13.4 Stress, Conflict, Coping, Health Psychology, and Prevention

Stress, Conflict, Coping, Health Psychology, and Prevention

The Clinical and Abnormal outline lists stress, conflict, and coping, health psychology, and prevention as separate subtopics. The physiology of the stress response (the HPA axis, cortisol, and the sympathetic nervous system) appears in Section 1.4; this section emphasizes the psychological models and their health consequences.

1. Three Ways to Define Stress

Stress as a Physiological Response

• Walter Cannon described the fight-or-flight response: rapid sympathetic arousal and adrenal medullary release of epinephrine that prepare the body for action.
• Hans Selye observed that rats exposed to many different noxious agents developed the same triad (enlarged adrenal glands, shrunken thymus and lymph nodes, stomach ulcers). His general adaptation syndrome (GAS) describes a nonspecific response to any prolonged demand:

Selye distinguished harmful distress from positive, motivating eustress.

• Tend and befriend: Shelley Taylor and colleagues (2000) proposed that, especially in females, stress also elicits nurturing offspring and seeking social affiliation, a pattern possibly supported by oxytocin and endogenous opioids.
• Allostatic load: Bruce McEwen described the cumulative wear and tear from repeated or chronic activation of stress systems.

Stress as Life Events and Daily Hassles

• Social Readjustment Rating Scale (SRRS): Thomas Holmes and Richard Rahe (1967) assigned life change units to events requiring readjustment: death of a spouse (100, the highest), divorce (73), marriage (50), and even positive events such as vacations. Totals of about 300 or more in a year were associated with higher illness risk, though the correlations are modest and the scale ignores how events are perceived.
• Daily hassles: Allen Kanner, Richard Lazarus, and colleagues (1981) found that everyday irritations (traffic, misplaced items, deadlines) predicted psychological symptoms and health better than major life events.

Stress as a Transaction: Cognitive Appraisal

Richard Lazarus and Susan Folkman (1984) defined stress as a transaction between person and environment that depends on appraisal:

• Primary appraisal: Is the event irrelevant, benign-positive, or stressful? Stressful events are appraised as harm/loss (damage already done), threat (anticipated harm), or challenge (opportunity for growth).
• Secondary appraisal: What can I do about it? Do I have the resources to cope?
• Reappraisal: Ongoing reevaluation as new information arrives.

The same event (a job interview) can be a threat to one person and a challenge to another, and challenge appraisals are associated with more adaptive cardiovascular responses.

2. Motivational Conflict

Kurt Lewin (1935) classified conflicts by the forces acting on a person; Neal Miller later modeled them with approach and avoidance gradients measured in rats wearing harnesses.

Miller showed that the avoidance gradient is steeper than the approach gradient: as the goal gets closer, fear rises faster than desire. Far from the goal, approach tendencies dominate; near it, avoidance dominates; the person hovers around the point where the gradients cross.

Frustration (blocked goal attainment) is a related stressor, linked to aggression in the frustration-aggression hypothesis (Section 8.4).

3. Coping

• Goodness of fit: Effective coping matches strategy to controllability.
• Emotion regulation: James Gross distinguished cognitive reappraisal (reinterpreting a situation before the emotion fully unfolds), which reduces negative emotion with few costs, from expressive suppression (inhibiting outward expression), which leaves physiological arousal high and impairs memory and relationships.
• Expressive writing: James Pennebaker found that writing about traumatic experiences for about 15–20 minutes on several days produced modest improvements in health indicators and fewer health-center visits.
• Learned helplessness and control: Perceived control reduces stress. Ellen Langer and Judith Rodin (1976) gave nursing-home residents responsibility for a plant and choices about activities; they became more active and alert, and an 18-month follow-up reported lower mortality than in a comparison group.

4. Personality, Social Support, and Health

• Type A behavior pattern: Meyer Friedman and Ray Rosenman (1959) described competitive, time-urgent, impatient, hostile individuals and linked the pattern to coronary heart disease in the Western Collaborative Group Study. Later research found that global Type A is a weak predictor; hostility (cynical mistrust and anger) is the component most consistently related to heart disease.
• Type D ("distressed") personality: Johan Denollet described the combination of negative affectivity and social inhibition, associated with poorer cardiac prognosis in some studies.
• Hardiness: Suzanne Kobasa (1979) found that executives who stayed healthy under stress scored high on commitment, control, and challenge.
• Optimism: Dispositional optimism (Michael Scheier and Charles Carver) predicts better coping and recovery, for example after coronary bypass surgery.
• Social support: People with stronger social ties live longer; a meta-analysis by Julianne Holt-Lunstad and colleagues (2010) found that stronger social relationships were associated with about 50% greater odds of survival. Sheldon Cohen and Thomas Wills (1985) distinguished a buffering effect (support protects mainly under high stress) from a main effect (support helps regardless of stress).

5. Psychoneuroimmunology

Psychoneuroimmunology (PNI) studies interactions among psychological processes, the nervous and endocrine systems, and immunity.

• Conditioned immunosuppression: Robert Ader and Nicholas Cohen (1975) paired saccharin-flavored water with cyclophosphamide, an immunosuppressive drug that also causes nausea. Later, saccharin alone suppressed immune function, and some conditioned rats died, showing that immune responses can be classically conditioned.
• Stress and infection: Sheldon Cohen and colleagues (1991) exposed volunteers to cold viruses; the higher the reported psychological stress, the more likely they were to develop colds.
• Stress and wound healing: Janice Kiecolt-Glaser and colleagues found that small standardized wounds healed more slowly in stressed caregivers of relatives with dementia (about 24% longer, roughly 9 days more) and in dental students during exams than during vacation.
• Mechanisms: Chronic stress elevates cortisol, which suppresses some immune functions, and promotes inflammation; stress also affects health indirectly through sleep, smoking, drinking, diet, and adherence.

6. Health Behavior and Adherence

• Health belief model (Irwin Rosenstock and colleagues): People take health action when they perceive susceptibility and severity, believe the benefits outweigh the barriers, encounter cues to action, and (in later versions) feel self-efficacy.
• Theory of planned behavior (Section 7.2) and the transtheoretical (stages of change) model (Section 13.2) are also widely used.
• Adherence: Many patients do not take medications as prescribed; adherence is often estimated at only about 50% for long-term therapies. Adherence improves with clear communication, simpler regimens, reminders, and a good provider relationship.
• Optimistic bias: Neil Weinstein showed that people believe they are less likely than others to experience negative health events, which can reduce precautions.
• Pain and placebo: Placebo analgesia is partly mediated by endogenous opioids and can be reduced by naloxone (Section 14.3); the gate control theory of pain appears in Section 2.4.

7. Prevention

Community psychology emphasizes prevention, empowerment, and changing environments rather than treating individuals one at a time. Effective prevention programs typically target modifiable risk and protective factors identified by developmental research (Section 12.5).