5 stress and physical and mental health

learning objectives 5

·   5.1 What is stress?

·   5.2 How does the body respond to stress?

·   5.3 What role does our emotional state play in our physical health?

·   5.4 What mental disorders are explicitly recognized as being triggered by stress?

·   5.5 What are the clinical features of posttraumatic stress disorder?

·   5.6 What are the risk factors for PTSD?

·   5.7 What treatment approaches are used for PTSD?

With its deadlines, interpersonal tensions, financial pressures, and everyday hassles, daily life places many demands on us. We are all exposed to stress, and this exposure affects our physical and our psychological well-being. Sometimes even leisure activities can be stressful. For example, a loss in the Superbowl is followed by an increase in heart attacks and death over the following two weeks in the losing team’s city (Kloner et al.,  2011 ). And watching a stressful soccer match more than doubles the risk of having acute cardiovascular problems (Wilbert-Lampen et al.,  2008 ). How are you affected by stress? Does it make you anxious? Does it give you migraines?

The field of  health psychology  is concerned with the effects of stress and other psychological factors in the development and maintenance of physical problems. Health psychology is a subspecialty within  behavioral medicine . A behavioral medicine approach to physical illness is concerned with psychological factors that may predispose an individual to medical problems. These may include such factors as stressful life events, certain personality traits, particular coping styles, and lack of social support. Within behavioral medicine there is also a focus on the effects of stress on the body, including the immune, endocrine, gastrointestinal, and cardiovascular systems.

But stress affects the mind as well as the body. As we discussed in  Chapter 3 , the role that stress can play in triggering the onset of mental disorders in vulnerable people is explicitly acknowledged in the diathesis-stress model. Moreover, exposure to extreme and traumatic stress may overwhelm the coping resources of otherwise apparently healthy people, leading to mental disorders such as  posttraumatic stress disorder (PTSD) , as in the following example.

Posttraumatic Stress in a Military Nurse Jennifer developed PTSD after she served as a nurse in Iraq. During her deployment she worked 12- to 14-hour shifts in 120-degree temperatures. Sleep was hard to come by and disaster was routine. Day in and day out there was a never-ending flow of mangled bodies of young soldiers. Jennifer recalled one especially traumatic event:

·  I was working one evening. We received information that a vehicle, on a routine convoy mission, had been hit by an improvised explosive device (IED). Three wounded men and one dead soldier were on their way to our hospital. Two medics in the back room were processing the dead soldier for Mortuary Affairs. The dead soldier was lying on a cot. The air was strong with the smell of burned flesh. I was staring at the body and trying to grasp what was different about this particular body. After a while I realized. The upper chest and head of the dead soldier was completely missing. We received his head about an hour later. (Based on Feczer & Bjorklund,  2009 ).

In this chapter we consider the role that stress plays in the development of physical and mental disorders. We discuss both physical and mental problems because the mind and the body are powerfully connected and because stress takes its toll on both. Although the problems that are linked to stress are many, we limit our discussion to the most severe stress-related physical and mental disorders. In the physical realm, we focus on heart disease. For mental disorders, we concern ourselves primarily with PTSD.

After a Superbowl loss, heart attacks and death increase in the losing team’s city.

What is Stress?

Life would be very simple if all of our needs were automatically satisfied. In reality, however, many obstacles, both personal and environmental, get in the way. A promising athletic career may be brought to an end by injury; we may have less money than we need; we may be rejected by the person we love. The demands of life require that we adjust. When we experience or perceive challenges to our physical or emotional well-being that exceed our coping resources and abilities, the psychological condition that results is typically referred to as stress (see Shalev,  2009 ). To avoid confusion, we will refer to external demands as  stressors , to the effects they create within the organism as  stress , and to efforts to deal with stress as  coping strategies . It is also important to note that stress is fundamentally an interactive and dynamic construct because it reflects the interaction between the organism and the environment over time (Monroe,  2008 ).

All situations that require adjustment can be regarded as potentially stressful. Prior to the influential work of Canadian physician and endocrinologist Hans Selye ( 1956 ,  1976 ),  stress was a term used by engineers. Selye took the word and used it to describe the difficulties and strains experienced by living organisms as they struggled to cope with and adapt to changing environmental conditions. His work provided the foundation for current stress research. Selye also noted that stress could occur not only in negative situations (such as taking an examination) but also in positive situations (such as a wedding). Both kinds of stress can tax a person’s resources and coping skills, although bad stress ( distress ) typically has the potential to do more damage. Stress can also occur in more than one form—not just as a simple catastrophe but also as a continuous force that exceeds the person’s capability of managing it.

Stress and the  DSM

The relationship between stress and psychopathology is considered so important that the role of stress is recognized in diagnostic formulations. Nowhere is this more apparent than in the diagnosis of PTSD—a severe disorder that we will discuss later. PTSD was classified as an anxiety disorder in DSM-IV. However, DSM-5 introduced a new diagnostic category called trauma- and stressor related disorders. PTSD is now included there. Other disorders in this new category are adjustment disorder and acute stress disorder. These disorders involve patterns of psychological and behavioral disturbances that occur in response to identifiable stressors. The key differences among them lie not only in the severity of the disturbances but also in the nature of the stressors and the time frame during which the disorders occur (Cardeña et al.,  2003 ).

Factors Predisposing a Person To Stress

 SHAPE \* MERGEFORMAT 

Stress can result from both negative and positive events. Both types of stress can tax a person’s resources and coping skills, although distress (negative stress) typically has the potential to do more damage.

Everyone faces a unique pattern of demands to which he or she must adjust. This is because people perceive and interpret similar situations differently and also because, objectively, no two people are faced with exactly the same pattern of stressors. Some individuals are also more likely to develop long-term problems under stress than others. This may be linked, in part, to coping skills and the presence of particular resources. Children, for example, are particularly vulnerable to severe stressors such as war and terrorism (Petrovic,  2004 ). Research also suggests that adolescents with depressed parents are more sensitive to stressful events; these adolescents are also more likely to have problems with depression themselves after experiencing stressful life events than those who do not have depressed parents (Bouma et al.,  2008 ).

Individual characteristics that have been identified as improving a person’s ability to handle life stress include higher levels of optimism, greater psychological control or mastery, increased self-esteem, and better social support (Declercq et al.,  2007 ; Taylor & Stanton,  2007 ). These stable factors are linked to reduced levels of distress in the face of life events as well as more favorable health outcomes. There is also some evidence from twin studies that differences in coping styles may be linked to underlying genetic differences (Jang et al.,  2007 ).

A major development in stress research was the discovery that a particular form of a particular gene (the 5HTTLPR gene) was linked to how likely it was that people would become depressed in the face of life stress. Caspi and colleagues ( 2003 ) found that people who had two “short” forms of this gene (the s/s genotype) were more likely to develop depression when they experienced four or more stressful life events than were people who had two “long” forms of this gene (the l/l geneotype). Although this specific finding was controversial for a while a recent meta-analysis has provided clear support for the original finding (Karg et al.,  2011 ). More generally, it is now widely accepted that our genetic makeup can render us more or less “stress-sensitive.” Researchers are exploring genes that may play a role in determining how reactive to stress we are (Alexander et al.,  2009 ; Armbruster et al.,  2012 ).

The amount of stress we experience early in life may also make us more sensitive to stress later on (Gillespie & Nemeroff,  2007 ; Lupien et al.,  2009 ). The effects of stress may be cumulative, with each stressful experience serving to make the system more reactive. Evidence from animal studies shows that being exposed to a single stressful experience can enhance responsiveness to stressful events that occur later (Johnson, O’Connor et al.,  2002 ). Rats that were exposed to stressful tail shocks produced more of the stress hormone cortisol when they were later exposed to another stressful experience (being placed on a platform). Other biological changes associated with stress were also more pronounced in these rats. These results suggest that prior stressful experiences may sensitize us biologically, making us more reactive to later stressful experiences. The term  stress tolerance  refers to a person’s ability to withstand stress without becoming seriously impaired.

Stressful experiences may also create a self-perpetuating cycle by changing how we think about, or appraise, the things that happen to us. Studies have shown that stressful situations may be related to or intensified by a person’s cognitions (Nixon & Bryant,  2005 ). This may explain why people with a history of depression tend to experience negative events as more stressful than other people do (Havermans et al.,  2007 ). For example, if you’re feeling depressed or anxious already, you may perceive a friend’s canceling a movie date as an indication that she doesn’t want to spend time with you. Even though the reality may be that a demand in her own life has kept her from keeping your date, when you feel bad you will be much more inclined to come to a negative conclusion about what just happened rather than see the situation in a more balanced or more optimistic way. Can you think of an example in your own life when something like this has happened to you?

Characteristics of Stressors

Why is misplacing our keys so much less stressful than being in an unhappy marriage or being fired from a job? At some level we all intuitively understand what makes one stressor more serious than another. The key factors involve (1) the severity of the stressor, (2) its chronicity (i.e., how long it lasts), (3) its timing, (4) how closely it affects our own lives, (5) how expected it is, and (6) how controllable it is.

Stressors that involve the more important aspects of a person’s life—such as the death of a loved one, a divorce, a job loss, a serious illness, or negative social exchanges—tend to be highly stressful for most people (Aldwin,  2007 ; Newsom et al.,  2008 ). Furthermore, the longer a stressor operates, the more severe its effects. A person may be frustrated in a boring and unrewarding job from which there is seemingly no escape, suffer for years in an unhappy and conflict-filled marriage, or be severely frustrated by a physical limitation or a long-term health problem. As we have already noted, stressors also often have cumulative effects (Miller,  2007 ). A married couple may endure a long series of difficulties and frustrations, only to divorce after experiencing what might seem to be a minor precipitating stressor. Encountering a number of stressors at the same time also makes a difference. If a man loses his job, learns that his wife is seriously ill, and receives news that his son has been arrested for selling drugs, all at the same time, the resulting stress will be more severe than if these events occurred separately and over an extended period. Symptoms of stress also intensify when a person is more closely involved in an immediately traumatic situation. Learning that the uncle of a close friend was injured in a car accident is not as stressful as being in an accident oneself.

A devastating house fire is not an event we can anticipate. It is almost impossible to be psychologically prepared to experience a stressor such as this.

Extensive research has shown that events that are unpredictable and unanticipated (and for which no previously developed coping strategies are available) are likely to place a person under severe stress. A devastating house fire and the damage it brings are not occurrences with which anyone has learned to cope. Likewise, recovery from the stress created by major surgery can be improved when a patient is given realistic expectations beforehand; knowing what to expect adds predictability to the situation. In one study, patients who were about to undergo hip replacement surgery watched a 12-minute film the evening before they had the operation. The film described the entire procedure from the patient’s perspective. Compared to controls who did not see the film, patients who saw the video were less anxious on the morning of the surgery, were less anxious after the surgery, and needed less pain medication (Doering et al.,  2000 ).

Unpredictable and uncontrollable events cause the greatest stress. These people are reacting to the collapse of the World Trade Center towers.

Finally, with an uncontrollable stressor, there is no way to reduce its impact, such as by escape or avoidance. In general, both people and animals are more stressed by unpredictable and uncontrollable stressors than by stressors that are of equal physical magnitude but are either predictable or controllable or both (e.g., Evans & Stecker,  2004 ; Maier & Watkins,  1998 ).

THE EXPERIENCE OF CRISIS

Most of us experience occasional periods of especially acute (sudden and intense) stress. The term  crisis  is used to refer to times when a stressful situation threatens to exceed or exceeds the adaptive capacities of a person or a group. Crises are often especially stressful, because the stressors are so potent that the coping techniques we typically use do not work. Stress can be distinguished from crisis in this way: A traumatic situation or crisis overwhelms a person’s ability to cope, whereas stress does not necessarily overwhelm the person.

Measuring Life Stress

Life changes, even positive ones such as being promoted or getting married, place new demands on us and may therefore be stressful. The stress from life changes can trigger problems, even in disorders, such as bipolar disorder, that have strong biological underpinnings (see Johnson & Miller,  1997 ). The faster life changes occur, the greater the stress that is experienced.

A major focus of research on life changes has concerned the measurement of life stress. Years ago, Holmes and Rahe ( 1967 ) developed the Social Readjustment Rating Scale. This is a self-report checklist of fairly common, stressful life experiences (see also Chung et al.,  2010 ; Cooper & Dewe,  2007 ). Although easy to use, limitations of the checklist method later led to the development of interview-based approaches such as the Life Events and Difficulties Schedule (LEDS; Brown & Harris,  1978 ). One advantage of the LEDS is that it includes an extensive manual that provides rules for rating both acute and chronic forms of stress. The LEDS system also allows raters to consider a person’s unique circumstances when rating each life event. For example, if a woman who is happily married and in good financial circumstances learns that she is going to have a baby, she may experience this news in a way that is quite different from that of an unmarried teenager who is faced with the prospect of having to tell her parents that she is pregnant. Although interview-based approaches are more time consuming and costly to administer, they are considered more reliable and are preferred for research in this area (see Monroe,  2008 ).