demands of the situation and the available resources.
Ongoing process of appraisal and reappraisal (not static)
Can alter the stress problem OR regulate the emotional response.

33. Emotion-Focused Coping
Aimed at controlling the emotional response to the stressor.
Behavioural (use of drugs, alcohol, social support, distraction) and cognitive (change the meaning of the stress).
Often used when the person feels he/she can’t change the stressor (e.g., bereavement); or
Doesn’t have resources to deal with the demand.

34. Problem-Focused Coping
Aimed at reducing the demands of the situation or expanding the resources for dealing with it.
Often used when the person believes that the demand is changeable.

35. Coping responses – respond yes or no.
Tried to see the positive side of it.
Tried to step back from the situation and be more objective.
Prayed for guidance or strength.
Sometimes took it out on others when I felt angry and depressed.
Got busy with other things to keep my mind off the problem.
Read relevant material for solutions and considered several alternatives.
Took some action to improve the situation.
Think about a very stressful personal crisis or life event you experienced in the last year—the more recent and the more stressful the event, the better for this exercise. How did you handle this situation and your stress? Some of the ways people handle stress are listed below. Respond “yes” or “no” to each one, indicating which you used.

36. Problem-Focused Coping
Planful Problem-Solving – analyzing the situation to arrive at solutions and then taking direct action to correct the problem.
Confrontive Coping – taking assertive action, often involving anger or risk taking to change the situation.

37. Emotion-Focused Coping
Seeking social support – can be either problem or emotion-focused coping.
Distancing – cognitive effort to detach
Escape-avoidance – wishful thinking or taking action to escape or avoid it.
Self-control – attempting to modulate one’s feelings in response to the stressor.
Accepting responsibility – acknowledging one’s role in the situation while trying to put things right.
Positive reappraisal – create positive meaning.
Cognitive effort to detach oneself from the situation or to create a positive outlook.
Escape-avoidance coping is particularly maladaptive because the person is prevented from either learning that the feared event never happens or prevented from learning that one can effectively cope with the event.
Positive reappraisal: trying to create a positive meaning from the situation in terms of personal growth.

38. Cognitive Re-structuring
Process by which stress-provoking thoughts are replaced with more constructive one.
Many of these personality constructs seem to affect health via their effect on coping styles. How might coping style influence health? One example is with cognitive re-structuring.

39. Gender and Coping
Men generally employ problem-focused coping strategies more than emotional focused strategies.
Opposite for women, with women more often employing emotion-focused strategies.
If men and women in same occupation, gender differences disappear, suggesting that societal sex roles influence choice of coping strategies.
The study of gender differences in coping was conducted by a psychologist at York University, Esther Greengalss. Study was presented at the Society of Health Psychology in montreal in 1996.

40. Socio-economic Status (SES) and Coping
People with higher SES tend to use problem-focused coping strategies more often (Billings & Moos, 1981).
Why do people who have lower SES use problem-focus coping strategies less often than those with high SES?
SES = socio-economic status
Why SES related to coping strategies? Perhaps people of lower SES have less sense of personal control and so have less confidence in being able to change the stress with problem-focused strategies. Alternative, the nature of the stressors of lower SES people may be ones that are less controllable and so less open to be able to be handled by problem-focused strategies.

41. Personality or Coping Style
Negative affectivity
Pessimism – optimism
Hardiness
Personality factors that influence how one responds to stress. Negative affectivity is a pervasive negative mood marked by anxiety, depression a,d hostility. High negative affectivity is associated with greater distress, more drinking, more likely to be depressed, poorer health, greater reports of physical symptoms, and they are more likely to commit suicide.
Pessimism-optimism – Seligman’s ASQ – pessimists more likely to attribute negative events in their lives to internal (someone wrong with me), stable (never gong to change), and global (effects all aspects of my life) qualities. Pessimists generally associated with poorer health and premature mortality. Optimists on the other hand have better health, engage in more effective coping strategies, and are more likely to engage in slef-management health care practices. Scheirer and Carver’s work with optimism-pessimism.

42. Life Orientation Test (Scheier & Carver)
In uncertain times, I usually expect the best.
If something can go wrong for me it will.
I always look on the bright side.
I’m always optimistic about my future.
I hardly ever expect things to go my way.
Things never work out the way I want them to.
I’m a believer in the idea that “every cloud has a silver lining.”
I rarely count on good things happening to me.
Overall, I expect more good things to happen to me than bad.
Optimists retain more knowledge form health education, engage in more adaptive coping strategies, have better health outcomes following coronary artery bypass surgery and breast cancer surgery.

43. Personality or Coping Style
Negative affectivity
Pessimism – optimism
Hardiness
Hardiness is characterized by high commitment (tendency to get involved fully), internal locus of control, and challenge (willingness to undertake change and to confront new activities that represent opportunities for growth). Numerous studies attest to how hardiness relates to both good mental and physical health. Studies have been done with students, community adults, soldiers, employees, etc. Hardi individuals tend to see things as less stressful, see fewer stressors in their environment, and more like to engage in adaptive coping strategies.

44. Social Support
Emotional support – expression of empathy, understanding, caring, etc.
Esteem support – positive regard, encouragement, validating self-worth
Tangible or instrumental – lending a helpful hand.
Information support – providing information, new insights, advice.
Network support – feeling of belonging
Note that not all social support is necessarily beneficial to health. For example, some studies have found that too much or overly intrusive social support may actually exacerbate stress. In a study we did we found that while participating in pleasurable social activities was associated with a lower risk of premature mortality following an acute myocardial infarction, larger sized social networks was associated with a higher mortality risk (CAMIAT study).
Social support may affect health by both a main effect (I.e., higher social support better regardless of background stress level) and as a buffering effect (I.e., buffers the effect of stress on health). Some suggestion that social support is best when it matches the kind of support available with the individual’s needs.
Note that social support can also be a source of stress when supporters don’t provide the kind of support we need (e.g., not empathic, keep offering unrealistic suggestions for what the person can achieve). Talk about our bone-marrow transplant study when patients are afraid to talk about their fears to supporters because they don’t want to alarm their family and friends and conversely, family and friends don’t ask them about how their feeling for fear of raising the thought of a cancer recurrence (I.e., cloak of silence). This reluctance can lead to social isolation.
Caregivers can also suffer by the constant demands placed on them.

45. Factors Influencing Utilization or Availability of Social Support
Temperament – people differ in their needs for social support. Social support can be detrimental if you are the type of person who likes to handle things on your own.
Previous experience with social support influences your likelihood of seeking out social support in the future.

46. Threats to Social Support
Stressful events can interfere with your ability to use social supports.
People under stress may become so focused on talking about their problems that they drive their support systems away.
Supports agents may react in a way that makes the problem worse.
Support providers may be adversely effected by providing support.
Negative effects of inappropriate actions of social support agents may have a stronger negative effect on well-being than does positive support have on improving well-being. Talk about the CAMIAT study.
Long-term provision of care for another has been tied to both psychological distress and compromised health. Go to Alzheimer’s study.

47. Alxheimer’s Disease (AD) – Effect on Caregivers
Subsample of the Cardiovascular (CVD) Health Study, a prospective study of risk factors for CVD in the elderly.
Excluded: disabled confined to wheel chair, unable to attend field centres, or undergoing cancer treatment.
Caregivers defined as those whose spouse had difficulty with one activity of daily living due to physical or mental health problem.
392 caregivers and 427 non-caregivers recruited.
Schultz, R., & Beach, S.R. (1999). Caregiving as a risk factor for mortality, The caregiver health effects study. Journal of the American Medical Association, 282,
Total CVD sample consisted of 5201 men and women.

48. AD – Effect on Caregivers
Caregivers were asked to rate the degree of mental and physical strain associated with caregiving (3-point response format).
Sample subdivided into four groups: non-caregivers; spouse disabled but not helping him/her; caregiver but no reports of strain; and caregiver with reports of strain.
Followed for 4.5 years (range 3.4 – 5.5 years).
Main outcome – mortality (100% follow-up achieved).
Schultz, R., & Beach, S.R. (1999). Caregiving as a risk factor for mortality, The caregiver health effects study. Journal of the American Medical Association, 282,
Deaths confirmed by medical records, death certificates, obituaries, etc.

49. AD – Effect on Caregivers Results
81% of caregivers were providing care.
56% reported caregiver strain.
Mortality – 9.4% in non-caregivers; 17.3% in ‘caregivers’ not providing care; 13.8% in non-strained caregivers; and 17.3% in strained caregivers.
Schultz, R., & Beach, S.R. (1999). Caregiving as a risk factor for mortality, The caregiver health effects study. Journal of the American Medical Association, 282,
Association between caregiver status and mortality was X2 = 9.38, p = After adjustment for SES (age, sex, race, education, stressful life events); and physical health at baseline, participants providing care and experiencing strain had mortality risk 63% higher than those whose spouses were not disabled (RR = 1.63; 95% CI, 1.00 – 2.65). The RR for the other two caregiver groups did not differ significantly from the non-caregivers. They also found suggestive evidence for the diatheses-stress hypothesis in that there was a trend for the highest mortality to occur in the group who were strained caregivers and who also had physical illnesses. Mortality in the latter group was 33% but RR not quite significant.
What might be mediating factors for the higher mortality risk of caregivers? Perhaps stress, lack of time to take care of their own health, no time to exercise, poor diet, etc.

50. Generally Social Support Associated with Good Effects
Increase survival rates in women who have breast cancer.
Lower blood pressure
Decrease risk of mortality

51. Psychological Predictors of Sudden Cardiac Death in CAMIAT
J. Irvine, A. Basinski, B. Baker, S. Jandciu, M. Pickett, J. Cairns, S. Connolly, M. Gent, R. Roberts, & P. Dorian,
Psychos Med 1999
Funded by Heart and Stroke Foundation of Ontario

52. Psychosocial Predictors of Sudden Cardiac Death in CAMIAT
Measures:
Cook-Medley Index: measures of hostility, anger, cynicism
Beck Depression Inventory
Symptom Checklist-90: psychological distress
Social Support: measures of social participation, network and perceived social support

53. Psychosocial Predictors of Sudden Cardiac Death

54. Stress Management
Providing stress management is probably the most common psychological service in a health psychology practice. What do we mean by stress management?

55. Stress Management – teaches coping techniques
Reduce harmful environmental conditions
Teaches techniques by which person can develop stress tolerance.
Helps client maintain a positive self-image.
Help maintain emotional equilibrium.
Help client maintain or develop satisfying relations with others.
Stress management focuses on the main elements of a coping response. What are some methods of stress management?

56. Cognitive Therapy – Albert Ellis, Aaron Beck
Assumes that stress arises or is augmented by faulty or irrational ways of thinking.
Catastrophizing – “It is awful if I get turned down when I ask for a date”.
Overgeneralizing – “I didn’t get a good grade on this test. I can’t get anything right”.
Selective abstraction – Only seeing specific details of the situation (e.g., Seeing the negatives but missing the positive details).

57. Cognitive Therapy
Often these irrational beliefs or faulty thinking errors stem from past “programming”.
E.g., Not receiving adequate love and nurturance as a child may lead to feelings that loved ones in the present don’t “quite love you enough”.
Hypothesis testing – client is encouraged to test out these irrational beliefs by collecting evidence for or against the belief.

58. Cognitive Therapy Errors in Information Processing -
Irrational Thinking Errors include:
Emotional reasoning
Overgeneralization
Catastrophic thinking
Mind reading
Selective negative focus, etc.
Thase, M.E., & Beck, A.T. (1993). An Overview of Cognitive Therapy. In J. Wright, M.E., Thase, A.T. Beck, & J.W. Ludgate (Eds.). Cognitive Therapy with Inpatients: Developing a Cognitive Milieu. (pp 3-24), New York: Guilford Press.
Negative autonomic thoughts are frequently associated with errors in information processing.

59. Relaxation Therapy
Aims to either reduce hyperarousal or curb emotional-physiological reactivity.
Progressive muscular relaxation
Mental imagery
Meditation
Autogenic training
Positive effects on physiology as well as cognition and emotion. Remember the inverted U-relationship between arousal and performance.

60. Time Management
Set short-term (e.g., daily) and long-term (e.g., yearly) goals.
Make daily to-do lists (prioritize each).
Make a daily schedule for when and where you will carry out your to-do list items (estimate time allocated for each to-do item).
Revise throughout the day as needed.