12.1 An Introduction to Stress

stress and health

Stress and Stressors

We all have an intuitive sense of what stress is, and many of us are more familiar with it than we would like. But what exactly is stress, where does it come from, and how does it affect our physical and mental health? As with many concepts in psychology, stress is not easy to define. For example, people often report they experience the feeling of stress, almost as if stress is an emotion. Others describe stress as if it is a force that needs to be resisted. An engineer might say that stress refers to the application of a force on a target, such as the wing of an airplane, to determine how much load it can handle before breaking (Lazarus, 1993). Perhaps you have felt like you might “break” when the load you bear causes too much strain.

Here, stress is defined as the response to perceived threats or challenges resulting from stimuli or events that cause strain, analogous to the airplane wing bending because of an applied load. For humans, these stimuli, or stressors, can cause psychological, physiological, and emotional reactions. As you read this chapter, be careful not to confuse how we react to stressors with the stressors themselves; stress is the response and stressors are the cause (Harrington, 2013). Hans Selye (sel’ye; 1907–1982), an endocrinologist who studied the impact of hormones and stress, proposed that “stress is the nonspecific response of the body to any demand. A stressor is an agent that produces stress at any time” (1976, p. 53).

There are countless types of stressors. Stressors can be events, such as police academy driving tests. They can also be beliefs and attitudes, such as Eric’s thoughts and worries about not passing the driving test. Stressors can even be people, like the drill instructors who run the police academy’s Saturday morning physical training. Starting at 6:00 a.m., these guys lead Onondaga’s aspiring police officers through 3 hours of running, push-ups, and other backbreaking exercises. If a student makes one mistake, the drill instructors are more than happy to point it out with the full force of their lungs. Mind you, this is all for the cadet’s own benefit. The instructors are preparing the students for one of the more unpleasant aspects of police work: being ridiculed and insulted by the public. Police officers must learn how to brush off rude comments, maintain their composure, and carry on with their duties.

Welcome to the Academy Police cadets practice arrest procedures at an academy in Gurabo, Puerto Rico. Drill instructors go to great lengths to prepare aspiring police officers for the extreme physical and mental stressors they will face on their beats.

DENNIS RIVERA/The New York Times/Redux Pictures

What are some of the stressors in your life? Some exist outside of you, like homework assignments, dirty dishes in the sink, and job-related problems. Others are more internal, like the anxiety stemming from a strained relationship or the pressure of looming deadlines. Generally, we experience stress in response to stressors, although there is at least one exception to this rule: People with anxiety disorders can feel intense anxiety in the absence of any apparent stressors (Chapter 13). Which brings us to another point: Stress is very much related to how one perceives the surrounding world.

In many cases, stress results from a perceived threat, because what constitutes a threat differs from one person to the next. The police academy driving test might have been threatening to Eric because he felt anxious about failing it, while another student viewed the test as an opportunity to shine. Similarly, Eric may have felt completely relaxed taking written exams that other students found highly threatening.

Remember that stress can have psychological, physiological, and emotional effects. Eric’s physiological reaction to the driving test may have included increased blood pressure, or heart rate, but he was far more aware of the psychological and emotional components of his stress response. Bursting through the starting gates, his mind raced from one thought to the next. He was envisioning every little thing he had to do to pass the exam and at the same time saying to himself, Eric, Eric, you can’t fail.

The very same day that Eric failed his driving test, he resolved to return to the academy and start the program again. This minor setback was not going to interfere with his childhood dream of becoming a police officer, and there was no way it was going to define his experience at the academy. “When you fall down, you have to get back up” Eric says. “That’s the only way to move forward in life.”

Not everyone would have responded this way. Plenty of people would have viewed the test not as a stumbling block, but as the end of their journey. (I guess I was never meant to be a police officer.) As you will learn in this chapter, the ways people experience and cope with stressors are highly variable. The same exam that has you rearranging your schedule to go to the library every day may not even faze a classmate. But come exam day, she may be shaking in her shoes while you calmly walk into the classroom, feeling cool and confident. A particular type of stressor may also trigger distinct reactions at different times. You might feel confident for the first midterm exam, but uneasy about the second midterm, even though you have spent the same amount of time preparing for each test. People’s beliefs about their ability to cope with stressors and the strategies they use to do so have a profound impact on their stress reactions. We will address these concepts later in the chapter, but first let’s focus on the positive. Not all stress is bad.

EVERYTHING HAPPENS FOR A REASON

In three decades of life, Eric has experienced his fair share of stressors. Immediately after graduating from high school in upstate New York, he traveled to an Air Force base in San Antonio, Texas, to begin basic training, a stepping-stone on the way to joining the military police. “You want to talk about psychological stress?” he says laughing. Try waking up at 4:00 a.m. to the sound of drill sergeants banging garbage cans and screaming, “Get out of bed!” Not a morning person? If you cannot wake up, shower, shave, and make your bed with perfect hospital corners (yes, they really expect to be able to bounce a quarter off the sheets) in a half-hour, you can be sure one of the drill sergeants will get in your face and scream something like, “Are you so stupid that you can’t make your bed?” or “Did you have Mommy make your bed when you were home?”

It’s Nonstop A dairy plant employee toils among steel vats of milk. Keeping the storage vessels and equipment sterile is an enormous responsibility; if the product becomes contaminated, thousands of consumers might be sickened. As Eric can testify, working as a sanitation manager can cause significant day-to-day stress.

P. Magielsen/Corbis

After about a year of arduous training in the Air Force, Eric suffered a disabling injury and had to be discharged. It was a huge letdown, but Eric believes everything happens for a reason. He returned to New York and got a job at a dairy plant where he met his future wife and moved up the company ranks to become a high-level manager. Working at the plant introduced Eric to a different type of pressure. As a sanitation manager, it was his job to make sure all the processing equipment was sterile. If he failed to identify and correct one weak point in the process, the company might fail an inspection, or worse, thousands of consumers could get food poisoning. In 2010 Eric faced one of the most stressful, and unfortunately common, events in life: He was laid off. But he didn’t view the job loss as a loss at all; he saw it as an opportunity to finally fulfill his childhood dream of pursuing a career in law enforcement. A few months later, he was training to become a police officer at Onondaga Community College.

When you ask Eric how the various stressors in his life affected him, he has few negative things to say. Even while working upwards of 70 hours at the plant each week, he was eating well, sleeping soundly, and maintaining balance in his life. Despite the long hours and constant pressure, he felt relatively happy and fulfilled. Have you ever considered that stressors shouldn’t always be avoided? According to arousal theory, humans seek an optimal level of arousal, and what is optimal is not the same for everyone.

Clearly, stressors cannot be avoided completely. And some stressors are enjoyable, such as the excitement before a big trip, or the birth of a new baby. For Eric, getting married and witnessing the birth of his first child were among the most stressful and joyful events in life. “Oh man, you want to talk about sweaty palms, me shaking and a whole lot of emotion?” he says, remembering the day he stood at the altar. And the birth of his son? “Unreal,” he says. Immediately after the delivery, doctors placed the infant on his mother’s chest. The baby’s eyes were still closed, but when he opened them, Eric was the first person he saw. It was the proudest moment of Eric’s life. This “good” kind of stressor leads to eustress (yōōˈ-stres), which is the stress response to agreeable or positive events. Of course, most people associate stress with negative events. These types of undesirable or disagreeable events lead to the particular stress response known as distress. Now let’s find out how eustress and distress might affect your health.

Major Life Events

Holmes and Rahe (1967) were among the first to propose that life-changing events are potentially stressors. In other words, any event that requires a life adjustment, such as marriage, the birth of a child, or a change in financial status, can cause a stress reaction. They also suggested that these life-changing events have a cumulative effect; the more events you experience in a row or within a brief period of time, the greater the potential for an increased stress reaction and negative health outcomes. Numerous studies have examined these types of events and the strain they cause. Think back to the analogy of applying a force to the wing of an airplane. The degree to which the wing bends (or breaks) indicates the strain it is under (Lazarus, 1993). Researchers have found links between certain life events (the force causing strain) and illnesses (the response) such as sudden cardiac death, heart attack, leukemia, diabetes, influenza, psychiatric disorders, and a variety of other conditions (Hatch & Dohrenwend, 2007; Rabkin & Struening, 1976).

Social Readjustment Rating Scale

Illnesses can be clearly defined and identified, but how do psychologists measure life events? Holmes and Rahe (1967) developed the Social Readjustment Rating Scale (SRRS) to do just that. With the SRRS, participants are asked to read through a list of events and experiences, and determine which of these happened during the previous year and how many times they occurred. A score is then calculated based on severity ratings of events and frequency of their occurrence. An event like the death of a spouse has a greater severity rating than something like a traffic violation. Participants are also asked to report on any illnesses or accidents they experienced during the same period. Researchers then use this information to look at the correlation between life events and health problems (Kobasa, 1979). Correlations range between .20 and .78, although they are generally lower than .30 (Rabkin & Struening, 1976). But remember, a correlation between life events and illness (or any correlation for that matter) is no proof of causality. There is always the possibility that a third factor, such as poverty, may be causing both illnesses and major life-changing events. Someone who is impoverished might not have employment or access to good health care, nutrition, and so forth. In this case, poverty is leading to stressful life events and poor health outcomes.

Popular in the late 1960s and 1970s, the Social Readjustment Rating Scale (SRRS) has evolved over the years. But as with many scales, the original version has now become outdated. (For example, the original scale included “mortgage over $10,000” as an event.) The rating scale has also been adapted to better match the life events of specific populations; for example, the College Undergraduate Stress Scale (Renner & Mackin, 1998; Figure 12.1). Even with this degree of specificity, the scale may not be suitable for every person. In addition to dealing with term papers, midterms, and other college-related life events, many of today’s college students face a host of other potential stressors, such as making car payments and raising children.

FIGURE 12.1Sample Items from the College Undergraduate Stress Scale

Source: Reprinted by permission of SAGE Publications/APA/LAWRENCE/ERLBAUM ASSOCIATES, INC. from Renner and Mackin (1998).

Another possible problem with self-report scales such as the SRRS is that people tend to forget events over time, or the opposite—they tend to focus more on past events than recent ones (Pachana, Brilleman, & Dobson, 2011). What’s more, not all negative life-changing events lead to bad outcomes. Some have even suggested that moderate exposure to stress makes us stronger, a view described as stress inoculation. Someone with a “low to moderate” degree of stress may end up with “better mental health and well-being” and a greater ability to cope with pain than those who either have faced no hardships or have had to handle an overwhelming level of adversity (Seery, 2011).

Looking across cultures, we see most people rate the weight of life-changing events very similarly (Leontopoulou, Jimerson, & Anderson, 2011; Scully, Tosi, & Banning, 2000). For example, when the SRRS was administered to French, Belgian, and Swiss participants, their rankings of how much readjustment the events would necessitate were similar to those made by Americans (Harmon, Masuda, & Holmes, 1970). Malaysians also have similar views about the amount of readjustment required for life events (Woon, Masuda, Wagner, & Holmes, 1971).

Posttraumatic Stress Disorder

One type of event not included in the SRRS, but which is familiar to police officers and other first responders, is a major disaster experience. These cataclysmic events include natural disasters such as hurricanes, earthquakes, and tornadoes, as well as multicar accidents, war, and terrorist attacks. The emotional and physical responses to such occurrences can last for many years, manifesting themselves in nightmares, flashbacks, depression, grief, anxiety, and other symptoms related to posttraumatic stress disorder.

In order to be diagnosed with posttraumatic stress disorder (PTSD), a person must be exposed to or threatened by an event involving death, serious injury, or some form of sexual violence. Someone could develop PTSD after witnessing a violent assault or accident, or upon learning about the traumatic experiences of family members, close friends, perhaps even strangers. For veterans and service members previously deployed to war zones in Afghanistan and Iraq, the estimated incidence of PTSD is 13.8%, based on a study of almost 2,000 participants questioned about symptoms within the last 30 days (Schell & Marshall, 2008). In contrast, around 3.5% of the general population is estimated to have received a PTSD diagnosis during the previous 12 months (American Psychiatric Association, 2013). In some cases, the exposure to trauma is ongoing. First responders like Eric, for example, may witness disturbing scenarios on a weekly basis.

Healing the Wounds of War Physician assistant Klubo Mulba (left) smiles at her former client, Surprise Otto, at JFK Hospital in Monrovia, Liberia. Mulba, who is one of Liberia’s first mental health clinicians, received her training through a joint program between The Carter Center and the Liberia Ministry of Health and Social Welfare. Liberia’s population is still recovering from a 13-year civil war that ended in 2003. Approximately 40% of the population is affected by PTSD (The Carter Center, 2013).

The Carter Center/P. Rohe

However, not everyone exposed to trauma will develop PTSD. Over the course of a lifetime, most people will experience an event that qualifies as a “psychological trauma,” but only 5 to 10% will actually develop PTSD as a result (Bonanno, Westphal, & Mancini, 2011). To be diagnosed with PTSD, a person must experience at least one of the following symptoms: (1) distressing, disturbing, and spontaneously recurring memories of an event; (2) dreams with content or emotions associated with the event; (3) “dissociative reactions” that include feeling as if the event is happening again (flashbacks); (4) extreme psychological distress when reminded of the event; or (5) obvious physical reactions to cues related to the event.

Many people with PTSD try to avoid the environmental cues (people, places, or objects) linked to the trauma. If someone were involved in a serious car accident on US Highway 101, then simply driving along that thoroughfare may trigger unwanted memories. Other symptoms include difficulty remembering the details of the event, unrealistic self-expectations, ongoing self-blame, and loss of interest in activities that once were enjoyable. Someone with PTSD might be irritable or aggressive, lashing out at loved ones for no apparent reason. She may have trouble sleeping and concentrating. Also associated with PTSD are dissociative symptoms, which may include distorted perceptions of the world, and the feeling of observing oneself from the outside (American Psychological Association, 2013d; Friedman, Resick, Bryant, & Brewin, 2011).

Among those at risk for PTSD are police officers (Berger et al., 2011), many of whom bear witness to bloody crime scenes, traumatized victims, and gun violence. But it is not just these types of traumas that impact police officers; just as important are the more chronic stressors, like being overworked and not having enough time with family (Collins & Gibbs, 2003). One study concluded that, for police officers, chronic stressors at work, such as discrimination and unpleasant relationships with coworkers, are associated with the symptoms of PTSD as well (Maguen et al., 2009), although such stressors (while they contribute) are not actually sufficient to define or diagnose it.

It’s Nonstop: Chronic Stressors

You don’t have to be a police officer to appreciate the burden of everyday stress. For some of us, stressors come from balancing school and work, or taking care of young children. Many face the constant stressor of battling a chronic illness like diabetes, asthma, or cancer (Sansom-Daly, Peate, Wakefield, Bryant, & Cohn, 2012), or caring for an adult child with a severe mental disorder (Barker, Greenberg, Seltzer, & Almeida, 2012). And for a growing number of people around the world, poverty is an overwhelming stressor.

The number of Americans living at or below the poverty line continues to increase. As of 2011, 22% of children under 6 years in the United States were living below the poverty level (Addy, Engelhardt, & Skinner, 2013). People struggling to make ends meet experience numerous stressors, including poor health care, lack of preventive health care, noisy living situations, overcrowding, violence, and underfunded schools (Blair & Raver, 2012; Mistry & Wadsworth, 2011). The cycle of poverty is difficult to break, so these stressors often persist across generations. The longer people live in poverty, the more exposure they have to stressors, and the greater the likelihood they will become ill (Miller, Chen, & Parker, 2011). For children in particular, the impact of socioeconomic status (SES) can have lifelong repercussions because environmental stressors affect the developing brain. Some of the factors associated with low SES and permanent changes to the brain include poor nutrition, toxins in the environment, and abuse. In some cases, the resulting disparities in brain development may lead to differences in “adult neurocognitive outcomes” (D’Angiulli, Lipina, & Olesinska, 2012). Factors linked to poverty have been associated with “inequalities” in the development of cognitive and socioemotional abilities, which can impact performance in school and at work (Lipina & Posner, 2012).

Another increasingly common source of stress is migration. The 214 million migrants dispersed across the world deal with varying degrees of acculturative stress (ə-ˌkəl-chə-ˈrā-tiv), or stress associated with adjusting to a new way of life (International Organization for Migration, 2013). How would it feel to leave behind your extended family and close friends, and move to a foreign land where the language, customs, holidays, and belief systems are new and different? Perhaps you have had this experience; about 1 in 10 people living in America were born in another country (U.S. Census, 2012).

There are various ways people respond to acculturative stress (Berry, 1997). Some try to assimilate, letting go of old ways and adopting those of the new culture. But assimilation can cause problems if family members or friends from the old culture reject the new one, or have trouble assimilating themselves. Another approach is to cling to one’s roots and remain separated from the new culture. Such an approach can be very problematic if the new culture does not support this type of separation and requires assimilation. A combination of these two approaches is integration, or holding on to some elements of the old culture, but also adopting aspects of the new one.

The degree of acculturative stress varies greatly from one individual to the next. Some people thrive on new soil (a prime example being Mohamed Dirie introduced in Chapter 9), while others struggle with the stress of starting over. What determines the intensity of acculturative stress, and why do some people seem to have an easier time with it than others?

Culture Shock A woman shops for groceries in the Chinatown area of Flushing in Queens, New York. Queens is the most ethnically diverse spot on the planet, providing a home for people from more than 100 countries (nyc.gov, 2013). Immigrants can either assimilate into, separate from, or integrate into their new cultures.

Mark Peterson/Redux

The stresses of acculturation tend to be gnawing and constant, but some stressors are sudden and dramatic. These are the types that ambulance drivers and paramedics encounter every day. Meet our next first responder, Kehlen Kirby.

THE PARAMEDIC’S ROLLERCOASTER

Kehlen Kirby sees more pain and suffering in one month than most people do in a lifetime. In his 8 years working as an emergency medical services (EMS) provider in Pueblo, Colorado, this 26-year-old man has witnessed the highest highs and lowest lows of human experience. He has rescued people from flaming car wrecks, treated teenage gang members for stab and gunshot wounds, and watched chain-smokers who are dying from emphysema beg for cigarettes en route to the hospital. “We have had people that are struggling to breathe, using every muscle in their body to breathe, but they just want to get that last puff before we load them into the ambulance,” Kehlen says. In between the sadness and suffering, though, there are also stories of hope and inspiration. One such tale takes place on the edge of a dark highway.

Life Saver Kehlen Kirby has one of the most stressful jobs imaginable—providing emergency medical services to people injured in car accidents, fires, and other traumatic incidents. The constant exposure to pain and suffering helps Kehlen maintain perspective on the hassles of daily life; he doesn’t sweat the small stuff.

Leslie Nazario/Portraits by Leslie

It was the middle of the night when Kehlen’s crew received a call about a medical emergency on the side of the freeway. Arriving at the scene, they found a woman on the passenger side of a car, legs propped up on the dashboard. There was a pool of blood on the floor. The woman was panicked and screaming, and the man on the driver’s side was not faring much better. It turned out that these poor souls were soon-to-be parents, and their baby boy was ready to make his debut. Upon closer examination, Kehlen could see the baby’s head beginning to emerge. There was no time to load the woman into the ambulance and race to the hospital. This infant was about to take his first breaths on US Route 50. Kehlen and his colleagues delivered the baby, and the mother went from a state of screaming hysteria to smiling, laughing bliss.

Being involved in life-or-death situations may be emotionally challenging, but it helps Kehlen keep things in perspective. “All the traumatic calls, the car wrecks and shootings, it makes you appreciate life,” he says. Kehlen will never ride in a car without wearing a seatbelt; he has seen the horrific consequences of not buckling up. He also doesn’t get too aggravated by everyday annoyances, like the sound of his newborn shrieking and wailing. (Like Eric, Kehlen recently became a dad.) Many new parents find a baby’s cries disconcerting. Not Kehlen. From his paramedic’s perspective, a crying baby means a breathing baby. “I love it when she cries,” he says. But the fact that Kehlen is unfazed by everyday annoyances like screaming infants and dirty laundry probably makes him the exception rather than the rule. Research suggests that these daily hassles can have a significant impact on us.

What a Hassle, What a Joy

Daily hassles are the minor problems or irritants we deal with on a regular basis, such as traffic, financial worries, misplaced keys, messy roommates—a list that does not seem to end. These hassles, although seemingly minor, are repetitive and ever present. The strain of dealing with them can add up, seemingly taking a toll on our health and well-being (DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982; DeLongis, Folkman, & Lazarus, 1988). For example, research suggests that hassles are closely associated with short-lived illnesses, such as colds and headaches (Bottos & Dewey, 2004; DeLongis et al., 1988; Pedersen, Zachariae, & Bovbjerg, 2010). It’s a good thing that the weight of our daily hassles is counterbalanced by the uplifts in our lives.

Uplifts are positive experiences that have the potential to make us happy. Think about the last time you smiled; it was likely in response to an uplift, such as a funny text from a good friend, a child presenting you with a handmade gift, or a congratulatory e-mail about one of your achievements. We all have hassles and uplifts, but how do they interact to affect our health and well-being? Researchers have been asking this question for decades.

DeLongis and colleagues (1988) developed a scale of daily hassles and uplifts, and used it to explore the relationship between stress and illness (Figure 12.2). They asked participants in their study to read through a list of 53 items that could be either hassles or uplifts, such as meeting deadlines, maintaining a car, interacting with fellow workers, and dealing with the weather. Participants then rated these items on a 4-point scale indicating “how much of a hassle” and “how much of an uplift” each was on that particular day (0 = none or not applicable, to 3 = a great deal). They also asked participants to report any illness, injuries, or symptoms they experienced that same day. What did they find? Over a 6-month period, there was a significant link between hassles and health problems. The more daily stressors the participants reported, the more likely they were to suffer from sore throats, headaches, influenza, back problems, and other health issues. More recently, researchers uncovered a link between daily stressors and cardiovascular risk factors, such as high blood pressure (Uchino, Berg, Smith, Pearce, & Skinner, 2006). Daily hassles also increase the risk of catching contagious diseases and may prolong the course of illness (Glaser & Kiecolt-Glaser, 2005).

FIGURE 12.2The Hassles and Uplifts ScaleOn their scale of daily hassles and uplifts, Delongis, Folkman, and Lazarus (1988) asked participants to consider how much of a hassle and how much of an uplift each item on the scale was the day of the test. Participants were instructed to circle a number rating the degree to which each item was a hassle (left column) and an uplift (right column). Numbers range from 0 (“none or not applicable”) to 3 (“a great deal”). The scale includes 53 items, a sample of which are shown here.

Sources: Copyright ©1988 by the American Psychological Association. Adapted with permission from DeLongis, Folkman, and Lazarus (1988).

How do hassles and uplifts affect psychological and social health? One group of researchers studied two Israeli populations (Jewish and Arab), exploring the similarities and differences within subgroups living in the same country. While differences existed, the researchers noted some important similarities. In both groups, for example, daily uplifts had a positive impact on “family satisfaction” and daily hassles had a negative impact on “life satisfaction,” though the meaning of “uplift” differed between the two groups (Lavee & Ben-Ari, 2008).

Now that we have explored various types of stressors, from major life events to everyday annoyances, let’s find out what occurs in the body and brain when we respond.