Chapter 16: Health & Stress

16.0: Learning Objectives

After completing this chapter, you should be able to:

1. Define different aspects of stress, including stressors and the stress response.

2. Distinguish between acute, chronic, and traumatic stressors.

3. Understand the integrated stress response involving psychological and biological components.

4. Understand the effects of stressors on mental health.

5. Understand the effects of stressors on physical health.

6. Describe factors that protect against the effects of stressors on health.

16.1 Introduction: The Fundamentals of Health and Stress

Think back to the last time you spoke in public. Maybe it was a presentation to your class, a wedding
toast, or an address to your club or society. Did you feel your heart race and your palms get sweaty? Did
you experience “butterflies” in your stomach? Were you thinking about making mistakes or about other
people’s judgments of your appearance or your words? Were you feeling nervous, anxious, or afraid?
Given that 64% of college students report fear of public speaking (Ferreira Marinho et al., 2017),
chances are high that you too experienced some of these bodily sensations, thoughts, and emotions.

If you did experience some of these psychological and biological changes in response to public speaking
or some other threat or challenge recently, congratulations! Your body is demonstrating adaptations
acquired over millennia that allowed your ancestors to survive and thrive in the face of life’s inevitable
stress. Without an integrated and appropriate approach to stress, your ancestors would have struggled
to reproduce and survive. Thus, they would have failed to pass on their genes, and you would not be
here. However, severe or prolonged stress can also be harmful, impairing our bodily systems and
increasing our risk for diseases of aging and early mortality.
In this chapter, you will learn about different aspects of stress. You will also learn definitions for specific
aspects of stress and why some psychologists think that we should drop the word stress from our
vocabulary altogether. We will discuss the integrated biological response that follows experiences of
stress and how stress can influence our mental and physical health. Finally, we will discuss things that
we can do to reduce any negative effects of stress on our bodies. It turns out that maintaining a healthy
lifestyle and using support from our friends and families can give us stress-busting superpowers!

16.2 What Is Stress?

What comes to mind when you think about the word stress? Like most people, you may associate a wide
variety of things with the concept of stress, such as final exams, conflict with your friends, worries,
financial strain, natural disasters, sweaty palms, a racing heart rate, a job interview, or walking down a
dark alley late at night. What do these varied events and experiences have in common? They are all
referred to as stress in our everyday lives. In fact, the word stress is used to refer to a wide range of
concepts, from external environmental stimuli to internal emotional experiences and bodily responses.

As in all areas of science, precise definitions are critical to our ability to make progress in psychology. In
fact, the use of precise language and definitions may be even more important in psychological science
because so many of our terms are used in our everyday lives as well as in psychology classes and
psychological research. To enhance stress research and to avoid the imprecision outlined above, some
scholars have proposed that we drop the word stress from our vocabularies altogether. Thus, we are
going to start by distinguishing among different types and aspects of stress and introducing some more
precise terms that you can use as you learn about stress.
16.2.1 Good versus Bad Stress

When thinking about definitions of stress, one of the most important distinctions to make is between
“good stress” and “bad stress.” Whereas good stress is beneficial for us, motivating us to work to
achieve our goals and even enhancing our functioning, bad stress can reduce motivation and impair
functioning. Even Hans Selye (Figure 16.2), one of the pioneers of stress research, emphasized the
upside of stress in our lives (Selye, 1980). He coined the term eustress to represent reactions to good
stress and contrasted it with the word distress, which represents reactions to bad stress. Eustress would
occur in the context of experiences such as marriage, having or adopting a child, getting a promotion at
work, or being confronted with manageable challenges in everyday life. In contrast, distress would be
experienced in response to situations typically perceived as negative, such as being the victim of a crime,
the loss or death of a loved one, failing a test, or experiencing challenges that you feel are beyond your
capacity.

Watch the video below of a talk given by psychologist Dr. Kelly McGonigal where she explains research
which suggests that our perception of a stressful experience can actually influence our physical response
to the situation.

How to make stress your friend | Kelly McGonigal - YouTube

Other models have emphasized the importance of stress for performance, again emphasizing an upside
of experiencing some stress. One classic and widely known theory of stress and performance is
the Yerkes-Dodson law, which outlines an inverted U-shaped curve for the relationship between stress
and performance (Yerkes & Dodson, 1908). This law specifies that too little or too much stress impairs
performance. Although well known and often discussed, the Yerkes-Dodson law has been widely
criticized and expanded upon since its publication over 100 years ago (Hancock & Szalma, 2018). A
review of over 25 years of research on stress and performance emphasized that there is very little
empirical evidence to support the idea of an inverted U-shaped relationship between stress and
performance (Muse et al., 2003).

One updated model of stress and performance is the Maximal Adaptability Model, which emphasizes
that humans and other organisms are actually highly adaptive to stressors and can maintain high levels
of performance even when experiencing underload or overload in terms of the demands of the
environment (Hancock & Warm, 1989). Given that striving to achieve goals or overcome adversity
inevitably involves stress, it is important to remember that we can function well despite the negative
aspects of stress.
16.2.2 Stressors and the Stress Response

So far we have used the word stress as a general term, but now it’s time to get more specific. First,
based on the highly influential Stress and Coping Theory (Lazarus & Folkman, 1984) and the work of
Hans Selye (Selye, 1980), we can discriminate between external and internal aspects of
stress. Stressors are external circumstances and stimuli that are perceived as having the potential to
disturb an individual’s balanced state. Stressors can range from mild (e.g., getting stuck in traffic or
making a mistake in an email address) to severe (e.g., experiencing extreme poverty or being physically
assaulted). Stress responses are internal integrated psychological and biological responses to stressors
that work to restore a balanced state. The stress response has psychological components that involve
thoughts (e.g., "I will get a really bad score on this test") and emotions (e.g., fear and anxiety), and
biological components that involve responses and feedback from bodily systems (e.g., increased blood
pressure and faster heart rate).
When it comes to precision in defining stressors, it is important that we distinguish among stressors
based on how long they last and their level of severity (see Table 16.1). For example, speaking in front of
your class for 15 minutes would have very different effects on you than dealing with long-term
unemployment. Acute stressors are short-term external circumstances or stimuli, lasting minutes to
hours, with the potential to disturb an individual’s balanced state. Some examples are giving a 15-
minute speech in public, taking an important exam, or realizing that you sent an embarrassing text to
the wrong person. Chronic stressors are enduring external circumstances or stimuli, lasting weeks to
years, with the potential to disturb an individual’s balanced state. Living in poverty, caring for an elderly
relative, and ongoing workplace stress are all stressors that can be considered chronic. Acute and
chronic stressors can vary in severity from mild to moderate to severe. The most severe stressors, those
involving a threat to your own or another’s life or physical integrity, are called traumatic stressors. Some
examples include experiencing or witnessing risks to life or physical integrity during war or combat,
sexual assault, childhood abuse, natural disasters such as earthquakes and tornadoes, and major fires.
16.2.3 The Stress Response: An Evolutionary Perspective (压力反应：进化的视角)

If you think back to the public speaking example at the start of the chapter, you will recall that we
discussed a host of responses to stressors that seem quite unpleasant. When speaking in public, you
may experience anxiety about making mistakes or about other people’s judgments of your appearance
or your words. We mentioned feelings of nervousness, anxiety, and fear, as well as physical sensations
such as a racing heart, sweaty palms and, “butterflies” in the stomach. Why have we evolved to
experience such a range of unpleasant experiences when confronted by stressors? How can it possibly
be helpful for us to experience such unpleasantness when we need to gather all our resources to deal
with the demands of the stressor? Of course, you know by now that stress responses can be beneficial.
They are all part of a highly coordinated set of responses that served to enhance the survival and
success of our ancestors, and they can also greatly benefit us today. In this section we will discuss the
stress response in more detail, and you will learn how it prepares us to deal with and protect ourselves
from stressors.

[Link] Alerts and Reactions to Restore Balance

When you think about the stress response, it is helpful to imagine our minds and bodies as balance
scales (see Figure 16.3). In the context of stress research, homeostasis describes the state when we are
in balance (Cannon, 1939). Stressors have the potential to move the scale out of balance, and the stress
response is a combination of alerts that the scale is out of balance and reactions that restore balance.
The alerts include psychological factors such as thoughts and emotions, as well as sensations in the body
that inform us there is a risk for disturbance to our balanced state. The reactions consist of psychological
and biological responses that are designed to restore balance. To summarize, homeostasis is when the
scale is balanced, stressors can unbalance the scale and disturb homeostasis, and the stress response
can shift the scale back to a balanced state of homeostasis again.
We can consider the stress response as an adaptation that helps us maintain homeostasis in the face of
life’s inevitable threats and challenges. In our ancestral past, encounters with predators such as bears
and tigers and attacks from other humans were much more common than they are in many (but not all)
societies today. Thus, evolution had plenty of opportunities to select for genes that would enhance our
survival in the context of these life-threatening situations. Encounters with predators and other humans
who threatened our lives increased the need for energy to help us fight or run away to minimize the risk
for injury or infection. A coordinated response that allowed us to mobilize energy to deal with a stressor,
avoid damage, and reduce risk for infection was greatly advantageous. Adaptations that allowed us to
mount this response even when only anticipating a potential stressor were also beneficial because they
allowed us to prepare for stressors even before directly experiencing them.
[Link] Neurobiological Responses to Stressors (对压力源的神经生物学反应)

The brain plays a critical role in stress responses. It allows us to detect and evaluate potential stressors,
and then it coordinates the stress response. The earliest stress responses typically occur in
the amygdala (McEwen, 2008). The amygdala is sometimes called the “neural watchdog,” because it
responds to potential stressors rapidly and sometimes even before conscious awareness (Figure 16.4).
The amygdala doesn’t act alone, but instead works in a coordinated way with other brain areas that can
either increase or decrease the amygdala’s response. Some of the most important of these other brain
regions are the hippocampus and the prefrontal cortex. The hippocampus sits adjacent to the
amygdala and is central to learning and memory. It also plays a key role in the consolidation of new
memories, and humans are particularly prone to encoding memories of situations that elicit stress
responses. The hippocampus allows us to filter ongoing experiences through past experiences and to
imagine things that have not yet happened. The prefrontal cortex is involved in higher-level processing
of stimuli in our environment. It allows us to increase or decrease our amygdala response to potential
stressors based on perceptions of other factors that make the stressor more or less threatening. For
example, if your amygdala reacts to the sight of a tiger at the zoo, your prefrontal cortex might dampen
this response based on recognizing that the tiger is secured within a pen and unable to get to you. Your
hippocampus might also dampen the response based on memories of encountering tigers at the zoo in
the past. Overall, your brain decides which situations are safe versus unsafe and elicits the appropriate
reactions to enhance your survival and well-being and then restore homeostasis.
[Link] Hormonal Responses to Stressors (对压力源的激素反应)

As an exercise, think back to the last time you or someone else posted something embarrassing about
you on a social media account. Perhaps it was a highly unflattering photo of you or a humiliating
anecdote. What happened in your body when you realized that this post was online for everyone to
see? As we have already discussed, your first response may have included bodily sensations such as
rapid increases in your heart rate, sweaty palms, and changes in your abdomen and digestive system
resulting in feelings of “butterflies in your tummy.” These changes occur at the level of your conscious
awareness. However, at a level below your consciousness, you were likely experiencing even more
changes across your bodily systems. Specifically, once the brain registers a stressor, the autonomic
nervous system (ANS) and the hypothalamic pituitary adrenal (HPA) axis are rapidly activated. The ANS
and the HPA axis are biological systems that produce specific hormones that can travel throughout our
bodies to coordinate and regulate our responses to a stressor. Below we talk about how each of these
systems can work to protect us from harm and restore balance.
As we learned in Chapter 3: Biology & Neuroscience, the ANS includes two major branches:
the sympathetic nervous system and the parasympathetic nervous system. These two branches of the
ANS work together to maintain homeostasis through a process of reciprocal inhibition, where the
activation of one system can suppress the other. A small brain region called the hypothalamus, located
at the base of the brain, is central to coordination of the ANS. Activity in the hypothalamus can promote
activity in the sympathetic nervous system (which functions as the “activator” of the ANS) and the
parasympathetic nervous system (which functions as the “regulator” of the ANS). Activation of the
sympathetic nervous system promotes the release of stress hormones called catecholamines from the
adrenal glands, which are located at the top of each of the kidneys. These catecholamines include
epinephrine and norepinephrine, which play a crucial role in preparing the body for the fight-or-flight
response, a process first described by Walter Cannon in 1939. In contrast, the parasympathetic nervous
system can dampen the fight-or-flight response and allow for the restoration of homeostasis. One way
to think about this relationship is that the sympathetic nervous system is analogous to the gas pedal on
your car, ramping up the stress response, whereas the parasympathetic nervous system is comparable
to the brake pedal, dampening the stress response.

Stressors can also activate the HPA axis, which creates a cascade of activities that ultimately promote
the release of the stress hormone cortisol from the adrenal glands. First, the amygdala sends signals to
the hypothalamus (which is central to both ANS and HPA responses to stressors) to release
corticotropin-releasing hormone (CRH). Second, CRH signals a gland located close to the hypothalamus
called the pituitary gland to release adrenocorticotropic hormone (ACTH). Finally, ACTH travels in the
bloodstream to the adrenal glands, where it promotes the release of cortisol.

Cortisol levels can fluctuate throughout the day and can be measured in the blood, urine, saliva, and
even hair. Cortisol is probably the most widely used biological marker of the stress response. People
who are exposed to an acute stressor show increases in levels of cortisol after about 15–20 minutes. A
highly influential meta-analysis of 208 laboratory-based studies showed that uncontrollable or socially
evaluative acute stressors elicited the most significant cortisol responses (Dickerson & Kemeny, 2004).
People who are experiencing chronic stressors also show alterations in levels of cortisol. To study the
effects of chronic stressors on cortisol, researchers measure cortisol at several times during the day. In
humans, cortisol typically increases rapidly after awakening and then declines throughout the day until
evening and bedtime. People experiencing chronic stressors tend to show a flattening of this response,
such that there are lower levels of decline throughout the day. For example, people experiencing low
socioeconomic status (i.e., financial strain, lower positions in the social hierarchy) show flatter daily
cortisol slopes characterized by lower awakening cortisol responses, lower total levels of cortisol output
throughout the day, and the flattest cortisol rhythms from morning to evening (Desantis et al., 2015).

What is the function of all of these changes? Activity in the ANS and HPA axis and the release of
catecholamines and cortisol prepare the cardiovascular, respiratory, and digestive systems to deal with
perceived stressors (Figure 16.5). In the cardiovascular system, our hearts beat faster and our blood
pressure increases, which allows us to run away from a stressor or use our bodies to fight off any
attackers. In the respiratory system, our breathing rate quickens and we can take in more oxygen to fuel
the stress response, allowing us to run away or fight. The rise in oxygen also allows us to fuel our brain
with oxygen, which can increase the brain’s capacity to respond to the stressor. Activation of the fight-
or-flight response suppresses the release of insulin by the pancreas, allowing glucose levels to increase.
Moreover, cortisol facilitates the transformation of fatty acids into glucose, further increasing our
energy supply. Digestive processes are suppressed to allow us to direct more energy toward efforts to
fight and flee.
In some cases, activation of these systems results not in fighting or fleeing, but in a freeze response. This
response often occurs in prey animals when they are completely overcome by a predator. Instead of
continuing efforts to fight or flee, these animals become immobile and outwardly unresponsive.
Accumulating evidence suggests that humans also engage in freeze responses to stressors, particularly
to stressors that are traumatic and uncontrollable (Schmidt et al., 2008).

Although the stress response can enhance our survival, it is harmful if it remains “switched on” for
prolonged periods. Thus, mechanisms that can shut down the stress response are vital for health and
well-being. As stated above, the two subdivisions of the ANS can work by reciprocal inhibition, with the
sympathetic nervous system serving as the activator and the parasympathetic nervous system acting as
the regulator/inhibitor. Within the HPA axis, there are negative feedback loops that serve as regulators.
For example, although the hormone cortisol is released in response to stressors, and it serves an
important role in mobilizing bodily resources such as glucose, it also acts to shut down HPA axis activity.
Specifically, cortisol can bind to receptors on the hypothalamus and pituitary gland to reduce the
production of CRH and ACTH. Thus, regulation is built into the HPA axis.

When thinking about whether stressors are helpful or harmful for us, the distinction between acute and
chronic stressors is critical. While acute stressors are known to elicit responses that can be beneficial
(e.g., mobilize energy, allow us to take in more oxygen), chronic stressors tend to cause harm to our
bodies (McEwen, 2004). Without appropriate regulation, acute stress responses would become chronic
stress responses.
[Link] Immune System Responses to Stressors (免疫系统对应激源的反应)

Some of the most exciting findings in stress research during the past decade have focused on the
immune system. While we have known for decades that psychological stressors can activate the fight-or-
flight response and HPA axis, we are only beginning to understand the profound effects of psychological
stressors on the immune system. Research has revealed that even everyday acute stressors can activate
the inflammatory response of the immune system (Steptoe et al., 2007). The inflammatory response, in
turn, allows the body to cope with the increased risk for infection and injury that accompanies some
stressors. For example, in our ancestral past, stressors were more likely to involve physical attacks that
were associated with injuries from fighting and efforts to flee. In response to acute psychological
stressors, the body increases levels of proteins that regulate inflammation. This inflammatory response
helps the body deal with the high likelihood of injury and infection (through any wounds) that may occur
as you flee a saber-toothed tiger. However, later in this chapter we will discuss how prolonged or very
high levels of this inflammatory response can also kill cells throughout the body and increase risk for the
diseases associated with aging.
16.3 Stress Research

Stress is something we all deal with on a daily basis, and as discussed above, our stress responses have
made a major contribution to our ability to survive as a species. So it is not surprising that the history of
research into stress and the stress response is long. Furthermore, stress research is still a key area of
psychological inquiry today. This section will review stress research, including methodologies used to
investigate stress.

16.3.1 In the Eye of the Beholder: The Importance of Perceptions (在旁观者眼中：感知的重要性)

Perception plays a key role in the interpretation of stressors and the generation of stress responses. A
stressor that one person views as highly threatening might be relatively benign to someone else. Think
about how you would feel if you had to give a 50-minute presentation on stress to your class. Would
that result in anxiety and worry and elicit a major stress response for you? Yet your professor gives
lectures to groups of varying sizes multiple times per week. It is likely that your anticipation of giving a
presentation in front of the class would generate higher levels of perceived stress than it does for your
professor. However, even a highly experienced professor likely experiences a stress response when
giving lectures, and this stress response would be much greater if they turned up to class unprepared.
Most theories of psychological stress emphasize perceptions in the definition of stressors. In other
words, stress is evaluated from the perspective of the person experiencing the stressor. For example,
stress and coping theory defines stress as the perception that demands exceed your ability to cope with
them (Lazarus & Folkman, 1984). The theory further discriminates between primary and secondary
appraisals, or judgments of stressors and their potential impact. Primary appraisals are based on your
perceptions of the stressor's characteristics and how much demand it represents, as well as its relevance
for you. For example, your perception of the difficulty level of an upcoming examination and its
weighting for your final GPA is part of your primary appraisal. Secondary appraisals are based on your
perceptions of the resources available for coping with a specific stressor. Resources can include internal
factors, such as your personality or perceived abilities, or external factors, such as social support or
financial resources, that will help meet the demands of the situation. For example, your perception of
how much time you have to study and how much you already know for a specific examination is your
secondary appraisal. These appraisals are central to our experiences of stressors as manageable or
unmanageable for us.

[Link] Challenge versus Threat

Challenge and Threat Theory (Blascovich & Mendes, 2010) distinguishes between challenges, defined as
situations in which resources exceed the demands of the situation, and threats, defined as situations in
which demands exceed the resources available for coping (see Figure 16.6). The features of stressors
play a significant role in determining whether they will be perceived as challenges or threats. Stressors
involving danger, uncertainty, uncontrollability, novelty, and high levels of effort all have higher
“demands” and are more likely to be perceived as threats. Stressors involving the potential for positive
outcomes and personal gain are more likely to be perceived as challenges. For a given individual, the
extent to which a specific situation is seen as a challenge or a threat depends on primary appraisals of
the stressor's characteristics and secondary appraisals of the resources available to cope with it. If you
perceive that a specific set of circumstances exceeds your ability to cope or adapt, then that is a threat
for you, even if it would not be considered a threat for someone else. Importantly, if you do not
perceive a stressor as exceeding your ability to cope or adapt, then it is a challenge for you even if it
would be considered a threat for someone else. Similar to the previous example of giving a presentation
to a classroom full of students, many students would perceive the task as a threat, whereas most
professors would not.
To better illustrate the importance of perceptions in challenge and threat appraisals, let’s review an
example. Imagine a scenario where two of your classmates, Javier and John, are selected to interview
for a well-paid internship at Facebook in California. These two students receive an identical email from
Facebook inviting them to fly out to California to interview for the position and specifying that they will
compete against 100 other students for four spots. Both students evaluate the demands of the situation
and the resources available for them to cope with those demands.

Javier is proud to have been selected as one of the 100 people to be interviewed, and he believes he has
as good a chance as anyone of getting one of the four spots. He feels excited and proud. Javier also
knows that the competition will be fierce and that Facebook interviews span multiple days and involve
various types of performance. Based on his experiences during mock internship interviews in one of his
courses, he feels confident that he will perform well. Also, Javier completed a project about Facebook
last year so he knows a lot about the company and its goals. He even has a friend who lives near the
Facebook headquarters that will support him when he’s visiting for his interview.

In contrast to Javier's excitement, John experiences mostly fear when thinking about his interview. He
immediately thinks about the demands of the situation. He wonders how he could possibly compete
against 99 other students. John has had some bad experiences at interviews in the past, and he doesn’t
know a lot about Facebook. Also, he has two part-time jobs on top of his college courses and knows that
he won’t have enough time to prepare for the interview adequately. Because he is a transfer student
who recently moved away from his hometown for school, John also feels that he doesn’t have anyone
who can help him prepare. In these scenarios, you can see that a combination of objective demands and
subjective evaluations determine whether the same situation is experienced as a challenge or a threat.
Later in this chapter, we will discuss how stress responses differ when stressors are perceived as threats
compared to challenges and how you can shift your appraisals to see more of your stressors as
challenges instead of threats. Fun fact: When you are experiencing a threat response, the blood rushes
away from your extremities. So, if you’re experiencing a threat response, you’ll notice that your hands
are icy cold.
16.3.2 Methodology in Stress Research: From Exposure to Perceived Stress (压力研究方法：从暴露到感知压力)

Much of what we have learned about the stress response comes from non-human animals such as rats
and mice. For example, rats have been used in experiments examining the effects of early life stressors
on the incidence of cardiovascular disease. Based on your understanding of ethics and experimentation
from Chapter 2: Research Methods, would it be ethical to conduct such an experiment on humans?
Hopefully, your answer is a definite “no,” because such an experiment would be highly unethical! To
conduct this type of research experiment, participants must be randomly assigned to one of the
conditions of the independent variable (IV), which in this case is stressor exposure. The dependent
variable (DV) would be cardiovascular disease incidence. Thus, if the participants were human, the
researcher would randomly assign children to experience stressors and then examine their rates of
developing cardiovascular diseases over their lifetime. First, such an experiment would be seriously
problematic, as intentional exposure to conditions that may increase risk of disease is unethical. Also, in
this longitudinal research study, the lifespan of most laboratory-raised rats is approximately two years,
while the lifespan of humans is much longer, and people would need to be followed for 50+ years. If you
think that exposure to stress really isn’t that big of a deal and not that unethical, consider instead that
the IV manipulation is the amount of cigarette packs smoked daily, where individuals would be randomly
assigned to smoke one, two, or no packs of cigarettes daily over the course of their lives. Obviously
there are health concerns with this research methodology!
Much research is done using laboratory-raised rats and mice. However, there are fundamental
differences between humans and other animals, particularly when it comes to stressors and the stress
response. For example, as we all know too well, humans can activate a stress response merely by
thinking about a stressor. You may have experienced this situation yourself. You are lying in bed trying
to sleep, and your mind wanders to think about a conversation you had at a party last week. You
remember talking to Jesse, your crush. You couldn’t hear him properly, but he was asking you about
potential options for a date. You shout “I’d love to go to see that movie with you” at the exact moment
that the music stops. He blushes bright red and clarifies that he was asking whether your best friend
would be interested in going to the movies with him. Imagine lying there in the dark, days after the
party. You would likely experience all the symptoms of the stress response again—from the racing heart
rate to the fear and anxiety—by simply thinking about the past experience. Mentally replaying the
mortifying conversation between you and Jesse causes your body to mount a stress response that
prepares you to fight or flee from a giant predatory animal. And what you really want to do is go to
sleep!

Because of these unique human cognitive abilities, our perceptions of and responses to stressors are
complex. If you were going to study the effects of stressors on mental and physical health, how would
you do it?

[Link] Studying Stressors in the Real World (研究现实世界中的压力源)

One approach to studying stress in humans is to take a group of people who have been exposed to a
specific stressor and compare them with a group of people who have not been exposed to that stressor.
Caregiving is a real-life situation where the demands often exceed the resources available to cope, and it
is a real-world stressor that is commonly used in stress research. Examples of the types of caregiving
used in research are caregiving for a spouse or parent with dementia and caregiving for an ill child.
Caregiving stressors can include many factors that increase the risk of the stress being perceived as a
threat, including uncertainty, uncontrollability, and high levels of effort (Whittaker & Gallagher, 2019).
Other life stressors that are sometimes used in research include chronic unemployment, financial strain,
natural disasters, and test-taking. When using these real-world stressors in research, it is important to
examine their severity and duration. Clearly, even a similar stressor can have a very different level of
severity for two people depending on the individuals’ primary and secondary appraisals of the situation.
Caregiving for a child with influenza is very different than caregiving for a child who has a chronic and
life-threatening illness. Moreover, the duration of time that we are exposed to something makes a huge
difference to our response. Having a sick child for two days is entirely different than caring for a child
who is ill for years.
To understand relationships between exposure to real-world stressors and various outcomes in humans,
researchers conduct correlational studies. By studying people who have experienced some category of
stressor (e.g., caregiving) and measuring an outcome of interest (e.g., depression), we can learn the
degree to which one predicts the other. These stressors have strong content validity, meaning they can
fully reflect the stressors that humans experience. However, selecting people who are dealing with just
one specific stressor is impossible, and researchers must consider the fact that people have a range of
different kinds of stressors in their lives. Some of the people who are unexposed to the index stressor
(e.g., caregiving) could have lives that are filled with other kinds of stressors (e.g., financial strain,
domestic violence), whereas others may have fewer other stressors. Using a single index stressor fails to
account for this level of complexity.

Finally, an event that is threatening for one person may be challenging for another. For example, for
some people, caregiving for a parent with dementia may be highly demanding and exceed their coping
resources. For another, it could be a welcome opportunity to give back to a beloved parent. Thus, there
are many obstacles to conducting human research on specific stressors, as many people experience
multiple stressors and the perception of a particular type of stressor differs dramatically across different
people and cultures.
[Link] Measuring Stressors with Questionnaires and Interviews

Another approach to studying real-world stressors is to administer questionnaires or conduct structured

interviews that ask about exposure to various types of stressors, such as childhood stressors, adulthood
traumas, and chronic difficulties. Questionnaire measures include the Life Events Checklist, which
assesses exposure to a range of traumatic stressors across the whole lifespan (Gray et al., 2004); the List
of Threatening Experiences, which queries participants about 12 stressors involving at least moderate
threats (Brugha & Cragg, 1990); and the Childhood Trauma Questionnaire, which asks about exposure to
different kinds of stressors only in childhood (Bernstein et al., 1994). Structured interview measures of
stress include the Life Events and Difficulties Schedule (LEDS) and the Stress and Adversity Inventory
(STRAIN). While the LEDS is a measure that requires a one-on-one interview by a trained individual, the
STRAIN is an online measure that can be completed by a research participant alone (Slavich & Shields,
2018). Questionnaires and interviews can be used to assess a large variety of stressful situations that a
person experiences.
Asking people about their exposure to different types of stressors means that you can capture the
stressor history of a specific individual. This allows researchers to examine the effects of cumulative
stressor exposure on well-being, health, and other outcomes. There are some caveats with these
measures, however. First, questionnaire measures are open to interpretation by participants, who may
vary widely in their definition of a specific situation based on the brief description given in the
questionnaire. For example, one person might endorse an item about exposure to a natural disaster
based on experiencing a minor earthquake while another person might not count this. Second, both
questionnaire and interview measures may focus on only a small subset of the potential stressors that
someone can experience in their lifetime. Therefore, while we may capture the history of stressors for
one individual, we may miss critical stressors for someone else. Third, it should be noted that sometimes
life events that are presumed to be happy occasions, such as getting married or having a baby, are also
considered to be stressful experiences. Although babies can bring joy and love to a person’s life, having
a child can also be stressful in many ways. This can include increases in fatigue, changes in the mother’s
body and hormone levels, the circumstances of the birth (i.e., planned versus unplanned), age and
maturity level of the parent(s), the financial resources available, possible physical complications for the
mother or infant, and the possibility of postpartum depression. Such events are often omitted from
questionnaire and interview measures of stressors. Finally, health problems in themselves can increase
risk for other kinds of stressors. For example, someone’s physical health may prevent him or her from
working, which then leads to financial strain. As such, we may overestimate the effects of stressors on
health because we are focusing on relationships that go from health to stressor rather than relationships
that go the other way. Thus, when studying real-world stressors, we must be careful about
drawing causal conclusions about associations with other outcomes. We must always think about
whether the direction of causality can go both ways: from stressor to outcome and from outcome to
stressor.
[Link] Studying Stressors in the Laboratory

Although observational studies in humans can teach us important things about the stress response in
humans, experimental studies are needed to discover causal relationships. Understandably, however,
most people won’t agree to be randomly assigned to major life stressors, and, clearly, it would be
unethical to do so. To better understand stressors and the stress response, we need methods that allow
us to study stressors and their consequences under controlled conditions in the laboratory.

The Trier Social Stress Test is one of the most widely used paradigms in experimental stress research in
humans (Kirschbaum et al., 1993). In this paradigm, participants are exposed to the acute stressor of
delivering a speech and performing challenging mental arithmetic in front of an audience. An example of
the speech task is that you are asked to give a speech presenting yourself as the ideal applicant for a job
vacancy. An example of the mental arithmetic task is that you serially subtract 13 or 17 from a large
number such as 3,981 (Try this and imagine doing it in front of an audience. It looks easy, but it's not!).
The task includes an anticipation period of 10 minutes during which participants prepare for their
upcoming speech and a test period of 10 minutes during which they perform the speech for five minutes
and mental arithmetic for five minutes. An important aspect of this stressor task is that the evaluative
audience maintains neutral expressions throughout the task, and they give you only neutral feedback.
For most people, this increases the demands of the task quite considerably, and the paradigm is
remarkably successful at eliciting biological stress responses in humans.

Acute laboratory stressors have some significant advantages for studying the effects of stressors on
some outcomes. First, people can be randomly assigned to stressor exposure and no stressor exposure,
and the effects can be monitored in real time. This means that the causal effects of stressors and the
time course of these effects can be studied. Moreover, given that the objective characteristics of the
stressor are constant across individuals, these acute stressors also allow us to examine the effects of
people’s subjective perceptions on outcomes.

Despite the clear advantages of acute laboratory stressors, there are also disadvantages. First, although
the acute stressor tasks can be demanding, ethical considerations limit the intensity of the stressor an
experimenter may introduce during an experiment. Second, acute and chronic stressors appear to have
different effects on biological systems, and what is adaptive in response to acute stressors may not be
adaptive in response to chronic stressors. For example, while the healthiest response to acute stressors
is to elicit a robust inflammatory response, it appears that increased inflammatory activity in response
to chronic stressors is harmful. Finally, we cannot use these brief stressors to thoroughly examine the
effects of stressors on health because those effects usually emerge with repeated or prolonged
exposure and we are rightly restricted to exposing people to very few acute stressors for research. In
fact, from an ethical point of view, we could never randomly assign people to levels of stressors that
could cause health problems.
[Link] Studying Perceived Stress

As emphasized in challenge and threat theory, subjective perceptions of demands and resources are
central to understanding the effects of stressors. In fact, the same stressor can be viewed as threatening
for one person and challenging for another. Therefore, we must be able to measure perceptions of
stressors—both demands and the resources available to cope with those demands. One method that we
have for measuring perceived stress is self-reporting, or asking people about their perceptions of stress
on a questionnaire. The Perceived Stress Scale (PSS) is one of the most widely used measures in all of
health psychology (Cohen, 1988). Scores on this scale have been associated with risk for mental and
physical health disorders in many studies, as we will discuss later in this chapter. The PSS aims to
examine the extent to which people perceive their lives as unpredictable, uncontrollable, and
overloaded.

There are several advantages to questionnaire measures of perceived stress. First, they can directly
focus on perceptions of stressors, demands, and resources, thereby giving us an index of perceived
stress for an individual. Second, a well-designed questionnaire measure of perceived stress can be
both reliable and valid and easily completed by most people. Third, paper-and-pencil or electronic
measures can be added to large-scale studies at a relatively low cost, allowing for large sample sizes.
However, it is challenging to design a reliable and valid questionnaire that captures all aspects of
perceived stress. Moreover, people may misinterpret items or use their own prior history as an anchor
for their responses, such that they may report relatively less stress if they have experienced high levels
of stress in the past or relatively high levels of stress if they have experienced less stress in the past.
Finally, as with questionnaire measures of stressor exposure, measures of perceived stress are likely to
conflate stressor exposures and outcomes. For example, if someone is experiencing high levels of
financial strain that already impact their mental health, then the measure of perceived stress may
reflect both the stressor exposure and its impact and lead to exaggerated interpretations of any causal
relationship between perceived stress and mental health outcomes.
The video below is a talk given by neuroscientist Dr. Robert Sapolsky which illustrates the myriad factors
that influence human behaviour, including how we respond to stressors we encounter. He gives a high-
level overview of his research into the biological characteristics that drive our actions.

The biology of our best and worst selves | Robert Sapolsky - YouTube

16.4 The Effects of Stressors on Health (压力源对健康的影响)

Stressors can have powerful effects on our minds and bodies, activating biological stress responses and
changing the functioning of our immune systems. As we have discussed, stressors may enhance our
ability to survive and thrive as we face the inevitable challenges of life. Given all that you have learned
so far, you might feel somewhat reassured that your body is prepared to rapidly respond to any future
encounters with lions, tigers, or bears, but what about the longer-term consequences of psychological
stress? What happens when we face chronic or traumatic stressors, and our biological stress response is
activated repeatedly or at a very high level? Unfortunately, for some people, such exposures can greatly
increase risk for health issues. Among groups exposed to these stressors, mental and physical disorders
as well as early mortality are more prevalent, which means they are more commonly observed in
individuals who experience chronic or traumatic stressors versus those who do not.
16.4.1 The Diathesis-Stress Model (素质-压力模型)

One critical issue to consider when thinking about the effects of stressors on health is that not all
individuals exposed to the same stressors have the same outcomes. Some people are highly resilient in
the face of stressors, while others are more vulnerable to stressor-related ill health. One model for this
phenomenon is called the diathesis-stress model (Monroe & Simons, 1991; see Figure 16.7). The
American Psychological Association dictionary of psychology defines the diathesis-stress model as the
“theory that mental and physical disorders develop from a genetic or biological predisposition for that
illness (diathesis) combined with stressful conditions that play a precipitating or facilitating role.” In
other words, some people show vulnerability to the adverse effects of stressors because of genetic or
biological factors that put them at increased risk for negative outcomes. More recently, some
investigators have emphasized the upside of the diathesis, describing it as a plasticity factor rather than
a vulnerability factor (Belsky & Pluess, 2009). In other words, the diathesis is viewed as a differential-
susceptibility factor, such that the same people who might be most vulnerable to the negative impact of
stressors may be those who will benefit most from an enriched environment.

As you read through the next section, you should bear a few things in mind:

1. Increased risk is not determinism. In other words, the fact that stressors increase risk for ill
health does not mean that everyone who experiences stressors develops poor health.

2. There are several things we can do to enhance our resilience to stressors, even if we have a
diathesis. These factors will be discussed in Section 16.5: Reducing Stress and Enhancing
Resilience.

3. Many of the disorders that are more common in people exposed to stressors are rare. This
means that even if risk doubled for someone exposed to a specific stressor, their absolute
risk remains quite low.

4. When evaluating the evidence from studies about stress and health in humans, remember that
these studies are typically observational. It is never possible to randomly assign people to the
kinds of stressors that would cause psychiatric disorders. Observational studies cannot show
causal relationships, only associations.
 5. It is often difficult and sometimes impossible to control for confounding variables in
observational studies on stressors and health. In other words, other variables might account for
the associations between stressors and health outcomes, such as biological risk factors for
psychiatric disorders also predisposing someone to experience stressors.

Thus, although there is a wealth of evidence linking stressors with ill health, it is vital that you consider
the limitations of this evidence.
16.4.2 Stress and Mental Health

One of the major impediments to fully understanding mental health is that we don’t fully understand
the causes of psychiatric disorders (World Health Organization, 2002). In this context, it is particularly
important to note that psychological stressors are widely recognized as risk factors for the most
common psychiatric disorders (Carr et al., 2013). Psychological stressors (e.g., financial strain or
traumatic stressors) along with genetic predisposition have robust effects on the incidence of mental
disorders and mental health in general. Exposure to psychological stressors is one of the strongest
known risk factors for depressive, anxiety, behavioral, and substance-use disorders, and it is also a major
risk factor for schizophrenia (Rutter, 1985). Moreover, the psychiatric disorder post-traumatic stress
disorder (PTSD) only occurs following exposure to traumatic stressors (American Psychiatric Association,
2013).

The onset of major depression has a strong association with exposure to stressors (Kendler et al., 2003;
Kendler et al., 1999). Importantly, however, researchers have discovered that not all stressors have the
same impact. Stressors that involve social rejection are more likely than other kinds of stressors to elicit
an episode of depression (e.g., Slavich et al., 2010). In other words, you are far more likely to get
depressed after someone breaks up with you than when you break up with someone. Likewise, being
fired is much more likely to cause depression than being laid off as part of company-wide layoffs.
Other investigators have distinguished among four different types of stressors and examined their
association with risk for depression. Loss events are those involving loss of people, material possessions,
employment, health, or cherished ideas about the self or close others. Humiliation events are those
involving devaluation of the self in relation to others or the sense of self, including incidents involving
rejection or failure. Entrapment situations are markedly difficult circumstances of at least six months’
duration that are likely to persist or worsen. Danger events are those involving the potential for future
loss, including the possibility of traumatic events. In an extensive study of 7,322 male and female adult
twins followed over time, stressors involving loss and humiliation were associated with large increases in
risk for episodes of major depression, whereas entrapment situations and danger events were not
(Kendler et al., 2003). In the same study, life events involving loss and danger predicted risk for
generalized anxiety disorder, indicating that the effects of stressors go beyond depression to other
psychiatric disorders. Other studies have linked childhood and adult stressors with increased risk for
psychosis (Mansueto & Faravelli, 2017).
[Link] Childhood Stress and Psychiatric Disorders

When it comes to the effects of stressors on mental health, one of the most common findings is
that childhood stressors appear particularly harmful. People exposed to chronic and traumatic stressors
in childhood are about twice as likely to develop major psychiatric disorders than those not exposed to
such stressors (McLaughlin & Sheridan, 2016). The World Health Organization (WHO) initiated the World
Mental Health (WMH) Survey, which allowed researchers to examine the prevalence rates and
correlates of mental disorders around the world. Specifically, the effects of childhood stressors on
mental health were examined in a large sample of 51,945 adults (Kessler et al., 2010). Information on 12
childhood stressors and psychiatric disorders were collected across 21 countries, of which nine countries
had high incomes, six had high-middle incomes, and six had low or low-middle incomes. Interestingly,
exposure to at least one type of childhood adversity was pretty similar across the countries, with 38.4%
reporting at least one childhood adversity in high-income countries, 38.9% in high-middle-income
countries, and 39.1% in low-/lower-middle-income countries. Individuals who reported exposure to
childhood stressors were at significantly higher risk for psychiatric disorders, including mood, anxiety,
behavior, and substance-use disorders. This finding was consistent across the countries surveyed.

Childhood stressors that most strongly increased risk for psychiatric disorders were family violence,
abuse, and neglect, as well as parental history of substance use, mental illness, and criminality. These
kinds of stressors increased the risk for psychiatric disorders by 30–140% across the countries. Other
childhood stressors, such as parental divorce, death, and family financial hardship, also increased risk for
psychiatric disorders, but the risks were smaller, ranging from 10–50%. Overall, the data indicate that
childhood stressors are common, and they have substantial effects on adult mental health.
16.4.3 Stress and Physical Health (压力和身体健康)

Mental and physical health are deeply intertwined. At the same time that stressors increase the risk for
mental disorders, they also increase the risk for physical disorders ranging from short-term illnesses like
colds and the flu to chronic diseases like cardiovascular and autoimmune disorders (Cohen et al., 2019).
Have you ever powered through to complete assignments at the end of the term, anticipating a nice
relaxing vacation afterward, only to find that you were completely knocked out by a virus during your
downtime? There is a reason why several days of marathon paper writing and studying with little sleep
can increase your risk of getting the flu or some other illness. To understand the mechanisms underlying
this experience, read on!

[Link] Stress and Acute Illnesses (压力和急性疾病)

Acute respiratory illnesses such as the common cold (rhinovirus) and the flu (influenza) are annoyingly
frequent. The Centers for Disease Control and Prevention (CDC) tell us that adults experience two to
three colds per year, with children experiencing even more. Given that it takes seven to ten days to get
over a cold, this is about 21 days per year, and 210 days over 10 years! Although most people recover
fully from colds, they can greatly impact productivity in healthy people and have more devastating
effects on those with existing health problems. So, do stressors and perceived stress really impact our
risk for developing colds?
In one famous study published in the New England Journal of Medicine, Sheldon Cohen and colleagues
exposed 394 healthy people to five different common respiratory viruses (Cohen et al., 1991). The 394
participants ranged in age from 18 to 54 years. (Of course, all participants gave informed consent to the
experiment before exposure!) For two days before and seven days after being exposed to the virus, the
subjects were quarantined either alone or with one or two others. The researchers’ observations
confirmed what you might assume based on your own experiences: Those who had the highest scores
on an index of “stress,” based on exposure to stressors, perceived stress, and negative affect, had the
highest risk for developing clinical colds. In fact, those who were in the highest quartile (top 25%) on the
stress index had almost twice the risk for clinical colds compared to those in the lowest quartile (bottom
25%). Subsequently, in a similar study, researchers found that positive emotional style, which refers to
the general trait-like tendency to experience more positive emotions, was protective against developing
the common cold in their clinical trials (Cohen et al., 2006). Thus, stress and personality may impact our
risks for developing annoying short-term illnesses such as colds. This research is highly relevant in the
context of the coronavirus disease-2019 (COVID-19) pandemic when psychological stressors are much
more common than usual, and we are trying to avoid contracting a contagious virus. Researchers are
now focused on uncovering risk and resilience factors for contracting COVID-19, including psychological
factors.
[Link] Stress and Asthma (压力和哮喘)

People who have an existing disorder that has an episodic course may be particularly vulnerable to the
harmful effects of stressors. One such group are those with asthma. Asthma is one of the most common
diseases of childhood, occurring in about 8.4% of children and 7.7% of adults, according to the CDC.
Each asthma attack can contribute to missing school or work, the need for costly medications that can
have adverse side effects, and an increase in the number of visits to the emergency room or doctor’s
office. Over time, asthma attacks can cause permanent damage to the airways. Therefore, prevention of
asthma attacks is critical for the health of individuals who suffer from the disorder. In this context,
evidence that links stressors to increased risk for asthma attacks is clinically important.

To examine if stressors increase risk for asthma-related events, one approach is to measure both asthma
attacks and stressors in a group of people who have asthma. One such study of 90 children with
moderate to severe asthma aimed to uncover the relationship between stressors and asthma attacks
(Sandberg et al., 2000). Researchers had participants who were aged 6–13 years record their major life
events using diaries that included a record of severe stressors and major chronic stressors, both of
which were predicted to increase asthma attacks. Risk for asthma attacks was measured by assessing
daily peak flow, which is a measure of how well air moves out of your lungs, as well as self-report data.
They followed each child for between 10 and 26 months. During this time, 423 asthma attacks occurred
overall, with some children having no asthma attacks and others having as many as 21 attacks during the
monitoring period. Based on the diaries, the investigators created scores for the number of stressors
that each child experienced during the study. Statistical analyses then showed that greater exposure to
stressors increased the risk of having an asthma attack. Thus, a combination of chronic and severe
stressors may alter airway functioning and increase the risk for adverse events in asthma.
[Link] Stress and Latent Viruses

People who suffer from cold sores know they are painful, annoying, and difficult to treat. Cold sore
sufferers also often have the sense that their outbreaks occur most often during times when perceived
stress is higher. Are they right? Can stressors increase risk for cold sores as well?

Cold sores are caused by the herpes simplex virus-1 (HSV-1), which is an example of a latent virus that
stays dormant in nerve cells and then reactivates at varying intervals. Researchers Dr. Janice Kiecolt-
Glaser and Dr. Ronald Glaser at Ohio State University conducted groundbreaking work to further our
understanding of the relationship between psychological stressors and latent viruses. In one of their
early studies, they recruited a sample of first-year medical students who were facing final examinations
(Glaser, Kiecolt-Glaser, Speicher, & Holliday, 1985). These students donated blood samples one month
before their final examinations, on the first day of their final examinations, and again during their
summer vacation. These blood samples were used to measure antibodies to three latent viruses,
including HSV-1, Epstein-Barr virus, and cytomegalovirus. As you might predict, the students
experienced high levels of perceived stress during examinations and lower levels of perceived stress
during their summer vacation. The researchers additionally found that antibody titers to the latent
viruses varied across the time periods, with the highest concentrations occurring during examinations
and significantly lower levels occurring during the summer vacation. These findings indicated that the
examination stressor was associated with activation of the latent viruses.

[Link] Stress and Chronic Illnesses (压力和慢性疾病)

The studies we have reviewed above indicate that stressors might increase our risk for developing acute
illnesses, including colds, asthma attacks, and activation of latent viruses. Delving deeper, there are data
to support the effects of psychological stressors on risk for a whole host of major chronic diseases as
well, including cardiovascular disease (CVD) and autoimmune disorders.
Some of the most robust findings in the field of health psychology are related to the effects of stress on
CVD risk and outcomes. Some studies have linked major acute stressors with increased risk for CVD
events. For example, a large body of work suggests that risk of CVD events increases after earthquakes
(Dimsdale, 2008). Earthquakes are unexpected events that can be traumatic and are often threatening
to life or physical integrity. Studies conducted following earthquakes in Japan have shown that exposure
to earthquakes is associated with increases in blood pressure and blood viscosity (Matsuo et al., 1998)
and increased risk of pulmonary embolism (Watanabe et al., 2008). Meanwhile, one study completed in
Los Angeles indicated that there were increased rates of death attributed to CVD on the day of the
Northridge earthquake in 1994 (Leor et al., 1996). Unfortunately, determining the underlying causes of
these observations is often challenging because major earthquakes are often accompanied by a whole
host of negative events, including significant financial losses, lack of access to electricity that can lead to
changes in water consumption and diet, being evacuated from one’s home, and sleep disruption. Any of
these factors could contribute to CVD events, making it difficult for researchers to confirm a clear
connection between the stressor of the earthquake itself and any associated increases in risk of CVD
events.

Are there other short-term events that don’t come with all of these complicating factors? Believe it or
not, researchers have found links between major sporting events and CVD events. Some of the earliest
of these studies reported that fans were more likely to experience arrhythmias and even heart attacks
when their teams were playing important games in the soccer and rugby World Cups (Wilbert-Lampen
et al., 2008). Subsequently, researchers in the United States asked if the same phenomenon would take
place during the Super Bowl, a highly publicized and often highly charged sporting event. Their research
focused on two years when Los Angeles teams played in the Super Bowl, 1980 (LA Rams) and 1984 (LA
Raiders; Kloner et al., 2009). The researchers examined rates of death from all causes and cardiovascular
causes in LA County on the days when an LA team was playing in the Super Bowl and 14 subsequent
days and compared them to “control” days at the same time of the year when they were not playing. As
in previous studies, the researchers were particularly interested in whether the team won or lost made a
difference to outcomes. As predicted, the researchers found that deaths overall, including CVD-related
deaths, were significantly higher in LA County during the Rams' losing 1980 game. In contrast, during the
winning Raiders' 1984 game, there was a lower mortality rate in LA County. Despite these compelling
findings across countries and sports, some researchers have urged caution. Even when it comes to a
sporting event, there are potential confounds or factors beyond the stressor that could explain the
findings. For example, it is possible that people change their behavior during sporting losses, perhaps
drinking more alcohol or sleeping less.
In addition to the potentially harmful effects of major acute stressors, chronic stressors such as work-
related stressors, relationship problems, and social isolation can also be dangerous for cardiovascular
health. Numerous studies have shown that chronic stressors increase the risk of adverse cardiac events.
In one interesting study called the Whitehall study, researchers followed a group of 10,308 British civil
servants over a 14-year period and tracked their exposure to job-related stress along with the incidence
of metabolic syndrome, which is a known precursor to CVD. Their findings indicated that risk for
metabolic syndrome increased with the number of times a person was exposed to job-related stressors
(Chandola et al., 2006). These findings were supported by a meta-analysis of 14 prospective studies that
collectively included 83,014 participants. Their results indicated that high levels of job strain were
associated with a 40–50% increased risk of CVD (Kivimäki et al., 2006). Therefore, exposure to persistent
chronic stress may have long-term consequences for our cardiovascular health.
Autoimmune diseases are diseases that emerge when the immune system attacks cells of its own body.
Such diseases include multiple sclerosis, lupus, thyroiditis, rheumatoid arthritis, and inflammatory bowel
disorders such as Crohn’s disease and ulcerative colitis. We have already discussed that stressors have
profound effects on the immune system partly by increasing the levels of various stress hormones, but
could they also increase the risk of the immune system turning on an individual’s own cells? Evidence is
mounting that stressors may increase risk for these disorders.

One group of individuals who have experienced particularly high levels of exposure to traumatic and
chronic stressors are military personnel who served in Iraq and Afghanistan in the aftermath of the
World Trade Center attacks on September 11, 2001. Researchers have had the chance to examine the
effects of stressors on autoimmune disorders in some of these individuals who have left the military or
retired but receive their health-care from the Department of Veteran Affairs. One study of these
veterans examined whether the traumatic stressor-related disorder PTSD is associated with increased
risk for being diagnosed with autoimmune diseases, including multiple sclerosis, lupus, thyroiditis,
rheumatoid arthritis, and inflammatory bowel disorders (O’Donovan et al., 2015). Results indicated that
veterans with PTSD had about twice the risk of being diagnosed with one of the autoimmune diseases.
They additionally found that veterans who had been treated for military sexual trauma exposure had a
significantly higher risk for autoimmune disorders, even when adjusting for the effects associated with
PTSD. Therefore, it appears that PTSD or military sexual trauma alone increased the risk for developing
major autoimmune disorders.

There is also evidence that childhood stressors can increase the risk for autoimmune disorders. One
study that has been particularly informative about the effects of childhood stressors on physical health
outcomes is the Adverse Childhood Experiences (ACEs) Study, which was completed by an American
integrated managed-care consortium called Kaiser Permanente and the Centers for Disease Control and
Prevention. A sample of 15,357 adults reported their prior exposure to eight specific forms of stress in
childhood, including childhood physical, emotional, or sexual abuse; witnessing domestic violence;
growing up with household substance abuse, mental illness, parental divorce, or an incarcerated
household member (Dube et al., 2009). The total number of childhood stressors that were endorsed by
participants was used as a measure of cumulative childhood stressor exposure; these numbers were
then examined in association with the prevalence of autoimmune diseases. Investigators examined
participants’ prevalence rates for 21 different autoimmune diseases. What they found was that people
with greater than or equal to two ACEs had a 70–100% increased risk for different types of autoimmune
diseases. Although the research was correlational in nature, it appears that the degree of exposure to
extreme stressors in childhood is strongly associated with the development of autoimmune diseases in
adulthood.

Figure 16.9 below summarizes some of the different effects stressors can have on our physical health.
Click on the icons to learn about the effects of stressors on different parts of the body.
Figure 16.9: Stress can impact many different parts of the body. In this figure, the effects of stress on the
body are described, including effects on the brain (e.g., headaches, difficulty sleeping, increased
irritability, increased negative feelings, and increased risk for mental disorders), the heart (e.g.,
increased blood pressure and heart rate and increased risk for cardiovascular disease), the stomach
(e.g., nausea, vomiting, cramps), and the immune system (e.g., increased susceptibility to infection,
longer duration of infection and increased risk of autoimmune disorders). The physical manifestation of
stress can be varied and depend on an individuals' biological makeup and the level of stress that they
experience.
16.4.4 Pathways from Stress to Mental and Physical Disease (从压力到精神和身体疾病的途径)

One of the most important considerations when evaluating research is whether the relationship
between stressors and health outcomes are causal or merely correlational. If there are no plausible
pathways linking stressors with health outcomes, we would be more likely to think that the relationship
is due to other variables, such as genetics or common risk factors that increase the risk of both
experiencing stressors and ill health. In contrast, if we can identify plausible pathways by which stressors
could cause mental and physical diseases, we might be able to move toward enhancing health at the
population level by reducing exposure and adverse reactions to stressors. Identifying the causal pathway
from stressors to ill health is important for another reason: If we can uncover the pathway, we will be
closer to intervening to reduce the negative impact of stressors on health outcomes.
[Link] Inflammation (炎症)

Inflammation is central to our survival in situations involving physical injury and infection. However, it
also plays a critical role in the everyday functioning of our bodies: going to battle with viruses and
bacteria below the level of our conscious awareness, killing our own cells when they mutate, and
healing internal and external wounds. Not all inflammation is beneficial, however. While inflammatory
proteins play a crucial role in protecting us, they can also kill our own cells and cause harm to our
bodies. If the inflammatory response gets out of control, even for a short time, it can cause sepsis and
even death. As we age, levels of inflammatory proteins in our bodies slowly rise and are associated with
increased risk for chronic diseases. As the levels of inflammatory proteins rise over time, we develop
what is called chronic inflammation. As you age, you want this background of chronic inflammation to
increase as slowly as possible.

As we discussed in Section 16.2: What Is Stress?, our acute stress response includes a short-term
increase in inflammatory activity, which can protect us against the harmful short-term effects of
stressors that include risk for injury and infection. However, it appears that chronic and traumatic
stressors increase levels of inflammation in ways that are less helpful and actually harmful to us (Hänsel,
Hong, Cámara, & von Känel, 2010). In particular, chronic and traumatic stressors result in higher levels of
chronic inflammation, which in turn increase our risk for CVD and autoimmune diseases (Medzhitov,
2008). Moreover, a growing body of evidence indicates that inflammation plays a key role in the
functioning of the brain and can even contribute to psychiatric symptoms, including symptoms of
depression, anxiety, and PTSD (Miller & Raison, 2016). Thus, inflammation may be an essential
mechanism by which chronic and traumatic stressors increase risk for mental and physical ill health.

Which types of stressors are associated with chronic inflammation? Exposure to numerous types of
stressors has been associated with elevated inflammation. Separate studies have indicated that
childhood and adulthood stressors increase the risk for increased inflammation in later life. A meta-
analysis of 25 papers indicated that childhood trauma is associated with elevated levels of inflammatory
markers (Baumeister et al., 2016). Elevated inflammation has also been observed in association with
traumatic stressors experienced in adulthood, as well as with chronic stressors, including financial strain,
low socioeconomic status, and caregiving for relatives with dementia (Hänsel et al., 2010). In one study
of 11,198 older individuals, investigators found that childhood adversities and adulthood traumatic
stressors were independently associated with elevated levels of inflammation (Lin et al., 2016). Thus, it
appears that stressors in childhood or adulthood can alter levels of inflammation later in life.
[Link] Biological Aging (生物老化)

Biological aging is a complex phenomenon that remains incompletely understood. If we did fully
understand biological aging, there would likely be a major drive to make all of us immortal, and this
would come with a whole host of complicated ethical issues! One thing we do know is that as we grow
older, many cells in our body become functionally impaired and unable to divide to create new cells.
Eventually, this functional impairment and lack of cell renewal can cause a host of physical diseases that
we call diseases of aging, including cardiovascular and autoimmune diseases as well as
neurodegenerative diseases.

When searching for mechanisms of the effects of stressors on diseases of aging, researchers have
discovered that exposure to psychological stressors may actually accelerate the biological aging process.
The marker used most commonly in this stress and aging research is the telomere. Telomeres are DNA–
protein complexes that cap chromosomes and protect against damage to the DNA that encodes our
genes. Telomeres shorten over time, and the length of the telomeres in our immune cells predicts our
risk for a whole host of diseases of aging and death (see Figure 16.10). Longer telomeres are associated
with protection against disease and a longer lifespan. In 2009, Drs. Elizabeth Blackburn, Carol Greider,
and Jack Szotak won the Nobel Prize for their work on telomere biology. Thinking about stress-related
mechanisms of accelerated biological aging brings us once again to inflammation. It turns out that
chronic inflammation is an important mechanism of biological aging in general and of telomere
shortening in particular.
A groundbreaking study conducted by Drs. Elissa Epel, Elizabeth Blackburn, and others linked
psychological stress with telomere length for the first time in 2004 (Epel et al., 2004). The sample for the
study included 58 healthy pre-menopausal women who were biological mothers of either a healthy child
or a chronically ill child. Perceived stress and immune cell telomere length were measured in all of the
mothers. There were no significant differences in telomere length between the groups of mothers with
healthy versus chronically ill children. However, some of the mothers had very young children, and the
researchers reasoned that the duration of caregiving might be an important factor in any effects of
caregiving stress on telomere length. The data supported this line of reasoning, showing that a longer
duration of caregiving for a chronically ill child was associated with shorter telomere length. Moreover,
across all the women, higher levels of perceived stress were associated with shorter telomere length.
These data indicate for the first time that psychological stress may accelerate the rate of biological
aging. Since the publication of Dr. Epel’s research on the connection between stressors and telomere
length, numerous papers and some meta-analyses have replicated the finding, linking perceived stress
as well as exposure to chronic and traumatic stressors with shorter telomere length (Mathur et al., 2016;
Ridout et al., 2018). Overall, this work indicates that the stressors we experience may be associated with
the aging of our bodies.
16.5 Reducing Stress and Enhancing Resilience (减轻压力和增强复原力)

We have talked a lot about the negative impact of stressors on health outcomes. We have examined
evidence indicating that people exposed to chronic and traumatic stressors are at higher risk for mental
and physical disorders, and we have discussed some mechanisms by which stressors may cause ill
health. Are there ways to protect ourselves from the negative impacts of psychological stressors? In this
final section of the chapter, we will focus on revealing these stress-busting superpowers. These factors
can have two different types of effects. First, they can have direct effects on health outcomes. In other
words, they are health enhancing for everyone, regardless of whether a person is exposed to stressors
or not. Second, they can have stress-buffering effects, which means they specifically enhance resilience
to stressors.

What happens to your lifestyle when you experience stressors? Do you tend to “stress eat” sugar and
carbohydrates and exercise less? Or do you turn to alcohol or illicit drugs to try to cope with the
negative feelings that emerge following the stressors? Does your sleep suffer, either because you don’t
have the time to get the sleep you need or because you suffer from insomnia and lie awake feeling
frustrated as you struggle to manage negative thoughts and feelings? For most people, stressors come
with impairments in lifestyle factors associated with health. When it comes to protecting ourselves from
the harmful effects of stressors, the number one strategy is to maintain a healthy lifestyle. But what is a
healthy lifestyle when it comes to resilience to stressors? Five factors stand out as particularly (super)
powerful in protecting us from the negative effects of stressors; physical activity, sleep, diet, social
support, and engaging in active relaxation practices.
16.5.1 Physical Activity (身体活动)

College campuses all over the United States have people who are opposites in terms of their physical
activity. You may recognize yourself in one of these groups, or you may be in between them. There are
those who lay out running gear at night before going to sleep, waking at 5.30 a.m. to head to the
running track, embracing the burn as they complete lap after lap before heading to class. There are also
those who don’t even own running gear and who are much more likely to be found playing hooky than
basketball. Those in the former group are likely to be enhancing their health overall, and specifically
enhancing their resilience to stressors.

The American Heart Association highlights that people who maintain an active lifestyle have lower death
rates than sedentary people, even when they have CVD risk factors such as high blood pressure, high
cholesterol, diabetes, or confirmed heart disease. For example, relative to normal-weight fit individuals,
unfit individuals have twice the risk of mortality regardless of weight factors such as body mass index
(Barry et al., 2014). Physical activity is not just beneficial for physical health, however; it also decreases
risk for mental health problems. Using data from the Harvard Alumni Study, researchers found that
physical activity protected men from physician-diagnosed depression over 23–27 years of follow up
(Paffenbarger et al., 1994).
While physical activity appears important for health outcomes for everyone, it might be particularly
important in the face of stressors. For example, one study indicated that the strength of the relationship
between stressor exposure and mental and physical health outcomes was reduced in physically active
compared to inactive people (Kobasa et al., 1982). In other words, maintaining physical activity in the
face of stressors may protect us from some of the adverse effects of stressors on health. However, given
that this is again an observational study, it is also possible that people who can remain physically active
when experiencing stressors are protected from poor health outcomes because of other, unmeasured
factors.

One pathway from physical activity to better outcomes in the face of stressors is that it can actually
change how our bodies respond to stressors in our daily lives. Physical exercise impacts the stress
response itself and may make our autonomic nervous systems and hypothalamic-pituitary-adrenal axes
more resilient to acute stressors (Rimmele et al., 2007). Moreover, it appears that maintaining a
physically active lifestyle may protect us from the accelerated biological aging associated with chronic
perceived stress (Puterman et al., 2010). Remember, however, that other explanations may also be
possible. For example, perhaps only individuals who maintain their physical health in the face of
stressors are able to stay physically active. Moreover, physically active people may differ in many ways
from people who are not physically active, not just in their levels of physical activity. For example,
people who maintain a physically active lifestyle tend to have different personalities than those who are
physically inactive. In fact, a meta-analysis of 64 studies indicated that physically active people tend to
differ on the Big Five personality traits, showing higher levels of extraversion, conscientiousness,
openness, and agreeableness, and lower levels of neuroticism (Wilson & Dishman, 2015). In turn, the Big
Five personality traits may influence health through numerous pathways, not only physical activity
(Strickhouser et al., 2017).

In sum, physical activity helps protect us against poor mental and physical health outcomes. Some of the
pathways to such protections may include buffering against the damaging effects of both chronic and
acute stressors on biological systems. However, we must be cautious when interpreting the results of
observational studies linking physical health with health outcomes, because health may influence our
ability to be physically active and physically active people may differ in many ways from physically
inactive people.
16.5.2 Sleep

Another pathway to better health in the face of stressors is to maintain a healthy sleep schedule. Sleep
is highly beneficial for health, and good sleep is associated with better overall physical health, better
metabolic health, lower risk for obesity, lower risk for chronic and acute diseases, lower levels of
inflammation, and longer telomere length (Buysse, 2014). Thus, maintaining a healthy sleep schedule in
the face of stressors may be highly beneficial for your health.

However, the definition of “good sleep” is complicated. First, it’s not merely about sleeping for longer
periods. Large-scale studies repeatedly find that both sleeping too little (less than six hours) and sleeping
too much (more than nine hours) are associated with health problems. However, most of these studies
are observational and cross-sectional, and it is possible that poor health causes longer sleep rather than
vice versa. Second, you may know someone who only needs to sleep six hours a night to feel awake and
refreshed, whereas you may need a minimum of nine hours to feel functional. Why the difference? One
factor is that some individuals are more efficient sleepers, meaning that they go into the important
stages of sleep more quickly and stay in those phases longer. As you know from Chapter 6: States of
Consciousness, humans need both deep sleep where our brainwaves are exclusively delta waves (i.e.,
stage 4 sleep) and REM sleep to feel refreshed and restored. Third, the amount of sleep one needs
decreases with age: A newborn baby requires approximately 16 hours of sleep (although these are not
consecutive hours, much to the dismay of many new parents), while your 75-year-old grandmother
needs an average of approximately 5 hours of sleep. Sleep quality can also be affected by the presence
of parasomnias and other sleep disorders.
We probably don’t need to tell you that stressors can impair sleep, reducing the ability to acquire one of
the key stress-busting superpowers. It is the rare person who has not experienced difficulty sleeping in
the face of stressors. To consider one example, imagine you are facing a major exam. You have studied
hard and finally get to a point where you are ready to sleep so that you’ll have enough energy for your
exam the next day. You feel exhausted from studying so hard for so long, you are yawning at your desk,
and you can barely keep your eyes open. However, as soon as your head hits the pillow, you find
yourself wide awake, full of anxious thoughts and unable to sleep! If it’s any consolation, you are not
alone. Others also struggle to sleep when facing exams. In particular, exam stressors have been linked
with longer sleep latency, which is a measure of how long it takes to fall asleep, and worse sleep quality
(Jernelöv et al., 2009). However, getting a good night’s sleep is important before taking an exam, since
sleep plays a vital role in the consolidation and encoding of the course material you studied. A good
wind-down routine and a clear break between study sessions and sleep can help to ease the transition.

What happens to you after a night of poor sleep? Are you better or worse at dealing with stressors the
following day? Are you more likely to have a meltdown about some minor stressor? Researchers believe
that sleep plays a vital role as a restorative process that allows us to resolve intense emotional
experiences. Accumulating data support the idea that sleep allows for restoration and healing in the
brain (Xie et al., 2013). People who are sleep deprived are more likely to have a negative response to
stressors and may be more sensitive to psychological stressors than their well-rested counterparts. In
fact, adolescents with sleep disturbance and poor sleep efficiency experience higher levels of depression
than adolescents without sleep disturbance when exposed to family-related stressors (Chiang et al.,
2017). Knowing the damaging effects of sleep loss, it makes you wonder why so many businesses want
their employees to put in long hours. Having a more well-rested group of employees likely has many
advantages.
16.5.3 Diet

What happens to your dietary intake when you are exposed to stressors? Do you eat more or less? Do
you think that the stressors you have experienced have impacted your weight? If so, did they increase or
decrease your weight? Ideas about “stress eating” and “comfort foods” are widely seen in the media.
“Emotional eating” is often touted as one of the main reasons why weight loss efforts fail. Therefore,
you may be surprised to hear that studies on rodents indicate that stressors most often lead to
decreases in food intake! In fact, rats and mice lose weight when exposed to stressors in the laboratory
(Dallman et al., 2003). Research shows that humans may also decrease their food intake when exposed
to stressors. For example, one study of U.S. marines found that they ate less than usual on the first day
of combat (Popper et al., 1989). Although lack of time was reported to be the most common reason that
the marines decreased their food intake in this study, fear was also reported as playing an important
role.
Are the media and dieting gurus simply wrong? Do stressors only decrease our food intake? It may not
be as simple as that. Mary Dallman and colleagues made considerable strides in our understanding of
stress and eating at her laboratory at the University of California, San Francisco, where she conducted
studies on rodents. It turns out that the “type” of food may be of critical importance when we consider
whether psychological stressors increase or decrease food intake. Studies in the Dallman laboratory
showed that rats exposed to stressors eat more food, but only if the food offered to them is high in fat
or sugar content. In other words, they tended to eat more of what we humans call “comfort foods.”
Such types of food can down-regulate the stress response, dampening activity in the HPA axis and
reducing levels of cortisol (Dallman et al., 2003). Thus, eating comfort foods rich in fat and sugar may
actually work to decrease the stress hormone cortisol, which we know plays a fundamental role in the
stress response and the negative impact of stressors.

So what typically happens in humans who, unlike rats, create their menus from a wide array of foods
available in supermarkets? Because we typically can’t randomly assign humans to specific diets as in the
experimental studies Dallman conducted with her rats, one strategy for examining the long-term dietary
effects of stressors in humans is to examine effects on weight or body mass index (BMI). If stressed,
people eat food rich in fat and sugar to reduce stress responses; therefore, one would expect to see
their weight increase over time more than less stressed people. Large-scale studies have shown this to
be true: Higher BMI and obesity levels are found in highly stressed populations (Tomiyama, 2019).

In an attempt to uncover mechanisms of this link between stress and weight gain, researchers have
examined if eating reduces stress responses to acute stressors in the laboratory. In one such study,
researchers at the University of California, Los Angeles, exposed 150 women to an acute stressor in the
laboratory. They then offered them no food, healthy food, or unhealthy food during their stressor.
Results indicated there were no effects of food type on cortisol responses to the acute stressor
presented in the laboratory, casting doubt on whether the findings from Dallman’s rats apply to humans
(Finch et al., 2019). However, the laboratory stressor was relatively mild and short lived. More research
is needed to examine if comfort eating reduces stress responses and cortisol levels outside of the
laboratory in the context of more severe acute stressors or chronic stressors.
In sum, it appears that stressors and high levels of perceived stress may impact eating behavior and
weight gain. While rat research indicates that high-fat and high-sugar comfort foods may dampen the
stress response, research in humans does not yet support this hypothesis. Given that overweight and
obesity are major risks for ill health (Dixon, 2010), the long-term consequences of stress eating may be
dire.

16.5.4 Social Support

Humans are social animals. The “social brain” hypothesis proposes that humans and other primates
evolved relatively large and metabolically expensive brains to navigate the complex social networks in
which we operate (Dunbar, 1998). In fact, people with stronger social relationships have a 50% higher
likelihood of survival compared to those with weaker social connections (Holt-Lunstad et al., 2010). This
effect is similar in size to effects associated with widely recognized health risks, including smoking and
alcohol consumption. Additionally, the benefit of social networks for longevity is more significant than
other factors that affect mortality, including level of physical activity and weight. As such, when it comes
to your health, pursuing close ties with family and friends may be as important as avoiding smoking and
more important than going to the gym.
How do our social relationships exert such powerful effects on our health? As with the other stress-
busting superpowers, social support seems to exert strong effects on inflammation and biological aging.
Numerous studies have now documented that people who are more socially connected have lower
levels of inflammatory proteins. Social integration is an index of how strong our ties to family, friends,
religious groups, and broader communities. Some of the most robust findings link social inclusion with
lower levels of inflammatory markers (Kiecolt-Glaser et al., 2010). Marriage seems particularly
beneficial, with older men who were married showing significantly lower levels of the inflammatory
marker C-reactive protein (CRP) in the population-based National Social Life, Health, and Aging Project
(Sbarra, 2009). In fact, married older men had a reduction in risk for high CRP comparable to that
associated with having normal blood pressure or BMI or not smoking.

Could it be that our complex social networks serve a critical purpose in the face of stressors? Our social
ties can provide various kinds of support. These include emotional, instrumental, informational, and
appraisal support.

 Emotional support refers to expressions of empathy, love, and caring when someone is
experiencing stressors or high levels of perceived stress.

 Instrumental support includes tangible help, such as offering to take notes for someone who
misses a class or bringing food to a friend who is dealing with a crisis.

 Informational support comprises the advice and information that people give us to change the
impact of a stressor. For example, learning new study techniques from a classmate may reduce
your perceived stress about a challenging college course.

 Appraisal support refers to help evaluating the demands of a situation and the resources
available to cope with it. You receive appraisal support when someone helps you clarify the
actual requirements of a class and the various sources of information you can use to help you
study.

Mechanisms by which different types of social support may enhance our resilience to stressors include
reduced acute biological and psychological responses to stressors, as well as reduced levels of resting
inflammation and a slower rate of telomere shortening (Glaser et al., 2010).

There’s a flip side to our social relationships, however. Social rejection is itself a stressor that seems to
have a host of negative effects, ranging from activating biological stress responses to increasing
inflammation and accelerating biological aging (Slavich et al. 2010). Moreover, relationship problems are
bad for us, both mentally and physically. For example, relationship breakups are a strong risk factor for
depression (Kendler et al., 2003). When it comes to physical health, relationship issues can also impact
our health behaviors. In a sample of 38,865 men, being divorced or widowed was associated with
increased alcohol consumption and decreased BMIs, but also decreased vegetable intake (Eng et al.,
2005). Thus, our social relationships may have powerful effects on our mental and physical health. So,
when it comes to your health, choose your friends and romantic partners wisely!
16.5.5 Active Relaxation (主动放松)

When we think about relaxation, we usually think about our leisure activities, like watching a movie,
going to a spa, or maybe even engaging in physical activity. However, methods have been developed
that actively elicit a relaxation response. One of the most influential and common of these methods is
mindfulness. Mindfulness is one specific kind of meditation practice (Ludwig & Kabat-Zinn, 2008). It is
characterized by a focus on the present moment and a nonjudgmental and accepting approach to one’s
thoughts and feelings. When engaging in mindfulness meditation, you might be asked to focus on your
breath and to allow your thoughts and feelings to arise without judging or focusing on them. The roots
of mindfulness are in Buddhism, where it is practiced with the goals of cultivating compassion and
alleviating suffering. However, the practice requires no specific religious or metaphysical beliefs. Ludwig
and Kabat-Zin (2008) propose that mindfulness has the potential to decrease pain perception; increase
pain or disability tolerance; reduce negative feelings and psychological symptoms; lower the need for
medications; enhance medical decision making; improve adherence to medical treatments; increase
motivation for lifestyle modifications; improve social relationships; and reduce biological stress
reactivity.
If mindfulness can indeed have such potent effects on so many outcomes related to health, we would
expect to see substantial benefits on the health of those who practice mindfulness. Indeed, a review of
empirical studies concluded that it could bring about enhanced subjective well-being, reduced negative
psychological symptoms, decreased emotional reactivity to stressors, and improvements in behavior
regulation (Keng et al., 2011). In addition, a meta-analysis that summarized the results of 20 studies on a
total of 1,605 participants concluded that the specific mindfulness training program called mindfulness-
based stress reduction (MBSR) has benefits for both mental and physical health (Grossman et al., 2004).
The included studies were both experimental, involving random assignment, and observational,
involving analysis of data on people who were and were not engaged in MBSR. The studies covered
numerous populations, including people with chronic pain, cancer, cardiovascular disease, and
psychiatric disorders. MBSR was beneficial in improving quality of life and reducing negative
psychological symptoms such as depression and anxiety. Also, MBSR enhanced physical health as
indexed by medical symptoms, pain perception, physical impairments, and functional quality of life.
Based on the data we have discussed so far, mindfulness may be a powerful tool to manage life
stressors. However, it is worth noting that a review of the mindfulness literature revealed evidence
of publication bias (Coronado-Montoya et al., 2016). Specifically, the authors reported that there were
more positive findings in the literature than would be expected. Additionally, bias in the literature may
also be a function of the “file drawer phenomenon,” where research without statistically significant
findings is not published. Thus, caution must be advised when interpreting these data. Although
mindfulness may not be the cure-all some practitioners might want it to be, it may be one active
approach that can help reduce the impact of stressors on your health.
16.6 Summary

In this chapter, you learned:

 The word “stress” is used to refer to a wide range of concepts ranging from external
environmental stimuli to internal emotional experiences and bodily responses. Precise
terminology is needed in order to make progress in our understanding of stress.

 When thinking about definitions of stress, one of the most important distinctions to make is
between “good stress”, which is sometimes called eustress, and “bad stress”, which is
sometimes called distress. Whereas eustress is beneficial for us, motivating us to work to
achieve our goals and even enhancing our functioning, distress can reduce motivation and
impair functioning.

 Stressors are external circumstances and stimuli that are perceived as having the potential to
disturb an individual’s balanced state. Stress responses are internal integrated psychological and
biological responses to stressors that work to restore a balanced state.

 We can distinguish among stressors based on how long they last and their level of severity.
Acute stressors last minutes to hours and chronic stressors last weeks to years. Acute and
chronic stressors can vary in severity from mild to moderate to severe. Traumatic stressors are
severe and involve a threat to your own, or another’s life or physical integrity.

 Homeostasis is the word used to describe the state when we are in balance (Cannon, 1939).
Stressors disturb homeostasis, and the stress response aims to restore homeostasis.

 Brain areas, including the amygdala, hippocampus, and prefrontal cortex, play a critical role in
activating and regulating the stress response.
 The autonomic nervous system (ANS) and the hypothalamic pituitary adrenal (HPA) axis are
rapidly activated are biological systems that produce specific hormones that can travel
throughout our bodies to coordinate and regulate our responses to a stressor.

 The ANS includes two major branches, the sympathetic nervous system and the
parasympathetic nervous system, which can work together to maintain homeostasis through a
process in which the activation of one system can suppress the other.

 The fight-or-flight response is the bodily response that allows animals to run or flee from
perceived stressors (Cannon, 1939). Activity in the ANS and HPA and release of stress hormones
called catecholamines and cortisol prepare the cardiovascular, respiratory, and digestive
systems to deal with a perceived stressor.

 Research has revealed that even everyday acute stressors can activate the inflammatory
response of the immune system, which allows for the killing of any foreign invaders such as
viruses and bacteria as well as healing of bodily tissue.

 Most theories of psychological stress emphasize “perceptions” in the definition of stressors. In

other words, stress is defined “in the eye of the beholder”. For example, “Stress and Coping
Theory” defines stress as the perception that demands exceed your ability to cope (Lazarus &
Folkman, 1984).

 Primary appraisals are based on your perceptions of stressor characteristics and of how much
demand it represents, as well as its relevance for you. Secondary appraisals are based on your
perceptions of the resources available for coping for a specific stressor.

 Challenge and Threat Theory (Blascovich & Mendes, 2010) distinguishes between challenges,
defined as situations in which resources exceed the demands of the situation, and threats,
defined as situations in which demands exceed the resources available for coping.

 Approaches to studying stressors include examining the effects of specific real-world stressors
such as caregiving, measuring stressors with questionnaires and interviews, exposing people to
standardized acute stressors in the laboratory, and measuring perceived stress using
questionnaires.

 Diathesis-stress models emphasize that mental and physical disorders develop from a genetic or
biological predisposition for that illness (diathesis) combined with stressors.

 Exposure to psychological stressors is one of the strongest known risk factors for the most
common psychiatric disorders, including depressive and anxiety disorders. Stressors
experienced in childhood may have the greatest impact on our risk for psychiatric disorders.

 Stressors also increase risk for physical health disorders ranging from short-term illnesses like
colds and flus to chronic diseases like cardiovascular and autoimmune disorders.

 Chronic inflammation may play a role in the relationship between stressor exposure and risk for
major psychiatric and physical health disorders. Severe and prolonged stressors appear to
increase chronic inflammation, which in turn contributes to the development of chronic
psychiatric and physical health disorders.
 Exposure to psychological stressors may also accelerate the biological aging process. The
markers used most commonly in this stress and aging research are telomeres, DNA-protein
complexes that cap the ends of our chromosomes and protect against damage to our genes.

 Maintaining a healthy lifestyle can protect us from the adverse effects of stressors; the number
one strategy is to maintain a healthy lifestyle. Specifically, being physically active, getting
adequate sleep, maintaining a healthy diet, maximizing our social support, and engaging in
active relaxation practices may enhance our resilience to stressors.