Stress and Illness

Glenn A. Melvin PhD

Readings
Introduction to Health
Psychology in Australia
Morrison et al (Eds)
Chapter 11 - Stress, health
and illness: theory
Chapter 12 - Stress and
Illness Moderators

Concept of stress
Elusive!
3 approaches to studying stress
Stress as an external stimulus
Stress as a transaction between
the external event and the
individuals reaction
Stress as an internal physiological
reaction

Stress as an External Stimulus

Stress is any outside force or event that has an
effect on our body or mind
Effects can be physical or psychological
Stress results from various events/demands
Different events stress different people
Typical events:
Work pressures
Interpersonal conflict
Financial pressure
Family problems

Marriage
Divorce
Moving House
Changing job

Deaths
Major events
Public speaking
Children

Holmes and Rahe Life Events Theory

Tried to measure the effect of various external
events and relate them to health
Started by generating a list of stressful events
from 5000 participants
Then got subjects to rank them
Then asked subjects to score against marriage
(score 500), divorce (score 1000)
Then developed social readjustment rating scale

Social Readjustment Rating Scale

(>200 per year increase risk)
Life Event
Death of Spouse
Divorce
Marital separation
Jail term
Death -family member
Personal injury/illness
Marriage
Fired at work
Marital reconciliation
Retirement

100
73
65
63
63
53
50
47
45
45

Ill-health in family member

Pregnancy
Sex difficulties
Gain of new family member
Business readjustment
Change in financial state
Death of close friend
Change job
Vacation
Christmas

44
40
39
39
39
38
37
36
13
12

Stress as a Transaction
This psychological model
considers not only the nature
of the stress, but the nature
of the person who
experiences the event.

Appraisal Affects the Stress Response

Primary Appraisal how the subject
appraises the event (harm, threat, challenge,
benign)
Secondary Appraisal how the subject
appraises their own resources and ability to
cope. Later also added the emotional
element how the persons emotional
response influences their appraisal e.g. a
loss event causes sadness, a threat event
causes anxiety.

STRESS

RESOURCES < DEMANDS

Factors Influencing Appraisal

The timing how soon; is it at an expected time in
life?
Predictability of the event (e.g., course of an
illness)
Perceived control
Amount of life change required (e.g. having a
baby)
Extras mental state, anxiety, previous events

Stress as an Internal
Physiological Reaction
The final way to study stress is to study how the
body responds
Once a stress is perceived by the Central
Nervous System, a complex array of physiological
events occur that prepare the body to handle the
stress
Mainly involves the Autonomic Nervous System
and the Neuro-endocrine system

Autonomic Nervous System

The ANS is part of the peripheral nervous system,
and it acts to control many unconscious bodily
function, such as heart rate, digestion, respiration
rate, salivation, perspiration, diameter of the
pupils, micturition (urination), and sexual arousal.
It is classically divided into two subsystems: the
parasympathetic nervous system and
sympathetic nervous system
The SNS and the PNS act in harmony to control
functions, the SNS is like the accelerator and the
PNS the brake

SNS acute response to Stress

Promotes a "fight or flight" response, corresponds with arousal
and energy generation, and inhibits digestion.
Diverts blood flow away from the gastro-intestinal (GI) tract and skin
via vasoconstriction.
Blood flow to skeletal muscles and the lungs is not only maintained,
but enhanced (by as much as 1200% in the case of skeletal
muscles).
Dilates bronchioles of the lung, which allows for greater alveolar
oxygen exchange.
Increases heart rate and the contractility of cardiac cells (myocytes),
thereby providing a mechanism for the enhanced blood flow to
skeletal muscles.
Dilates pupils and relaxes the lens, allowing more light to enter the
eye.
Provides vasodilation for the coronary vessels of the heart.
Inhibits peristalsis.

PNS gets things back to normal

Promotes a "rest and digest" response, promotes calming of
the emotional responses, return to regular function, and
enhances digestion.
Dilates blood vessels leading to the GI tract, increasing blood
flow. This is important following the consumption of food, due to
the greater metabolic demands placed on the body by the gut.
Constricts the bronchiolar diameter when the need for oxygen
has diminished.
Constriction of the pupil.
Stimulates salivary gland secretion, and accelerates peristalsis,
so, in keeping with the rest and digest functions, appropriate
PNS activity mediates digestion of food and indirectly.

Cox & Mackay Transactional Model of Stress

BEHAVIOURAL
REACTIONS

EXTERNAL
EVENTS

Insult
Assault
Frustration
Demand

COGNITIVE
PROCESSES

Aggressive
Escape or avoidance
Problem Solving

Appraisal of
threat
Expectations
of coping or
not and
consequences

EMOTIONAL
REACTIONS
Usually
anxiety

PHYSIOLOGICAL
REACTIONS
Autonomic response

The impact of stress

1. ORGANISATIONAL EFFECTS:
Burnout, low morale, low performance, poor
working relationships, absenteeism, high
turnover, job dissatisfaction, high use of
health facilities, accidents,

What stress does to you

2. BEHAVIOURAL EFFECTS:
Drug use, alcohol, smoking, overeating,
appetite, impulsive/aggressive outbursts,
accident proneness, restlessness,
blaming others, withdrawal, isolation..
3. COGNITIVE EFFECTS:
Concentration, task performances,
defensiveness, mental blocks,
sleepiness, focus on details.

What stress does to you

4. EMOTIONAL EFFECTS:
Anxiety, anger, boredom, depression,
fatigue, frustration, irritability, moodiness,
tension, nervousness, self-hate, worry .

What stress does to you

5. PHYSICAL EFFECTS:
Imbalance including blood glucose, heart
rate, bp, breathing, (allostatic load)
Numbness, tingling, physical pain,
fatigue, medically unexplained symptoms
Result: damage to organs, chronic
disease, death

Types of Stress
Acute Stress
Cataclysmic
?PTSD
Routine e.g.
exams

Chronic
e.g. work stress

Cataclysmic
Big events initially cause panic, anxiety,
withdrawal, anger, disorientation, sleep
disturbance, eating problems
Can increase risk of mental illness including PostTraumatic Stress Disorder
Flashbacks and reliving
Avoidance
Hyperarousal

Acute Stress
Your anxiety can affect your
performance in exams
The Yerkes-Dodson Law there is an
optimum level of arousal necessary to
maintain attention and memory, too
much and you deteriorate, too little
and you dont perform

Chronic Stress
The work place is the commonest site to
study chronic stress
Chronic stress leads to burn out
What makes work stressful?

Demand
Controllability
Predictability
Ambiguity

The Stress & Illness Link!

Direct Route - direct physiological changes in the
endocrine and immune system
Indirect Route
Via responses to stress such as smoking, drinking
and eating
Via the manner in which people respond to stress
(via personality)
Via increase use of health resources

But
everything bad in human health now is not
caused by stress, nor is it in our power to cure
ourselves of our worst medical nightmares merely
by reducing stress and thinking healthy thoughts
full of courage and spirit and love. Would it were
so. And shame on those who sell this view.
Sapolsky, 1994

Stress and Heart Disease

Stress changes heart rate and vessel constriction
via the SNS, which in theory can alter rate of
vessel damage
Stress is associated with hypertension, and
smoking
Stress reactivity thought to contribute to rates of
heart disease
Depression has stronger links

Stress and Bowel Disease

Stress has been associated to varying degrees
with most bowel diseases
Strong association with Irritable Bowel Syndrome
Less so with Inflammatory bowel disease
(Ulcerative Colitis, Crohns Disease)

Stress and Multiple Sclerosis

Acute stress has a small impact on acute
relapses (but not chronic stress) and vice versa.
Stress management > wait-list control
number of new lesions (MRI) during 24 week
treatment but effects were not sustained after
treatment (Mohr et al. 2012, Neurology)

Factors that modify the impact of stress on

health
Health
Stress

factors

Factors

Social Support
Coping
Personality
Locus of Control
Depression/Anxiety

Social Support
Definition
Types
Emotional
Esteem
Instrumental
Information
Network

Effects of Social Support

Mortality
Heart Disease Orth-Gomer, Unden and Edwards
1988

Overall House 1982

IHD, cancer, stroke Vogt 1992
Elderly, Giles 2005

Lots of friends 0.78 likelihood of mortality over 10 years

Friends vs Relatives and children

Effects of Social Support

Disease
AMI Rosengren 93
Rheumatoid Arthritis Evers 2003
Breast Cancer in at risk women Price 2003

Effects of Social Support

How does social support work?
Direct effect theory
Healthier lifestyle
Decreased physiological reactivity
? Immunity and endocrine effects

Buffering theory
Changes ones appraisal and coping responses

Effects of Social Support

High practical SS in pain patients may deskill
Gil 85

Type of support and how it is received is

important

Coping
What a person does to reduce the impact of a
perceived stressor
Decrease negative emotions
Alter the stressor directly
Eg: relationship break-up

Classification of coping strategies

Adaptive
Maladaptive

Coping Strategies
Individual coping with chronic conditions varies:
Cognitive responses
- helplessness: emphasis on negative aspects, increased disability
- acceptance: decreases negative cognitions
- perceived benefit: adds optimistic meaning to the condition

Controllability
Efficacy/self-efficacy
Optimism
Problem vs emotion-focused coping

Coping Maladaptive Strategies

Alcohol to excess
Violence
Drug taking
Complete Denial

Coping - Styles
Problem Focussed
Planning, confronting, seeking information

Emotion Focussed
Support seeking, venting, praying, reframing

Attentional
Vigilant monitoring

Avoidant
Distraction ,daydreaming

Coping
To be useful, must be flexible
One size does not fit all
*Which would work best for sitting exam sup?
Or receiving a life altering diagnosis?
*Recall a recent stressful life-event?
What strategies did you use to deal with it?

Personality

Hostility
Angry, negative world view, aggressive
Hostility
Unhealthy behaviour
Less accepting of support
Increased physiological responses

Hostility & CHD Hemingway and Marmott

Personality
Neuroticism
Anxious thoughts, feelings and behaviours
Higher self-reported illnesses
BUT no objective increase in physical
illnesses

Personality
Optimism
Positive outlook and expectations
Optimism associated with less stress
before surgery and greater quality of life after
in context of health crisis e.g., diagnosis of
cancer
after unsuccessful in vitro fertilisation
Carver et al., 2010

Personality
Hardiness
Feelings of commitment, control and challenge
and rich, varied, rewarding childhood experiences
dispositional resilience
In high stress environments the more hardiness,
the less illness,
better immune functioning (Sandvik et al 2013)
Hardiness acts as a buffer between stress & illness (Kobasa
79)
Hardiness associated with lower PTSD symptoms in military
personnel (Escolas et al. 2013)

Locus of Control (LOC)

Belief of where responsibly/control lies for the forces
that affect ones life
Internal
External
LOC
Back pain increased internal LOC
less
disability and more exercise
Stroke increased internal LOC
less
physical disability
BUT a high internal LOC if unrealistic can be
maladaptive

Depression and Anxiety

Depression & CHD Hemingway and Marmot 99
Depression can increase the risk of
mortality following AMI Frasure-Smith 95
How?
Depression

Behaviours
Appraisal

Conclusions
Stress is a vague concept
Stress is hard to measure & study
3 approaches
Stress as an external stimulus
Stress as a reaction between the external event and the
individuals reaction
Stress as a internal physiological reaction

Stress has a range of psychological and

physiological effects, which can impact directly or
indirectly on health
Moderators of the link between stress and illness
exist

Identify components of Cox & Mackeys

Model in the following vignette
Juan, a 47 year old male, presented to his GP and
reported feeling constantly restless, jumpy and
having difficulty sleeping. He reported having recently
invested a large sum of money in an investment that
was losing money and he was having trouble with his
wife who was threatening to leave him. He reported
feeling stressed and losing his appetite. When asked
how he was coping, he replied that he was falling
behind at work, was trying desperately to connect with
his wife and he wanted some sleeping pills. Juan
reported feeling that he would be lost and lonely if
his girlfriend were to leave him it would be a disaster
he confided.

Identify components of Cox & Mackeys

Model in the following vignette
Sara, an 18 year old student, had four university
assignments to complete by the end of semester,
pressure from her boss to work more hours at his
part time job, and needed to find a new place to
live immediately following her lease running out.
Sara could identify solutions to each of these
problems. She put together a plan of attack and
a timetable for the week and worked steadily. She
felt a bit wound up but was not over-aroused
during the week but reflected Ive had tougher
weeks than this.