1. Stress, Coping and Health – 8th Edition
Chapter 13
Stress, Coping and Health – 8th Edition

2. The Relationship Between Stress and Disease
Contagious diseases vs. chronic diseases
Biopsychosocial model
Why?
The Biomedical Model is unable to fully account for health
Mind-body question
Biomedical treatments only
Failures to account for many psychological factors and health
Placebo effects – how to explain
Health psychology
Health promotion and maintenance
Discovery of causation, prevention, and treatment
Primary prevention, secondary prevention, tertiary prevention
Changing pattern of what is the primary cause of death in last 100+ years. – F 13.1
Prior to the 20th century, the principal threats to health were contagious diseases caused by infectious agents: smallpox, diphtheria, etc. Nutrition, public hygiene, and medical treatment have obliterated many of these diseases. Unfortunately, chronic diseases such as heart disease and cancer, diseases that develop gradually, continue to increase.
The traditional view of physical illness as a purely biological phenomenon has given way to a new model, the biopsychosocial model, which holds that physical illness is caused by a complex interaction of biological, psychological, and sociocultural factors.
Health psychology is the field of study that seeks to determine the importance of psychological factors in illness, as well as in prevention and health maintenance.

3. Levels of Prevention Primary Prevention Secondary Prevention
Prevent disease
Identify causes
Promote health behaviors
Secondary Prevention
Catch disease in early stages
Prevent further deterioration
There are three levels of prevention that can be considered:
Primary prevent focuses on prevention of disease and disability, e.g. educating teenagers to quit smoking, encouraging hygiene, immunizations, medical check-ups, flu shots, condom use, seat-belt use.
Secondary focuses on early detection and management of illness with a goal towards cure or prevention of further deterioration, e.g. regular screening and removing of small tumors in females at risk for familial breast cancer, or the use of medications with asthmatics to control future attacks.
Tertiary prevention focuses on maintaining quality of life for people with chronic illnesses. Cure is no longer an option, but through careful management, suffering can be decreased, and quality of life therefore improved.
Tertiary Prevention
Manage illnesses with no
cure

4. Figure 13.1 Changing patterns of illness

5. Stress: An Everyday Event
Major stressors vs. routine hassles
Cumulative nature of stress
Psychological Stress - Lazarus
Cognitive appraisals: primary and secondary
Major types of stress
Frustration – blocked goal
Conflict – two or more incompatible motivations
Approach-approach, approach-avoidance, avoidance-avoidance – Figure 13.2
Change – having to adapt
Holmes and Rahe – Social Readjustment Rating Scale – Life Change Units – Table 13.1
Pressure – expectations to behave in certain ways
Perform/conform
Figure 13.3 – pressure and psychological symptoms – Weiten (1988)
Overview of Stress Process – Figure 13.4
Stress is defined in the text as any circumstances that threaten or are perceived to threaten one’s well being and that thereby tax one’s coping ability.
Researchers have discovered that minor stresses (Lazarus – daily hassles) like moving, experiencing changes in household responsibilities, etc. can add up to be as stressful as a major traumatic event like a divorce or disaster; the cumulative nature of stress. The experience of feeling stressed depends largely on cognitive processes; going on a new date is exciting for some, terrifying for others. People’s appraisals of events are very subjective and influence the effect of the event.
Psychologists have outlined 4 principle types of stress:
Frustration, which occurs in any situation in which the pursuit of some goal is thwarted. Ex. traffic jams.
Conflict occurs when two or more incompatible motivations or behavioral impulses compete for expression. 3 types of conflict have been studied extensively: approach-approach – when a person has a choice between 2 attractive goals, approach-avoidance – when a choice must be made about whether to pursue a single goal that has both attractive and unattractive aspects…results in vacillation, or going back and forth…rats actually run up and down a ramp in this type conflict.
Life changes are any noticeable alterations in one’s living circumstances that require readjustment. Holmes and Rahe (1967) developed the Social Readjustment Rating Scale to measure life change as a form of stress, giving higher points (life change units) for more stressful events.
Pressure involves expectations or demands that one behave in a certain way…pressure to perform or to comply.

6. Psychological Stress
Richard Lazarus (1966) (p. 512) defined psychological stress as “…a generic term for the whole area of problems that includes the stimuli producing stress reactions, the reactions themselves, and the various intervening processes.”
Lazarus and Folkman (1984) define psychological stress as “a particular relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well being.”

7. Appraisal Process
The primary appraisal process determines whether the environment is perceived as psychologically threatening, harmful, or challenging to the person.
The secondary appraisal process is a complex evaluative process in which a person considers resources available to cope with the primarily appraised stressor.

9. Figure 13-3 – Pressure and psychological symptoms (Weiten, 1988, 1998)
A comparison of pressure and life change as sources of stress suggests that pressure may be more strongly related to mental health than change is. In one study, Weiten (1988b) found a correlation of .59 between scores on the Pressure Inventory (PI) and symptoms of psychological distress. In the same sample, the correlation between SRRS scores and psychological symptoms was only .28.
Figure 13-3 – Pressure and psychological symptoms (Weiten, 1988, 1998)

11. Responding to Stress Emotionally
Emotional Responses
Annoyance, anger, rage
Apprehension, anxiety, fear
Dejection, sadness, grief
Positive emotions
Slide 12, after 9/11 – correlations between emotion and resilience
Emotional response and performance
The inverted-U-hypothesis – Figure 13.5 – performance and task complexity
Stress responses are multidimensional, including emotional, psychological, and behavioral realms.
Emotions commonly elicited by stress are listed on the slide.
Apparently there are strong links between cognitive appraisals and which set of emotions one experiences as a function of a stressor; self-blame leads to guilt, helplessness to sadness, etc. Positive emotions may also occur during periods of stress, with positive emotions experienced while under duress having adaptive significance, promoting creativity and flexibility in problem solving, facilitating the processing of important information about oneself, and reducing the adverse physiological effects of stress.
High emotion can sometimes negatively influence task performance, more so for highly complex tasks and less so for simple ones (the inverted-u-hypothesis).

12. XXXXXXXX
Slide 12
Table 13-2, p. 518

14. Responding to Stress Physiologically
Physiological Responses
Fight-or-flight response
Selye’s General Adaptation Syndrome
Alarm
Resistance
Exhaustion
Brain-body pathways in stress – Figure 13.6
sympathetic adrenal medullary (SAM)
hypothalamic pituitary adrencortical (HPA)
Physiological effects of stress include the fight-or-flight response, discovered by Walter Cannon (1932). The FF response is a physiological reaction to threat in which the autonomic nervous system (ANS) mobilizes the organism for attacking (fight) or fleeing (flight) an enemy.
The fight-or-flight response is adaptive if one is faced with a predator; however, modern stressors are more long term (the checkbook).
Hans Selye began studying stress in the 1930’s to determine the effects of these chronic stressors. He used an animal model, exposing them to both physical and psychological stressors to determine effects, which were nonspecific. That is, the reactions did not relate to the type of stress.
Selye formulated a theory about how stress reactions occur called the general adaptation syndrome.
The alarm stage occurs when an organism recognizes a threat and mobilizes resources – essentially enters the FF response.
The resistance stage occurs when the stress is prolonged. This is a period when physiological arousal stabilizes but is still above baseline, as the organism copes with the stressor.
The exhaustion stage occurs when the body’s resources are depleted…Selye believed that this is where diseases of adaptation come in.

15. Physiological Stress
Hans Selye first introduced the term stress to medicine in He noted that animals were induced by a variety of stimuli to show the “syndrome of just being sick” which resulted in adrenal enlargement, gastrointestinal ulcers, shrinkage of the thymus and lymph nodes. This reaction was termed the “general adaptation syndrome” and “stress is the nonspecific response of the body to any demand made upon it”.

16. Figure 13.6 – Brain-body pathways
in stress: SAM and HPA systems
Lundberg (2002), “[Two] neuroendocrine systems have been of particular interest in the study of stress; the sympathetic adrenal medullary (SAM) system with secretion of the two catecholamines, epinephrine and norepinephrine, and the the hypothalamic pituitary adrencortical (HPA) system with the secretion of cortisol.”
Figure 13.6: Brain-body pathways in stress.
In times of stress, the brain sends signals along two pathways. The pathway through the autonomic nervous system controls the release of catecholamine hormones that help mobilize the body for action. The pathway through the pituitary gland and the endocrine system controls the release of corticosteroid hormones that increase energy and ward off tissue inflammation.

17. Responding to Stress Behaviorally
Behavioral Responses: Coping – emotion focused
Frustration-aggression hypothesis
catharsis
Defensive Coping – ego defense mechanisms –Freud – Table 13.2
Constructive Coping – problem focused
Behaviorally people respond to stress at different levels.
Coping refers to active efforts to master, reduce, or tolerate the demands created by stress. These may involve giving up and blaming oneself (learned helplessness – passive behavior produced by exposure to unavoidable aversive events), striking out at others aggressively (usually the result of frustration…Dollard’s frustration-aggression hypothesis), self-indulgement (eating, drinking, smoking, shopping), defensive coping (erecting defense mechanisms), or constructive coping (realistically appraising situations and confronting problems directly).

18. Table 13.2
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Source: Adapted from Carson, R. C., Butcher, J. N., & Coleman, J. C. (1988). Abnormal psychology and modern life. Glenview, IL: Scott, Foresman. Copyright © 1988 by Scott, Foresman and Company. Adapted by permission of the publisher.
Note: See Table 12.1 for another list of defense mechanisms.
Table 13-3, p. 523

19. Emotion-focused coping and Problem-focused coping
“Emotion-focused (or palliative) coping refers to thoughts or actions whose goal is to relieve the emotional impact of stress. These are apt to be mainly palliative in the sense that such strategies of coping do not actually alter the threatening or damaging conditions but make the person feel better.” Monat and Lazarus (1991, p. 6)
“Problem-focused coping refers to efforts to improve the troubled person-environment relationship by changing things, for example, by seeking information about what to do, by holding back from impulsive and premature actions, and by confronting the person or persons responsible for one’s difficulty.” Monat and Lazarus (1991, p. 6)

20. Effects of Stress: Behavioral and Psychological
Impaired Task performance
Burnout – antecedent-components-consequences – Figure 13.7
Posttraumatic Stress Disorders (PTSD) – effects on hippocampus (cortisol) – prevelance of traumatic events – Slide 22
Reaction to traumatic stress – Figure 13.8
Psychological problems and disorders – more in Chapter 14
Positive effects – eustress – Positive Psychology – Flow (Csikszentmihalyi)
Roy Baumeister’s work shows that people under pressure to perform may feel self-conscious, which leads to disruption of attention and “choking” under pressure.
Burnout involves physical, mental, and emotional exhaustion that is attributable to long-term involvement in emotionally demanding situations…loss of meaning.
PTSD involves enduring psychological disturbance attributed to the experience of a major traumatic event…seen after war, rape, major disasters, etc. Symptoms include re-experiencing the traumatic event in the form of nightmares and flashbacks, emotional numbing, alienation, problems in social relations, and elevated arousal, anxiety, and guilt.
Chronic stress might contribute to many types of psychological problems and mental disorders, from sleep problems and unhappiness, to full-fledged psychological disorders such as schizophrenia and depression.
From a positive psychology perspective, effects of stress are not entirely negative. Recent research suggests that stress can promote personal growth or self-improvement, forcing people to develop new skills, reevaluate priorities, learn new insights, and acquire new strengths. Conquering a stressful challenge may also lead to improved coping abilities and increases in self-esteem.

21. Figure 13.7 – The antecedents, components,
Figure 13.7: The antecedents, components, and consequences of burnout.
Christina Maslach and Michael Leiter have developed a systematic model of burnout that specifies the antecedents, components, and consequences of this syndrome. The antecedents on the left in the diagram are the stressful features of the work environment that cause burnout. The syndrome itself consists of the three components shown in the center of the diagram. Some of the unfortunate results of burnout are listed on the right. (Based on Leiter & Maslach, 2001)
Figure 13.7 – The antecedents, components,
and consequences of burnout

22. XXXXXX Slide 22

23. Effects of Stress: Physical
Psychosomatic diseases
Heart disease
Cholesterol and inflammation (C-reactive protein) and risks – Figure 13.9
Type A behavior - 3 elements
strong competitiveness
impatience and time urgency
anger and hostility (note in F most related to cornary events)
Emotional reactions and depression – Figure – study by Pennix et al. (2001) – anger and coronary risk
Stress and immune functioning
Reduced immune activity
Possible health problems linked to stress – Table 13.3
Stress-illness correlation – Figure 13.12
Historically, psychosomatic diseases were defined as physical ailments with a genuine organic basis that are caused in part by psychological factors, especially emotional distress…things like hypertension, ulcers, asthma, eczema, and migraine headaches. Now we know that stress contributes to a diverse array of other diseases once thought to be completely physiologically based and using the term psychosomatic disease as a separate category has fallen into disuse.
Heart disease accounts for nearly one-third of the deaths in the U.S. each year, and atherosclerosis, or gradual narrowing of the coronary arteries, is the principle cause of CHD. Risk factors for CHD include smoking, lack of exercise, high cholesterol levels, and high blood pressure. Recently, researchers have shown that inflammation may contribute to atherosclerosis, as well. Personality factors have been linked to risk for coronary heart disease. These personality characteristics have been collectively labeled Type A personality and include 3 main elements (listed on the slide). The hostility factor has been indicated as the most important predictor in this cluster of behaviors.
Emotional reactions can trigger cardiac symptoms in patients with stable coronary disease. Depressive disorders may also be a risk factor for heart disease, with some studies showing that the risk of CHD is doubled with depression.
Stress has also been shown to decrease the immune response, the body’s defensive reaction to invasion by bacteria, viral agents, or other foreign substances…decreasing white blood cells called lymphocytes. The featured study in the text explores the effects of stress on contracting the common cold.

25. Table 13.3a Health Problems that may be Linked to Stress

26. Table 13.3b Health Problems that may be Linked to Stress

27. XXX 13.12

28. Factors Moderating the Impact of Stress
Social support
The perceived comfort, caring, esteem or help received from others.
Types: emotional, belongingness, instrumental (tangible), informational, esteem/relational, and network (Facebook and MySpace?)
The existence or quantity of social relationships
the amount of assistance individuals believe is available to them
the amount of assistance individuals receive
Alameda County Study in 1965 – related to health outcomes, tend to live longer
Increased immune functioning
Optimism
expectation of good things will happen and bad things will not happen, contrasted to pessimism
Related to psychological well-being, physical well-being
More adaptive coping
Pessimistic explanatory style
Conscientiousness
Fostering better health habits
Autonomic reactivity
Cardiovascular reactivity to stress
Many factors moderate the effects of stress on illness, and individual differences in impact appear to be related to these moderating variables.
Social support, or the various types of aid and succor provided by members of one’s social network, appear to decrease the negative impact of stress.
Having an optimistic style also appears to lead to more effective coping with stress, while pessimistic styles have been related to passive coping and poor health practices.
Conscientiousness also appears to be related to increased longevity, possibly because being conscientious leads to better health habits.
Finally, physiological factors, such as cardiovascular reactivity to stress, appear to play a role in how significant the impact of stress is on an individual.

29. Health-Impairing Behaviors
Smoking – prevalence in U.S. - Figure 13.13
Smoking cessation – Figure 13.14
Poor nutrition – obesity – “Super Size” generation
Cholesterol and coronary risk – Figure 13.15
High fructose corn syrup effects
Lack of exercise – increased T.V. watching effects study
Obesity – BMI – United States 2005 & 2008 data – CDC – Slide 33 & 34 – changes over the years
Alcohol and drug use
Risky sexual behavior
Transmission, misconceptions, and prevention of AIDS – AIDS Risk Knowledge Test - Figure 13.16
Self-destructive behavior is surprisingly common. Take smoking, for example. A 25 year old male who smokes two packs a day has an estimated life expectancy 8.3 years shorter than that of a similar, nonsmoker. Health risks decline quickly for those who give up smoking, but quitting is difficult and relapse rates are high.
Poor nutritional habits and lack of exercise have been linked to heart disease, hypertension, and cancer, among other things.
Obesity and BMI greater than and equal to 30 – CDC data
Alcohol and drug use carry the immediate risk of overdose and the long-term risk of many diseases.
Acquired Immune Deficiency Syndrome (AIDS) is clearly influenced by behavior. AIDS is transmitted through person-to-person contact involving the exchange of bodily fluids, primarily semen and blood.
Misconceptions about AIDS are common, either overestimations or underestimations of risk. Many young heterosexuals downplay their risk for HIV, causing them not to adopt the behavioral practices that minimize risk.
So why do people engage in health impairing behavior? Most of these develop gradually and often involve pleasant activities. Risks lie in the distant future, and people tend to underestimate risks that apply to them personally.

30. Figure 13.13 The prevalence of smoking in the United States

31. Figure 13.14 Quitting smoking and cancer risk

32. Figure 13.15 – The link between cholesterol and coronary risk
In a review of several major studies, Stamler et al. (2000) summarize crucial evidence on the association between cholesterol levels and the prevalence of cardiovascular disease. This graph is based on a sample of over 11,000 men who were ages 18 to 39 at the beginning of the study (1967–1973) when their serum cholesterol level was measured. The data shown here depict participants’ relative risk for coronary heart disease during the ensuing 25 years, as a function of their initial cholesterol level. (Data from Stamler et al., 2000)
Fig , p. 535

33. BMI Classifications – Slide 30
BMI = 19-25; Normal; Low Risk
BMI = 25-30; Moderately overweight; Some Risk
BMI = 30-35; Class 1 obesity; High Risk
BMI = 35-40; Class 2 obesity; Very High Risk
BMI> 40; Class 3 obesity; Extreme Risk
A rating of 25 or higher is considered overweight, 30 or higher is obese, and 40 or higher is extremely obese. For example, a 5-foot-8-inch person who weighs 190 pounds would be overweight; a person at the same height who weighs 230 pounds is obese.
- Americans are even fatter than they think they are, with nearly a third of all adults - almost 59 million people - rated obese in a disturbing new government survey based on actual body measurements.
One in five Americans, or 19.8 percent, had considered themselves obese in a 2000 survey based on people's own assessments of their girth.
The new survey puts the real number at 31 percent - a doubling over the past two decades. The new number is considered more reliable since people consistently underestimate their weight.
BMI > 30, or ~ 30 lbs. overweight for 5'4" person for CDC

34. BMI Classifications – Slide 31
BMI = 19-25; Normal; Low Risk
BMI = 25-30; Moderately overweight; Some Risk
BMI = 30-35; Class 1 obesity; High Risk
BMI = 35-40; Class 2 obesity; Very High Risk
BMI> 40; Class 3 obesity; Extreme Risk
A rating of 25 or higher is considered overweight, 30 or higher is obese, and 40 or higher is extremely obese. For example, a 5-foot-8-inch person who weighs 190 pounds would be overweight; a person at the same height who weighs 230 pounds is obese.
- Americans are even fatter than they think they are, with nearly a third of all adults - almost 59 million people - rated obese in a disturbing new government survey based on actual body measurements.
One in five Americans, or 19.8 percent, had considered themselves obese in a 2000 survey based on people's own assessments of their girth.
The new survey puts the real number at 31 percent - a doubling over the past two decades. The new number is considered more reliable since people consistently underestimate their weight.
BMI > 30, or ~ 30 lbs. overweight for 5'4" person for CDC

35. Reactions to Illness Seeking treatment
Ignoring physical symptoms
Communication with health care providers
Barriers to effective communication
Following medical advice
Noncompliance
Biopsychosocial factors in health – Figure 13.17
Many reactions to illness are not conducive to health. For example, many people ignore physical symptoms, resulting in delay in medical treatment.
Even when they seek medical help, communication between patients and health care providers is not always honest or efficient.
Noncompliance with medical advice is a serious issue. Noncompliance is more likely if instructions are hard to understand, when they are difficult to follow, and when patients are unhappy with their doctor.

36. Figure 13.17 – Biopsychosocial factors in health
Physical health can be influenced by a remarkably diverse set of variables, including biological, psychological, and social factors. The host of factors that affect health provide an excellent example of multifactorial causation.

37. Stress Management Relationship to coping to self-esteem
Cognitive reappraisal – Ellis’s model – Figure 13.18
Humor – Figure 13.19
Relaxation Response – Benson – Figure and Slide 41
Stress Inoculation Training – Slide 42
Physical fitness and mortality – Figure 13.21

38. Figure 13.18 – Albert Ellis’s A-B-C model of emotional reactions
Although most people attribute their negative emotional reactions directly to negative events that they experience, Ellis argues that events themselves do not cause emotional distress; rather, distress is caused by the way people think about negative events. According to Ellis, the key to managing stress is to change one’s appraisal of stressful events.
Figure – Albert Ellis’s A-B-C model of emotional reactions

39. Figure 13.18: Possible explanations for the link between humor and wellness.
Research suggests that a good sense of humor buffers the effects of stress and promotes wellness. Four hypothesized explanations for the link between humor and wellness are outlined in the middle column of this diagram. As you can see, humor may have a variety of beneficial effects.
Figure – Possible examination for the link between humor and wellness
Fig , p. 543

40. Stress management techniques -adapted from Monat & Lazarus (1991)
Environment/Lifestyle: time management, proper nutrition, exercise, finding alternatives to frustrated goals, stopping bad habits
Personality/Perception: assertiveness training, thought stopping, refuting irrational ideas, stress inoculation, modifying type A behavior
Biological responses: progressive relaxation, relaxation response, meditation, breathing exercises, biofeedback, autogenics

41. Relaxation Response – Benson – Slide 41
“The relaxation response is perhaps best understood as a psycho-physiological state of hypoarousal engendered by a multitude of diverse technologies [techniques]” (Everly, 1989, p.149)
Meditation - a self-generating practice of a variety of techniques designed to induce the relaxation response by use of a repetitive focal device
Progressive relaxation - relax selected muscles by first tensing then relaxing the muscles

42. Stress Inoculation Training developed by Donald Meichenbaum – Slide 42
Stage 1 - education - the person is given a framework for understanding his/her stress response
Stage 2 - rehearsal - the person learns to make cognitive self-statements as a form of coping and problem solving
Stage 3 - application - the person uses the information and skills learned in the first two stages in actual stress situations, moving from lower to higher stress situations