Adjustment Disorders

What types of stressors increase the likelihood of adjustment disorders? What factors increase the risk of developing an adjustment disorder? How are adjustment disorders different from more chronic conditions?

5 stress and physical and mental health

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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.

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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

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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.

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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 ).

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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 ).

Resilience

After experiencing a potentially traumatic event, some people function well and experience very few symptoms in the following weeks and months. This kind of healthy psychological and physical functioning after a potentially traumatic event is called resilience . You might be surprised to learn that resilience is not rare. In fact, resilience is the most common reaction following loss or trauma (Bonnano et al., 2011 ; Quale & Schanke, 2010 ).

But why are some people more resilient than others? Research suggests that there is no single factor that predicts resilience. Rather, resilience is linked to a variety of different characteristics and resources. Factors that increase resilience include being male, being older, and being well educated. Having more economic resources is also beneficial. Some earlier studies suggested that, after the 9/11 attacks in New York, African Americans and members of some Latino groups fared more poorly and showed lower levels of resilience compared to whites. However, race and ethnicity are often confounded with social class. Importantly, when social class is controlled for, statistics show that race and ethnicity are no longer predictive of reduced resiliency.

It also helps to be a positive person. Research shows that people who can still show genuine positive emotions when talking about their recent loss also tend to adjust better after bereavement (see Bonnano et al., 2011 ). In contrast, having more negative affect, being more inclined to ruminate, and trying to find meaning in what has happened is associated with people doing less well after a traumatic event.

The importance of positive and negative emotions is nicely illustrated in a study of 80 people who were being treated in a specialized rehabilitation hospital (Quale & Schanke, 2010 ). All had multiple traumatic injuries or severe spinal cord injuries, usually caused by accidents. The people who showed most resilience in the months after their injuries were those who, when interviewed shortly after arriving in the hospital, reported that they generally had an optimistic approach to life. In addition to optimism, being generally high on positive affect and low on negative affect also predicted having a more resilient trajectory (as opposed to a distress trajectory) over the period of rehabilitation treatment.

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Resilience is the most common response to a potentially traumatic event. Optimism, positive emotions, and having more economic resources are all predictive of resilience.

Finally, it is interesting to note that people who are very self-confident and who view themselves in an overly positive light also tend to cope remarkably well in the face of trauma. Although people with this kind of self-enhancing style are sometimes unpleasant to interact with, such a style may serve them well in times of crisis. For example, in a recent prospective study, Gupta and Bonanno ( 2010 ) showed that college students with this self-enhancing style coped much better over a four-year period than people who did not.

in review

· • What factors play a role in determining a person’s stress tolerance?

· • What characteristics of stressors make them more serious and more difficult to adapt to?

· • Describe two methods that can be used to measure life stress.

· • What is resilience? Describe three factors that increase resilience and three factors that are associated with reduced resilience.

Stress and the Stress Response

To understand why stress can lead to physical and psychological problems, we need to know what happens to our bodies when we experience stress. Faced with the threat of a perceived stressor, the body undergoes a cascade of biological changes. Two distinct systems are involved here. The sympathetic-adrenomedullary (SAM) system (see Gunnar & Quevedo, 2007 ) is designed to mobilize resources and prepare for a fight-or-flight response. The stress response begins in the hypothalamus, which stimulates the sympathetic nervous system (SNS). This, in turn, causes the inner portion of the adrenal glands (the adrenal medulla) to secrete adrenaline (epinephrine) and noradrenaline (norepinephrine). As these circulate through the blood, they cause an increase in heart rate (familiar to all of us). They also get the body to metabolize glucose more rapidly.

The second system involved in the stress response is called the hypothalamus-pituitary-adrenal (HPA) system (which we introduced in Chapter 3 ; also see Figure 5.1 ). In addition to stimulating the SNS, the hypothalamus releases a hormone called “corticotrophin-releasing hormone” (or CRH). Traveling in the blood, this hormone stimulates the pituitary gland. The pituitary then secretes adrenocorticotrophic hormone (ACTH). This induces the adrenal cortex (the outer portion of the adrenal gland) to produce the stress hormones called glucocorticoids. In humans, the stress glucocorticoid that is produced is called cortisol . Figure 5.1 illustrates this sequence of events.

Cortisol is a good hormone to have around in an emergency. It prepares the body for fight or flight. It also inhibits the innate immune response. This means that if an injury does occur, the body’s inflammatory response to it is delayed. In other words, escape has priority over healing, and tissue repair is secondary to staying alive. This obviously has survival value if you need to run away from a lion that has just mauled you. It also explains why cortisone injections are sometimes used to reduce inflammation in damaged joints.

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FIGURE 5.1 The Hypothalamic-Pituitary-Adrenal (HPA) Axis. Prolonged stress leads to secretion of the adrenal hormone cortisol, which elevates blood sugar and increases metabolism. These changes help the body sustain prolonged activity but at the expense of decreased immune system activity.

image9 Explore the simulation LivePsych! Stress and Immune System on MyPsychLab .

But there is also a downside to cortisol. If the cortisol response is not shut off, cortisol can damage brain cells, especially in the hippocampus (see Sapolsky, 2000 ). At a very fundamental level, stress is bad for your brain. It may even stunt growth (babies who are stressed don’t gain weight in the normal way and “fail to thrive”). Accordingly, the brain has receptors to detect cortisol. When these are activated, they send a feedback message that is designed to dampen the activity of the glands involved in the stress response. But if the stressor remains, the HPA axis stays active and cortisol release continues. Although short-term cortisol production is highly adaptive, a chronically overactive HPA axis, with high levels of circulating cortisol, may be problematic.

Biological Costs of Stress

The biological cost of adapting to stress is called the allostatic load (McEwan, 1998 ). When we are relaxed and not experiencing stress, our allostatic load is low. When we are stressed and feeling pressured, our allostatic load will be higher. Although efforts to relate specific stressors to specific medical problems have not generally been successful, stress is becoming a key underlying theme in our understanding of the development and course of virtually all physical illness. Moreover, the focus now is not just on major stressors such as job loss or the death of a loved one, but also on daily stressors such as commuting, unexpected work deadlines, or even computer problems (Almeida, 2005 ). For example, a person with allergies may find his or her resistance further lowered by emotional tension. Similarly, when a virus has already entered a person’s body—as is thought to be the case in multiple sclerosis—emotional stress may interfere with the body’s normal defensive forces or immune system. In like manner, any stress may tend to aggravate and maintain certain disorders, such as migraine headaches (Levor et al., 1986 ) and rheumatoid arthritis (Affleck et al., 1994 ; Keefe et al., 2002 ).

The Mind–Body Connection

The link between stress and physical illness involves diseases (like colds) that are not directly related to nervous system activity. This suggests that stress may cause an overall vulnerability to disease by compromising immune functioning. Psychoneuroimmunology is the study of the interaction between the nervous system and the immune system. Although it was once thought that the immune system was essentially “closed” and responsive only to challenges from foreign substances, we now realize that this is not the case. The nervous system and the immune system communicate in ways that we are now beginning to understand.

Evidence continues to grow that the brain influences the immune system and that the immune system influences the brain. In other words, a person’s behavior and psychological states do indeed affect immune functioning, but the status of the immune system also influences current mental states and behavioral dispositions by affecting the blood levels of circulating neurochemicals; these, in turn, modify brain states. For example, we have already seen that glucocorticoids can cause stress-induced immunosuppression . In the short term, this can be adaptive (escape first, heal later). However, it makes sense that longer-term stress might create problems for the immune system. To appreciate why this might be, we need to describe briefly the basics of immune functioning.

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When we are relaxed and calm, our allostatic load is low.

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When our allostatic load is high, we experience the biological signs of stress including high heart rate and increased levels of cortisol.

Understanding the Immune System

The word immune comes from the Latin immunis, which means “exempt.” The immune system protects the body from such things as viruses and bacteria. It has been likened to a police force (Kalat, 2001 ). If it is too weak, it cannot function effectively, and the body succumbs to damage from invading viruses and bacteria. Conversely, if the immune system is too strong and unselective, it can turn on the body’s own healthy cells. This is what may happen in the case of autoimmune diseases such as rheumatoid arthritis and lupus.

The front line of defense in the immune system is the white blood cells. These leukocytes (or lymphocytes ) are produced in the bone marrow and then stored in various places throughout the body, such as the spleen and the lymph nodes. There are two important types of leukocytes. One type, called a B-cell (because it matures in the bone marrow) produces specific antibodies that are designed to respond to specific antigens. Antigens (the word is a contraction of antibody generator) are foreign bodies such as viruses and bacteria, as well as internal invaders such as tumors and cancer cells. The second important type of leukocyte is the T-cell (so named because it matures in the thymus, which is an important endocrine gland). When the immune system is stimulated, B-cells and T-cells become activated and multiply rapidly, mounting various forms of counterattack (see Figure 5.2 ).

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FIGURE 5.2 Immune System Responses to a Bacterial Infection .

Source: J. W. Kalat. 2001 . Biological Psychology, 7th ed. Belmont, CA: Wadsworth.

T-cells circulate through the blood and lymph systems in an inactive form. Each T-cell has receptors on its surface that recognize one specific type of antigen. However, the T-cells are unable to recognize antigens by themselves. They become activated when immune cells called macrophages (the word means “big eater”) detect antigens and start to engulf and digest them. To activate the T-cells, the macrophages release a chemical known as interleukin-1. With the help of the macrophages, the T-cells become activated and are able to begin to destroy antigens (Maier et al., 1994 ).

B-cells are different in structure from T-cells. When a B-cell recognizes an antigen, it begins to divide and to produce antibodies that circulate in the blood. This process is facilitated by cytokines that are released by the T-cells. Production of antibodies takes 5 days or more (Maier et al., 1994 ). However, the response of the immune system will be much more rapid if the antigen ever appears in the future because the immune system has a “memory” of the invader.

The protective activity of the B- and T-cells is supported and reinforced by other specialized components of the system, most notably natural killer cells, macrophages (which we have already mentioned), and granulocytes. The immune system’s response to antigen invasion is intricately orchestrated, requiring the intact functioning of numerous components.

An important component of the immune system response involves cytokines . Cytokines are small protein molecules that serve as chemical messengers and allow immune cells to communicate with each other. Interleukin-1, which we have just discussed, is a cytokine. Another cytokine that you may have heard about is interferon, which is given to patients with cancer, multiple sclerosis, and hepatitis C.

Cytokines play an important role in mediating the inflammatory and immune response (see Kronfol & Remick, 2000 , for a review). They can be divided into two main categories: proinflammatory cytokines and anti-inflammatory cytokines. Proinflammatory cytokines such as interleukin-1 (IL-1), IL-6, or tumor necrosis factor help us deal with challenges to our immune system by augmenting the immune response. In contrast, anti-inflammatory cytokines such as IL-4, IL-10, and IL-13 decrease or dampen the response that the immune system makes. Sometimes they accomplish this by blocking the synthesis of other cytokines.

What makes cytokines especially interesting is that in addition to communicating with the immune system, they also send signals to the brain. Because the brain and the immune system can communicate via the cytokines, we can regard the immune system almost as another sensory organ. Far from being a self-contained system, the immune system can monitor our internal state and send the brain information about infection and injury. The brain can then respond. What this means is that the brain is capable of influencing immune processes. With this in mind, some of the findings discussed in this chapter (the link between depression and heart disease, for example, and the health benefits of optimism and social support) make much more sense. In a very tangible way, what is going on at the level of the brain can affect what is going on with the body, and vice versa.

We also know that IL-1 and other cytokines can stimulate the HPA axis (refer back to Figure 5.1 ). The resulting increase in cortisol sets off a negative feedback loop that is designed to prevent an excessive or exaggerated immune or inflammatory response. However, if this feedback system fails and is either too sensitive or not sensitive enough, serious disorders such as cancer, infection, or autoimmune diseases can develop. Because the brain is also involved in this feedback loop, emotional factors and psychosocial stresses may tilt the balance in the feedback loop in either a helpful or a detrimental way.

One implication of developments in cytokine research is that disorders of the brain could potentially have “downstream” effects on the immune system. In the opposite direction, problems with the immune system may also lead to some behavioral changes or even to psychiatric problems. For example, when you are ill you sleep more, have a diminished appetite, and have little sexual interest. This is classic sickness behavior. It may also result, at least in part, from the effects of specific cytokines on the brain. When cytokines such as IL-1 or interferon are injected, subjects become lethargic, lose their appetites, and have trouble concentrating, among other problems (Reichenberg et al., 2001 ). In other words, they have some of the symptoms of depression. And when cancer patients are treated with cytokines such as interferon, they experience both flu-like symptoms and depression, the latter of which is typically treated with paroxetine (Paxil), an antidepressant (Musselman et al., 2001 ). In short, cytokines may have great potential for helping us understand the links between physical and mental well-being that are at the heart of behavioral medicine.

Stress, Depression, and the Immune System

Did you know that stress slows the healing of wounds by as much as 24 to 40 percent (Kiecolt-Glaser et al., 2002 )? This is because stress is linked to suppression of the immune system (Segerstrom & Miller, 2004 ). The list of stressors that have been linked to immunosuppression is varied and includes sleep deprivation, marathon running, space flight, being the caregiver for a patient with dementia, and death of a spouse (Cacioppo et al., 1998 ; Schleifer et al., 1985 ; Schleifer et al., 1989 ; Vasiljeva et al., 1989 ). On the positive side, there is evidence that laughter is associated with enhanced immune functioning (Berk et al., 1988 ; Lefcourt, 2002 ).

Although short-term stress (such as occurs when we take an examination) compromises the immune system (Glaser et al., 1985 ; Glaser et al., 1987 ), it is the more enduring stressors such as unemployment or loss of a spouse that are associated with the most global immunosuppression. This is of particular concern in today’s difficult economic times. People who are unemployed have lower levels of immune functioning than people who are employed. The good news, however, is that immune functioning returns to normal again once people find another job (Cohen et al., 2007 ).

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Stress causes our immune system to function less efficiently.

Depression is also associated with compromised immune function (Kiecolt-Glaser et al., 2002 ). Moreover, the relationship between depression and suppression of the immune system is at least partially independent of specific situations or events that may have provoked depressed feelings. In other words, the state of being depressed adds something beyond any negative effects of the stressors precipitating the depressed mood.

research CLOSE-UP: Correlational Research

In contrast to experimental research (which involves manipulating variables in some way and seeing what happens), in correlational research the researcher observes or assesses the characteristics of different groups, learning much about them without manipulating the conditions to which they are exposed.

Although there is a great deal of evidence linking stress to suppression of the immune system, researchers are becoming aware that both chronic stress and depression may also enhance certain immune system responses, although not in a good way (Robles et al., 2005 ). Chronic stress and depression may trigger the production of proinflammatory cytokines such as interleukin-6 (IL-6). One correlational research study showed that women who were caring for a family member with Alzheimer’s disease had higher levels of IL-6 than women who were either anticipating the stress of relocation or who were experiencing neither of these stressors (Lutgendorf et al., 1999 ). This difference was found even though the women who were caregivers were 6 to 9 years younger than the women in the other two groups and even though IL-6 levels are known to increase with age. Major depression has also been linked to enhanced production of proinflammatory cytokines, including IL-6, but treatment with antidepressant medications can reduce this elevation (Kenis & Maes, 2002 ).

These findings are especially interesting in light of research showing a relationship between IL-6 and aging, as well as to chronic diseases including certain cancers and cardiovascular disease (Papanicolaou et al., 1998 ). Further evidence that higher levels of IL-6 are bad for health is suggested by their association with being overweight, smoking, and having a sedentary lifestyle (Ferrucci et al., 1999 ).

One group of investigators has reported that older adults (average age 71 years) who regularly attended church had lower levels of IL-6 and were less likely to die during the course of a 12-year follow-up than those who did not go to church regularly (Lutgendorf et al., 2004 ). These findings also held when other potential confounding variables such as age, social support, being overweight, having medical problems, and being depressed were also considered. Given all of the findings, it is not hard to see why researchers are becoming excited about the possibility that proinflammatory cytokines like IL-6 could be key mediators in the link between psychosocial factors and disease. Overall, what the research findings suggest is that chronic stress and depression can result in the immune system going out of balance in ways that may compromise health (see Robles et al., 2005 ). In short, the potential for psychological factors to influence our health and for our health to affect our psychological well-being is becoming ever more apparent.

in review

· • Describe the biological changes that occur when we are under stress.

· • What is cortisol? Is cortisol beneficial or harmful?

· • What is meant by the term allostatic load?

· • Describe the relationship between stress and the immune system.

Stress and Physical Health

This chapter concerns the role of stress in physical and mental disorders. In this section we concern ourselves with medical conditions that are linked to stress. Because the brain influences the immune system, psychological factors are of great importance to our health and well-being. How you view problems and cope with challenges, and even your temperament, may directly affect your underlying physical health.

Negative emotions such as depression, anxiety, and anger may be especially important to avoid because they are associated with poor health (Kiecolt-Glaser et al., 2002 ). On the other hand, an optimistic outlook on life, as well as an absence of negative emotions, may have some beneficial health consequences (see Rasmussen et al., 2009 ). Indeed, there is now a growing interest in positive psychology (Snyder & Lopez, 2002 ). This school of psychology focuses on human traits and resources such as humor, gratitude, and compassion that might have direct implications for our physical and mental well-being.

An illustration of this comes from a study by Witvliet and colleagues ( 2001 ). These researchers asked college students to select a real-life interpersonal offense (such rejection, betrayals of trust, and personal insults) that they had experienced in the past. The researchers then collected self-reports as well as heart rate, blood pressure, and facial muscle tension data from the students while they were imagining responding to the real-life transgression in a way that was either forgiving or unforgiving. In the forgiving condition, the students were asked to think about granting forgiveness or developing feelings of empathy for the perpetrator. In the unforgiving condition, they were asked to stay in the victim role, to go over the hurt in their minds, and to nurse a grudge.

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Forgiving those who have wronged us may lower our stress levels and enhance overall well-being.

The findings showed that when they were asked to be forgiving, participants did indeed report more feelings of empathy and forgiveness. And, when asked to ruminate and be unforgiving, participants reported that they felt more negative, angry, sad, aroused, and out of control. They also showed greater tension in their brows. Importantly, their heart rates went up, their blood pressures increased, and their skin conductance (a measure of SNS arousal) revealed more arousal. Even more striking was the finding that even after the grudge-harboring imagery was over and the subjects were told to relax, they were unable to do so. In other words, the high state of physiological arousal that had been triggered by dwelling on the past hurt could not easily be turned off.

What are the implications of these findings? Although fleeting feelings of anger probably do us no real harm, people who have a tendency to brood about the wrongs that other people have done to them may be doing themselves a major disservice. To the extent that perpetuating feelings of anger and increasing cardiovascular reactivity have consequences for heart disease and immune system functioning, harboring grudges may be hazardous to our health. Although it is not always easy, forgiving those who have offended us may lower our stress levels and enhance our well-being.

in review

· • What individual characteristics are associated with better or worse health?

· • What is positive psychology?

· • What are the physiological consequences of being unforgiving?

Cardiovascular Disease

Because cardiovascular disease is the leading cause of death in the United States (American Heart Association, 2001 ), and because the impact of stress on the heart has been well researched, we use this disease to illustrate the many links between psychological factors and physical disease. Some of these are illustrated in the following case study. As you read the case of Dr. M., consider the role that negative emotions play. Also consider Dr. M’s personality. Do you consider him an optimist or a pessimist?

The Angry Physician Dr. M was a 44-year-old physician. The middle son of parents who had emigrated from Italy, he was ambitious and determined to make a successful life for himself and his family. He worked long hours helping patients with cancer, and he was caring and compassionate. His patients loved him. But his job was also very stressful. Added to the many demands of maintaining a busy medical practice was the great sadness that he felt when (inevitably) many of his terminally ill patients died.

At home Dr. M was a loyal husband and devoted father to his three children. But he was not an easy person to live with. He found it hard to relax, and he had a very volatile disposition. He was frequently angry and would shout at everyone whenever he had had a bad day. Often his moods were caused by his feeling that he was not fully appreciated by the other doctors with whom he worked. Although his wife realized that he “just needed to vent,” his moods took a toll on the family. His children distanced themselves from him much of the time, and his wife became less and less happy in the marriage.

One day at work, Dr. M started to feel unwell. He began to sweat and experienced a heavy pressure in his chest. It was difficult for him to breathe. Dr. M recognized the severity of his symptoms and called out for medical help. He had a sudden and severe heart attack and survived only because he was working in a hospital at the time of the attack. If he had not received prompt medical attention, he almost certainly would have died.

After his heart attack Dr. M became very depressed. It was almost as though he could not accept that he, a physician, had a severe medical problem. Although he lived in fear of having another heart attack, his efforts to lose weight (which his doctor had told him to do) were sabotaged by his unwillingness to follow any diet. He would try and then give up, coming back from the Italian bakery with bags of pastries. Making the problem worse was the fact that because he was a doctor, his own doctors were somewhat reticent about telling him what he had to do to manage his illness. He went back to work, and his family walked on eggshells, afraid to do or say anything that might stress him. His wife tried to encourage him to follow the doctors’ recommendations. However, Dr. M’s attitude was that if he was going to die anyway, he might as well enjoy himself until he did.

Hypertension

When we are stressed the blood vessels supplying our internal organs constrict (become more narrow) and blood flows in greater quantity to the muscles of the trunk and limbs. When this happens the heart must work harder. As it beats faster and with greater force, our pulse quickens and blood pressure increases. When the period of stress is over, blood pressure returns to normal. If the emotional strain is more enduring, however, high blood pressure may become a chronic problem.

Ideally, blood pressure should be below 120/80. (By convention, the first number given is the systolic pressure when the heart contracts; the second is the diastolic or between-beat pressure; see Figure 5.3 on p. 139.) The unit of measurement is millimeters of mercury (Hg). The definition of hypertension is having a persisting systolic blood pressure of 140 or more and a diastolic blood pressure of 90 or higher. Blood pressure is simple and painless to measure by means of the familiar inflated arm cuff.

In general, blood pressure increases as we age. In younger adults, more men than women suffer from high blood pressure. After about age 50, however, the prevalence of hypertension is greater in women (Burt et al., 1995 ), probably because meno-pause amplifies the stiffness in the arteries that naturally occurs with increasing age (Takahashi et al., 2005 ). Current estimates suggest that sustained hypertension afflicts around 28 percent of Americans (Friedewald et al., 2010).

A small percentage of cases of hypertension are caused by distinct medical problems. However, in the majority of cases there is no specific physical cause. This is referred to as essential hypertension . Hypertension is an insidious and dangerous disorder. The person who has it may have no symptoms until its consequences show up as medical complications. Hypertension increases the risk of coronary heart disease and stroke. It is also often a causal factor in occlusive (blocking) disease of the peripheral arteries, congestive heart failure (due to the heart’s inability to overcome the resistance of constricted arteries), kidney failure, blindness, and a number of other serious physical ailments.

Many clinicians and investigators think that hypertension begins when a person has a biological tendency toward high cardiovascular reactivity to stress (e.g., Tuomisto, 1997 ; Turner, 1994 ). This might be considered to represent a diathesis, or vulnerability factor. Over time, and in the face of chronic and difficult life circumstances, which create stress, the vulnerable person will go from having borderline hypertension to having a serious clinical problem. Not being able to express anger in a constructive way (e.g., by expressing why one feels angry and trying to reach an understanding by engaging in open communication with the person one is angry with) may also increase a person’s risk for hypertension (Davidson et al., 2000 ).

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FIGURE 5.3 Defining Hypertension. Blood pressure levels once thought normal are now considered high enough to signal prehypertension.

HYPERTENSION AND AFRICAN AMERICANS

African Americans have much higher rates of hypertension than European Americans (40% versus 27%; see Fox et al., 2011 ). Their death rate from hypertension is also three times higher. Interestingly, the higher prevalence of hypertension in African Americans is not just found in the United States but seems to be the case for blacks worldwide. Rates of hypertension in young people are also alarmingly high. Ten percent of African American men aged 18 to 21 have hypertension compared with prevalence rates of 1 to 2 percent in other groups (see Friedewald et al., 2010).

Higher levels of stress from such factors as inner-city living, economic disadvantage, exposure to violence, and race-based discrimination may play a key role in this (Din-Dzietham et al., 2004 ; Wilson et al., 2004 ). Lifestyle may also be a factor. African American women in particular are more likely to be overweight than Caucasian women (see Whitfield et al., 2002 ). African Americans are also less likely to exercise than Caucasians are (Bassett et al., 2002 ; Whitfield et al., 2002 ), perhaps because many live in places where health clubs are scarce and it is not safe to walk outside.

Biological factors likely also play a role. Like most Americans, African Americans consume a lot of fast food, which is loaded with salt. There is evidence that, as a group, African Americans are more likely to retain sodium, which results in fluid retention and endocrine changes that in turn elevate blood pressure (Anderson & McNeilly, 1993 ). Renin, an enzyme produced by the kidneys that is linked to blood pressure, is also processed differently by African Americans. Finally, studies suggest that nitric oxide (a dissolved gas that is crucial for the proper functioning of blood vessels and blood cells) is produced in lower levels in the blood vessels of African Americans and may also be destroyed more quickly too. All of these biological differences, as well as the presence of some specific genes (see Fox et al., 2011 ), may increase the risk that African Americans have of developing hypertension.

Coronary Heart Disease

The heart is a pump, made of muscle. Coronary heart disease (CHD) is a potentially lethal blockage of the arteries that supply blood to the heart muscle, or myocardium. If the muscles of the heart are not getting enough oxygenated blood, the person may experience severe chest pain (angina pectoris). This is a signal that the delivery of oxygenated blood to the affected area of the heart is insufficient for its current workload. An even more severe problem is myocardial infarction. This results from a blockage in a section of the coronary arterial system. Because the heart muscle is being deprived of oxygen, tissue may die, permanently damaging the heart. If the myocardial infarction is extensive enough the person may not survive. Many instances of sudden cardiac death, in which victims have no prior history of CHD symptoms, are attributed to silent CHD. This often occurs when a piece of the atherosclerotic material adhering to the arterial walls (a “plaque”) breaks loose and lodges in a smaller vessel, blocking it. Every year, more than 900,000 people in the United States experience a myocardial infarction (Schwartz et al., 2010 ).

Risk and Causal Factors in Cardiovascular Disease

CHRONIC AND ACUTE STRESS

Stress increases the risk of having a heart attack. Several researchers have documented that deaths from CHD rise in the days and weeks following a severe earthquake (see Leor et al., 1996 ). As Figure 5.4 shows, after the Northridge earthquake in Los Angeles in 1994, the number of sudden deaths due to CHD rose from an average of 4.6 (in the days preceding the earthquake) to 24 on the day of the earthquake (Kloner et al., 1997 ). There was also an increase in sudden death from cardiac events after the Hanshin-Awaji earthquake in Japan (Kario & Ohashi, 1997 ).

Everyday forms of stress can also elevate risk for CHD and death (Matthews & Gump, 2002 ; Smith & Ruiz, 2002 ). A good example is work-related stress. Here the key factors appear to be having a highly demanding job and having little control over decision making. Both of these types of job stress increase risk for future CHD. Moreover, this association still holds when other negative health behaviors (such as smoking) are controlled (see Peter & Siegrist, 2000 ). It is also interesting to note that, in people who work, most heart attacks occur on a Monday. The stress of returning to work after the weekend is thought to play a role in this (Kloner et al., 2006).

Finally, simply being asked to give a 5-minute speech about an assigned topic to a small (but evaluative) audience was enough to produce detectable changes in cardiac function in about 20 percent of patients with existing coronary artery disease (see Sheps et al., 2002 ). Furthermore, those patients who were most reactive to this form of mental stress were almost three times more likely (compared to the less reactive patients) to die in the next 5 to 6 years. Mental stress is known to raise systolic blood pressure and also to cause an elevation in epinephrine. Mental stress may also reduce the oxygen supply to the heart muscle (Yeung et al., 1991 ). What the results of the Sheps study illustrate, however, is that stress does not have to be extreme or severe to be associated with lethal consequences later.

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FIGURE 5.4 Cardiac Deaths and Earthquakes. On the day of the Northridge earthquake in California (January 17, 1994), cardiac deaths showed a sharp increase.

Source: Leor et al., 1996 . The New England Journal of Medicine, 334(7), February 15, 1996, p. 415.

research CLOSE-UP: Risk Factor

A risk factor is a variable that increases the likelihood of a specific (and usually negative) outcome occurring at a later time. For example, obesity is a risk factor for heart disease; perfectionism is a risk factor for eating disorders.

PERSONALITY

Attempts to explore the psychological contribution to the development of CHD date back to the identification of the Type A behavior pattern (Friedman & Rosenman, 1959 ). Type A behavior is characterized by excessive competitive drive, extreme commitment to work, impatience or time urgency, and hostility. Many of us know people who are like this, and the term Type A is now quite commonly used in everyday language.

Interest in Type A behavior escalated after the results of the Western Collaborative Group Study began to be published. This investigation involved some 3,150 healthy men between the ages of 35 and 59 who, on entry, were typed as A or B status. (Type B personalities do not have Type A traits and tend to be more relaxed, more laid-back, and less time-pressured people.) All the men were then carefully followed for eight and a half years. Compared to Type B personality, Type A personality was associated with a twofold increase in coronary artery disease and an eightfold increased risk of recurrent myocardial infarction over the course of the follow-up (Rosenman et al., 1975 ).

The second major study of Type A behavior and CHD was the Framingham Heart Study. This began in 1948 and involved the long-term follow-up of a large sample of men and women from Framingham, Massachusetts (see Kannel et al., 1987 ). Approximately 1,700 CHD-free subjects were typed as A or B in the mid-1960s. Analysis of the data for CHD occurrence during an 8-year follow-up period not only confirmed the major findings of the earlier Western Collaborative Group Study but extended them to women as well.

Not all studies reported positive associations between Type A behavior and risk of coronary artery disease, however (Case et al., 1985 ; Shekelle et al., 1985 ). Moreover, as research with the construct has continued, it has become clear that it is the hostility component of the Type A construct (including anger, contempt, scorn, cynicism, and mistrust) that is most closely correlated with coronary artery deterioration (see Rozanski et al., 1999 , for a summary of studies).

A more recent development is the identification of the “distressed” or Type D personality type (Denollet et al., 2000 ). People with Type D personality have a tendency to experience negative emotions and also to feel insecure and anxious. Men with CHD who scored high on measures of chronic emotional distress were more likely to have fatal and nonfatal heart attacks over the 5-year follow-up period than were men who did not have these Type D personality traits (Denollet et al., 2000 ). People with higher scores on the negative affectivity component of Type D personality (see Figure 5.5 ) are also at increased risk of having more problems after cardiac surgery (Tully et al., 2011 ). Overall, the Type D personality construct also provides a way to tie in some of the other findings linking negative emotions and CHD, which we discuss more below.

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FIGURE 5.5 Characteristics of the Type D Personality .

Source: Based on Johan Denollet. 1998 Personality and coronary heart disease: The type-D Scale-16 (DS16). Annals of Behavioral Medicine, 20 (3) 209–215, and N. Kupper and J. Denollet ( 2007 ). Type D Personality as a prognostic factor in heart disease: Assessment and mediating mechanisms. Journal of Personality Assessment, 89 (3) 265–276.

DEPRESSION

People with heart disease are approximately three times more likely than healthy people to be depressed (Chesney, 1996 ; Shapiro, 1996 ). This may not strike you as especially surprising. If you had heart disease, perhaps you would be depressed too. However, depression is much more commonly found in people who have heart disease than it is in people who have other serious medical problems, like cancer (Miller & Blackwell, 2006 ). Furthermore, heart attack patients with high levels of depressive symptoms after having a heart attack are three times more likely to die over the next 5 years than patients who do not show high levels of depression (Glassman, 2007 ; Lesperance et al., 2002 ). The most recent research in this area suggests that anhedonia (which is a symptom of depression characterized by profound loss of interest or pleasure) may be especially predictive of increased mortality after a heart attack (Davidson et al., 2010 ).

Depression also appears to be a risk factor for the development of CHD. Pratt and her colleagues ( 1996 ), for 14 years, followed over 1,500 men and women with no prior history of heart disease. They found that 8 percent of those who had experienced major depression at some point and 6 percent of those who had experienced mild depression at some point had a heart attack during the 14-year follow-up interval. By contrast, only 3 percent of those without a history of depression suffered heart attacks. When medical history and other variables were taken into account, those who had experienced major depression were found to be four times more likely to have had a heart attack. Similar findings have also been reported in other studies (Ferketich et al., 2000 ; Ford et al., 1998 ).

Why are depression and heart disease so closely linked? Current thinking is that this is another example of the mind–body connection. Stress is thought to activate the immune system, triggering the production of proinflammatory cytokines such as IL-1, IL-6, and tumor necrosis factor by the white blood cells. Long-term exposure to these proinflammatory cytokines is thought to lead to changes in the brain that manifest themselves as symptoms of depression. Proinflammatory cytokines also trigger the growth of plaques in the blood vessels as well as making it more likely that those plaques will rupture and cause a heart attack. In other words, as illustrated in Figure 5.6 , the link between heart disease and depression is due to inflammation and the presence of inflammatory cytokines (see Miller & Blackwell, 2006 ; Robles et al., 2005 ). This is why doctors now test for the presence of C-reactive protein (CRP)—a molecule produced by the liver in response to IL-6—when they want to assess a person’s risk for heart disease. New research is also linking discrimination to elevated levels of CRP in African Americans (see The World Around Us box on p. 142).

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FIGURE 5.6 Model of how inflammatory processes mediate the relations among chronic stressors, depressive symptoms, and cardiac disease. Stressors activate the immune system in a way that leads to persistent inflammation. With long-term exposure to the molecular products of inflammation, people are expected to develop symptoms of depression and experience progression of cardiac disease.

Source: Miller & Blackwell. 2006 , Dec. Turning Up the Heat: Inflammation as a Mechanism Linking Chronic Stress, Depression and Heart Disease. Current Directions in Psychological Science, 15, (6): 269–272(4). Copyright © 2006. Reproduced with permission of Blackwell Publishing Ltd.

ANXIETY

Depression is not the only form of negative affect that is linked to CHD. Research has also demonstrated a relationship between phobic anxiety and increased risk for sudden cardiac death. In a classic early study, Kawachi, Colditz, and colleagues ( 1994 ) studied nearly 34,000 male professionals who had been assessed for panic disorder, agoraphobia, and generalized anxiety. Over the course of the 2-year follow-up study, sudden cardiac death was six times higher in the men with the highest levels of anxiety. The findings were replicated in a second study of nearly 2,300 men who were participating in a normative aging study (Kawachi, Sparrow, et al., 1994 , 1995 ). Prospective studies of women (who were free of cardiac disease at the start of the study) have also linked phobic anxiety with a higher risk of sudden cardiac death (Albert et al., 2005 ).

SOCIAL ISOLATION AND LACK OF SOCIAL SUPPORT

the WORLD around us: Racial Discrimination and Cardiovascular Health in African Americans

Experiences of discrimination have been linked to a number of bad health outcomes, including increased blood pressure and signs of cardiovascular disease. But how might this association arise? New research suggests that an important mediator in this relationship could be C-reactive protein, or CRP.

CRP is a protein synthesized in the liver. High levels of CRP signal widespread inflammation in the body. In an interesting study, Lewis and colleagues ( 2010 ) measured levels of CRP in blood samples taken from 296 older African Americans, whose average age was 73. These research participants also completed a questionnaire that asked about their experiences of everyday discrimination. Items on the questionnaire included being treated with disrespect, getting poorer service in restaurants or stores, as well as experiences of being insulted or harassed.

The findings revealed a significant correlation between everyday discrimination and CRP, where more experiences of discrimination were associated with higher levels of CRP. The association also remained even after factors such as smoking, high blood pressure, depression, and other health problems were considered. Although much more remains to be learned, these preliminary findings are very exciting. They provide a clue about a potential pathway through which experiences of racial bias might ultimately play a role in the poor cardiovascular health of older African Americans.

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Studies point to the strong link between social factors and the development of CHD. Monkeys housed alone have four times more atherosclerosis (fatty deposits in blood vessels that eventually create a blockage) than monkeys housed in social groups (Shively et al., 1989 ). Similarly, people who have a relatively small social network or who consider themselves to have little emotional support are more likely to develop CHD over time (see Rozanski et al., 1999 , for a review).

For people who already have CHD, there is a similar association. In one study of people who had already suffered a heart attack, those who reported that they had low levels of emotional support were almost three times more likely to experience another cardiac event (Berkman et al., 1992 ). In another study, death in CHD patients was three times more likely over the next 5 years if they were unmarried or had no one that they could confide in (Williams et al., 1992 ). Echoing these findings, Coyne and colleagues ( 2001 ) have shown that the quality of the marital relationship predicts 4-year survival rates in patients with congestive heart failure. Although uncertain at this time, it may be that the stress that comes from marital tension or from a lack of social support triggers an inflammatory response in the immune system, causing depression and heart problems as a result. It may also be that depression, which is linked to relationship problems, could trigger an inflammatory response in its own right.

THE IMPORTANCE OF EMOTION REGULATION

If hostility, depression, and anxiety are all predictive of developing coronary heart disease, is it beneficial to be able to regulate one’s emotions? New research suggests that it is. In one study of men and women without a history of heart disease, it was found that it was the people who were least able to control their anger who developed more heart problems over the next 10 to 15 years (Haukkala et al., 2010 ). In another study of 1,122 men who were followed for an average of 13 years, it was again those with the best emotion regulation skills who were the least likely to develop cardiac disease (Kubzansky et al., 2011 ). Taken together these findings suggest that self-regulation skills may be very important—not only for our psychological well being but for our physical health as well.

in review

· • What is essential hypertension, and what are some of the factors that contribute to its development?

· • What risk factors are associated with coronary heart disease?

· • What is Type A personality?

· • What is Type D personality?

· • How might racial bias play a role in the development of cardiovascular disease?

Treatment of Stress-Related Physical Disorders

As you have learned, environmental stressors are often closely linked to the development of a physical illness. Unfortunately, once an illness has developed and physical changes have taken place, removal of the stressor may not be enough to bring about recovery and restore health. This emphasizes the value of prevention and highlights the importance of stress management.

Biological Interventions

People who have serious physical diseases obviously require medical treatment for their problems. For patients with CHD, such treatments might include surgical procedures as well as medications to lower cholesterol or reduce the risk of blood clots. However, in light of the strong associations between depression and risk for CHD, treating depression is also of the utmost importance. Unfortunately, most people with clinical depression go untreated, resulting in an unnecessary added risk for CHD. Moreover, even though there is no medical risk factor that is more important in predicting mortality for patients who have already had a heart attack (Welin et al., 2000 ), physicians often fail to treat depression in their cardiac patients. Instead, they dismiss it as an understandable consequence of having had a life-threatening medical scare (Glassman, 2005 ). Of those with major depression at the time of a heart attack, approximately one-half of those who have gone without treatment remain depressed or else have relapsed again 1 year later (Hance et al., 1996 ). However, research shows that thousands of lives can be saved each year by giving antidepressant medications to patients who have suffered a myocardial infarction and who are depressed. In one study, patients treated with selective serotonin reuptake inhibitors (SSRIs) were much less likely to die or have another heart attack than patients who were not taking antidepressant medications (Taylor et al., 2005 ). It is also worth noting that, in this study, treatment with cognitive-behavior therapy (CBT; see Chapter 16 for more about this approach) was not associated with reduced mortality in the patients, although CBT treatment did help alleviate depression (see Berkman et al., 2003 ; Glassman, 2005 ).

Psychological Interventions

How can we help ourselves stay healthy in the face of stress? As we have already mentioned, developing effective emotion regulation skills is probably beneficial. Evidence suggests that the following approaches are also helpful.

EMOTIONAL DISCLOSURE

“Opening up” and writing expressively about life problems in a systematic way does seem to be an effective therapy for many people with illnesses (Pennebaker, 1997 ). In the first study of emotional disclosure in people with rheumatoid arthritis, Kelley, Lumley, and Leisen ( 1997 ) found that people who had written about their emotions had significantly less physical dysfunction than those assigned to a control condition. In another study, people with either rheumatoid arthritis or asthma were asked to write about either their most traumatically stressful life experience or (in the case of the control group) their plans for the day. Subjects wrote for 20 minutes for 3 consecutive days. When they were assessed 4 months later, the participants with rheumatoid arthritis who were assigned to the emotional disclosure condition were doing significantly better than the participants with rheumatoid arthritis assigned to the control group.

In studies that involve emotional disclosure, patients often experience initial increases in emotional distress during the writing phase but then show improvement in their medical status over follow-up. Why emotional disclosure provides clinical benefits for patients is still not clear, however. One reason could be that patients are given an opportunity for emotional catharsis, or “blowing off steam.” Another possibility is that writing gives people an opportunity to rethink their problems. Given what we know about the link between emotional and physical well-being, it is not unreasonable to speculate that both emotional catharsis and rethinking problems could help improve immune function or perhaps decrease levels of circulating stress hormones.

BIOFEEDBACK

Biofeedback procedures aim to make patients more aware of such things as their heart rate, level of muscle tension, or blood pressure. This is done by connecting the patient to monitoring equipment and then providing a cue (for example, an audible tone) to the patient when he or she is successful at making a desired response (e.g., lowering blood pressure or decreasing tension in a facial muscle). Over time, patients become more consciously aware of their internal responses and able to modify them when necessary.

Biofeedback seems to be helpful in treating some conditions, such as headaches (Nestoriuc et al., 2008 ). After an average of 11 sessions, patients report improvement in their symptoms and a decrease in the frequency of their headaches. Moreover, these treatment effects tend to be stable over time. Although it is especially helpful for children and adolescents, adults who have experienced headaches for a long time are also helped by biofeedback.

RELAXATION AND MEDITATION

Researchers have examined the effects of various behavioral relaxation techniques on selected stress-related illnesses. The results have been variable, though generally encouraging. For example, there is evidence that relaxation techniques can help patients with essential hypertension (see Blumenthal et al., 2002 ). Relaxation training can also help patients who suffer from tension headaches (Holroyd, 2002 ). However, in general, headache sufferers treated with biofeedback appear to do better than those treated only with relaxation, and the best clinical results occur when these two treatments are combined (Nestoriuc et al., 2008 ).

A growing topic of interest is meditation. Schneider and colleagues ( 2005 ) have shown that the daily practice of Transcendental Meditation may be helpful in reducing blood pressure. In this study, 194 African American patients with chronic hypertension were randomly assigned to receive training in either Transcendental Meditation or progressive muscle relaxation (which involves tensing and relaxing various muscle groups in a systematic way) or else to receive general information about lifestyle changes that would be helpful to them. Patients who practiced Transcendental Meditation for 20 minutes twice a day reduced their diastolic blood pressure significantly more than did patients who practiced muscle relaxation or who received sound health care advice.

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Making an effort to slow down and relax may provide many health benefits.

COGNITIVE-BEHAVIOR THERAPY

CBT has been shown to be an effective intervention for headache (Martin, Forsyth et al., 2007 ) as well as for other types of pain. CBT-oriented family therapy was markedly more successful than routine pediatric care in alleviating children’s complaints of recurrent abdominal pain (Robins et al., 2005 ). Some CBT techniques have also been used for patients suffering from rheumatoid arthritis. Compared to those receiving standard medical care, patients who received CBT showed better physical, social, and psychological functioning (Evers et al., 2002 ).

Finally, we note that making a conscious effort to slow down and enjoy life seems to be a prescription for better health. Meyer Friedman, who was the codiscoverer of the link between Type A behavior and heart disease, had a heart attack at age 55. A self-described Type-A personality, he made a conscious choice to change his ways in accordance with his own discoveries. To get more in touch with his slow, patient, and creative side, he read Proust’s languid seven-volume opus Remembrance of Things Past three times. In short, he trained himself to relax and to enjoy life. He had the last laugh at stress by living to the ripe old age of 90 (Wargo, 2007 ).

in review

· • Why is it so important to screen people with heart disease for depression?

· • What clinical approaches have been used to help people?

Stress and Mental Health

Our focus thus far has been to describe the nature of stress, highlighting the role it plays in physical disorders. But, as we have noted repeatedly throughout this chapter, when we experience stress, we pay a price not only in our bodies but also in our minds. In the sections below, we discuss the psychological consequences of experiencing the kind of stress that overwhelms our abilities to adjust and to cope. More specifically, we focus on two DSM disorders, adjustment disorder and PTSD. Both of these are triggered by exposure to stress. There is an important difference between them, however. In adjustment disorder, the stressor is something that is commonly experienced, and the nature of the psychological reaction is much less severe. In the case of PTSD, there is exposure to a traumatic stressor that is accompanied by fear, helplessness, or horror. Not surprisingly, the stress disorder that results from this can be intense and debilitating.

Adjustment Disorder

An adjustment disorder is a psychological response to a common stressor (e.g., divorce, death of a loved one, loss of a job) that results in clinically significant behavioral or emotional symptoms. The stressor can be a single event, such as going away to college, or involve multiple stressors, such as a business failure and marital problems. People undergoing severe stress that exceeds their coping resources may warrant the diagnosis of adjustment disorder (Strain & Newcorn, 2007 ). For the diagnosis to be given, symptoms must begin within 3 months of the onset of the stressor. In addition, the person must experience more distress than would be expected given the circumstances or be unable to function as usual.

In adjustment disorder, the person’s symptoms lessen or disappear when the stressor ends or when the person learns to adapt to the stressor. In cases where the symptoms continue beyond 6 months, the diagnosis is usually changed to some other mental disorder. Adjustment disorder is probably the least stigmatizing and mildest diagnosis a therapist can assign to a client. Next we discuss two situations that frequently lead to adjustment disorder.

Adjustment Disorder Caused By Unemployment

Work-related problems can produce great stress in employees (Lennon & Limonic, 2010 ). But being unemployed can be even more stressful. As a result of the recent recession millions of Americans have been coping with chronic unemployment. Tony is one of them.

Maybe Today Will Be the Day Tony wakes up at 5:30 every morning and makes coffee. He arranges his laptop, phone, and notepad on the kitchen table. And then he waits for the phone to ring. Unemployed for the last 16 months after losing his job as a transportation sales manager, Tony spends the day sending out resumes and cover letters. But most days nothing happens. “The worst moment is at the end of the day when it’s 4:30 and you did everything you could, and the phone hasn’t rung, the emails haven’t come through,” says Tony. He asks himself what he is doing wrong. Tony misses his old routine of getting dressed in the morning and going out to work. But he tries to stay optimistic. “You always have to hope that that morning when you get up, it’s going to be the day.” (Based on Kwoh, 2010 )

Unemployment reached a peak of 10.6 percent of the labor force in January 2010. It is now around 7.6 percent (Bureau of Labor Statistics, 2013 ). In almost every community, one can find workers who have been laid off from jobs they had held for many years and who are facing the end of their unemployment compensation. Unemployment is an especially severe problem for young minority males, many of whom live in a permanent economic depression with few job prospects. Rates of unemployment for blacks are twice as high as they are for whites (Bureau of Labor Statistics, 2013 ).

Managing the stress associated with unemployment requires great coping strength, especially for people who have previously earned an adequate living. Some people (like Tony in the case example above) find ways to stay focused and motivated, even though this can be very difficult at times. For others, however, unemployment can have serious long-term effects. One of the most disturbing findings is that unemployment, especially if it is prolonged, increases the risk of suicide (Borges et al, 2010 ; Classen & Dunn, 2011 ). Unemployment also takes its toll on other family members, especially children. When children live in families where a parent has lost a job, they are 15 percent more likely to have to repeat a grade at school (Stevens & Schaller, 2009 ).

in review

· • What is an adjustment disorder?

· • What kinds of stressors are potential triggers for the development of an adjustment disorder?

Posttraumatic Stress Disorder

In DSM-5 post-traumatic stress disorder is now grouped with other disorders in a new diagnostic category called trauma- and stressor-related disorders. Adjustment disorder, which we have just discussed, and acute stress disorder (see next section) are also part of this new diagnostic category. This is because the experience of major stress is central to the development of all of these conditions. image21 Watch the Video Bonnie: Posttraumatic Stress Disorder on MyPsychLab

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DSM-5 criteria for: Posttraumatic Stress Disorder

Note: The following criteria apply to adults, adolescents, and children older than 6 years.

· A. Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:

· 1. Directly experiencing the traumatic event(s).

· 2. Witnessing, in person, the event(s) as it occurred to others.

· 3. Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

· 4. Experiencing repeated or extreme exposure to aversive details of the traumatic event(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse).

Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

· B. Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:

· 1. Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).

Note: In children older than 6 years, repetitive play may occur in which themes or aspects of the traumatic event(s) are expressed.

· 2. Recurrent distressing dreams in which the content and/or affect of the dream are related to the traumatic event(s).

Note: In children, there may be frightening dreams without recognizable content.

· 3. Dissociative reactions (e.g., flashbacks) in which the individual feels or acts as if the traumatic event(s) were recurring. (Such reactions may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings.)

Note: In children, trauma-specific reenactment may occur in play.

· 4. Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

· 5. Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).

· C. Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:

· 1. Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

· 2. Avoidance of or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

· D. Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

· 1. Inability to remember an important aspect of the traumatic event(s) (typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs).

· 2. Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).

· 3. Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.

· 4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

· 5. Markedly diminished interest or participation in significant activities.

· 6. Feelings of detachment or estrangement from others.

· 7. Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).

· E. Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:

· 1. Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

· 2. Reckless or self-destructive behavior.

· 3. Hypervigilance.

· 4. Exaggerated startle response.

· 5. Problems with concentration.

· 6. Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

· F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1 month.

· G. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

· H. The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.

The diagnosis of PTSD first entered the DSM in 1980 (see the DSM table for current clinical criteria). At this time, psychiatry began to realize that many veterans were emotionally scarred and unable to return to normal civilian life after their military service in Vietnam. The proposal to include PTSD in the diagnostic system was initially opposed, not least because including a disorder that had a clear and explicit cause (trauma) was inconsistent with the atheoretical nature of the DSM. Nonetheless, a consensus emerged that any extreme, terrifying, and stressful event that was life-threatening and outside the ordinary bounds of everyday experience could lead to psychological symptoms similar to those experienced by the Vietnam veterans. In other words, at the time of its entry into the DSM (which is after all a manual of mental disorders), PTSD was viewed as a normal response to an abnormal stressor (see McNally, 2008 ). In the Thinking Critically About DSM-5 below we describe how changes to the diagnostic criteria for PTSD have changed over time.