11 - Stress and Health Psychology
ENDURING ISSUES IN STRESS AND HEALTH PSYCHOLOGY
We again encounter several of the enduring issues that interest all psychologists regardless of their area of specialization. To what extent do the methods that people use in coping with stress depend on the environment in which they find themselves (Person-Situation)? Can psychological stress cause physical illness (Mind-Body)? To what extent do people respond differently to severe stress (Diversity-Universality)?
SOURCES OF STRESS
The term stressor refers to any environmental demand that creates a state of tension or threat (stress) and requires change or adaptation (adjustment). Many situations prompt us to change our behavior in some way, but only some cause stress. Consider, for example, stopping at a traffic signal that turns red. Normally, this involves no stress. But now imagine that you are rushing to an important appointment or to catch a train and the red light will surely make you late. Here, stress is triggered because the situation not only requires adaptation, but it produces tension and distress as well.
Some events, such as wars and natural disasters, are inherently stressful for virtually everyone. Other less dramatic, day-to-day events are nonetheless sources of significant stress for large numbers of people. An August 2010 survey found that most Americans were experiencing moderate to high stress due to concerns about such things as money, work, the economy, family responsibilities and relationships. Stress is not limited, however, to dangerous or unpleasant situations. Even everyday events or good things can also cause stress, because they necessitate a change or adaptation. For example, a wedding is often both stressful and exciting (Ma, 2004).
Change
All stressful events involve change. But most people have a strong preference for order, continuity, and predictability in their lives. Therefore, anything - good or bad - that requires change has the potential to be experienced as stressful. The more change required, the more stressful the situation.
Questionnaires like the Undergraduate Stress Questionnaire (USQ) measure the amount of change, and, hence, the amount of stress in an individual's life.
Everyday Hassles
Some of the items on the Undergraduate Stress Questionnaire concern fairly dramatic, relatively infrequent events. However, many psychologists have pointed out that much stress is generated by "hassles," life's petty annoyances, irritations, and frustrations (Charles, Piazza, Mogle, Sliwinski, & Almeida, 2013). Such seemingly minor matters as having a zipper break, waiting in long lines, or dealing with the normal, daily stressors at work or at school can have a long-term impact because they affect family life (Repetti, Wang, & Saxbe, 2009). Richard Lazarus believed that big events matter so much, because they trigger numerous little hassles that eventually overwhelm us with stress. "It is not the large dramatic events that make the difference," Lazarus noted, "but what happens day in and day out, whether provoked by major events or not" (Lazarus, 1981, p. 62). Research confirms that people who have recently suffered a major traumatic event are more likely to experience a sustained stress reaction when exposed to minor stressors or hassles they might usually be able to tolerate (Cross, 2003). In the end, both major and minor events are stressful, since they lead to feelings of pressure, frustration, and conflict.
Pressure occurs when we feel forced to speed up, intensify, or shift direction in our behavior, or when we feel compelled to meet a higher standard of performance. Pressure on the job or in school is a familiar example. In our private lives, trying to live up to social and cultural norms about what we should be doing, as well as our family's and friends' expectations, also adds pressure.
Frustration
Frustration occurs when a person is prevented from reaching a goal because something or someone stands in the way. Delays are annoying because our culture puts great stock in the value of time. Lack of resources is frustrating to those who cannot afford the new cars or lavish vacations they desire. Losses, such as the end of a love affair or a cherished friendship, cause frustration because they often make us feel helpless, unimportant, or worthless. Failure generates intense frustration - and accompanying guilt - in our competitive society. We imagine that if we had done things differently, we might have succeeded; thus, we may feel personally responsible for our setbacks and tend to assume that others blame us for not trying harder or being smarter. Discrimination also contributes to frustration: Being denied opportunities or recognition simply because of one's sex, age, religion, sexual orientation, or skin color is extremely frustrating.
Conflict
Of all life's troubles, conflict is probably the most common. A boy does not want to go to his aunt's for dinner, but neither does he want to listen to his parents complain if he stays home. A student finds that both the required courses she wanted to take this semester are given at the same hours on the same days. Conflict arises when we face two or more incompatible demands, opportunities, needs, or goals. We can never completely resolve conflict. We must either give up some of our goals, modify some of them, delay our pursuit of some of them, or reign ourselves to not attaining all of our goals. Whatever we do, we are bound to experience some frustration, thereby adding to the stressfulness of conflicts.
In the 1930s, Kurt Lewin described two opposite tendencies of conflict: approach and avoidance. When something attracts us, we want to approach it; when something frightens us, we try to avoid it. Lewin (1935) showed how different combinations of these tendencies create three basic types of conflict: approach/approach conflict, avoidance/avoidance conflict, and approach/avoidance conflict.
Approach/approach conflict occurs when a person is simultaneously attracted to two appealing goals. Being accepted for admission at two equally desirable colleges or universities is an example. The stress that occurs in approach/approach conflict is that in choosing one desirable option, we must give up the other.
The reverse is avoidance/avoidance conflict, in which we confront two undesirable or threatening possibilities, neither of which has any positive attributes. When faced with an avoidance/avoidance conflict, people usually try to escape the situation altogether. If escape is impossible, some people vacillate between choosing one threat or the other, like a baseball player's being caught in a rundown between first and second base, while other people simply wait for events to resolve their conflict for them.
An approach/avoidance conflict, in which a person is both attracted to and repelled by the same goal, is the most common form of conflict. The closer we come to a goal with good and bad features, the stronger grow our desires to both approach and to avoid, but according to Lewin the tendency to avoid increases more rapidly than the tendency to approach. In an approach/avoidance conflict, therefore, we approach the goal until we reach the point at which the tendency to approach equals the tendency to avoid the goal. Afraid to go any closer, we stop and vacillate, making no choice at all, until the situation changes. A familiar example is a couple whose only quarrel is that one wants to get married, but the other is unsure. The second person wants to continue the relationship (approach), but is wary of making a life-long commitment (avoidance).
Self-Imposed Stress
So far, we have considered external sources of stress. Sometimes, however, people create problems for themselves quite apart from stressful events in their environment (Henig, 2009). Some psychologists argue that many people carry around a set of irrational, self-defeating beliefs that add unnecessarily to the normal stresses of living (A. Ellis & Harper, 1975; T. Lucas, Alexander, Firestone, & Lebreton, 2008). For example, some people believe that "I must be competent, adequate, and successful at everything I do." Still other people believe that "it is disastrous if everything doesn't go the way I would like." These people feel upset, miserable, and unhappy when things don't go perfectly. Self-defeating thoughts like these can contribute to depression (Beck, 1984; Young, Rygh, Weinberger, & Beck, 2008).
Lazarus and Folkman (1984, 1987) proposed that, in a sense, we always create stress for ourselves. They asserted that events are not inherently stressful. The key is how we evaluate those events. They proposed that this evaluative process requires three processes:
Primary Appraisal. How relevant is the situation to your self-esteem or well-being, the well-being of someone you care about, your financial resources, or important goals you are trying to achieve? In other words, what does it mean to you personally? Is it irrelevant? Or is it potentially harmful, threatening, or challenging?
Secondary Appraisal. If the situation is relevant, what are your options? Can the situation be changed or do you simply have to accept it? If you conclude that you are capable of coping, the situation may actually be experienced as a challenge. But if you conclude that you cannot cope with the situation, the situation will likely be experienced as harmful or threatening.
Coping Response. If you believe that the situation is controllable or changeable, what specifically can you do? The answer must consider both the situation and your coping skills, something that has been called "regulatory flexibility" (Bonanno & Burton, 2013).
It is important to understand that the same event or situation will not be experienced as stressful by everyone, a topic to which we now turn.
Stress and Individual Differences
Just as some people create more stress for themselves than others do, some people cope well with major life stresses, whereas others are thrown by even minor problems. What accounts for these differences? In part, as we have seen, the answer is to be found in the way we interpret our situation (Suzuki, 2006). Seeing a challenging situation or event as an opportunity for success rather than for failure is typically associated with positive emotions such as eagerness, excitement, and confidence (Bouckenooghe, Buelens, Fontaine, & Vanderheyden, 2005). People's overall view of the world also affects how well they cope with stress. Optimists, who tend to appraise events as challenges rather than threats, are generally better able to cope with stressful events than are pessimists, who are more likely to dwell on failure (Ben-Zur, 2008). Similarly, people with an internal locus of control see themselves as being able to affect their situations while those with an external locus of control are more likely to appraise events negatively (Ryan & Deci, 2000).
Hardiness and Resilience
Even after experiencing a major disaster, only a minority of people experience serious psychological harm (Bonanno, Brewin, Kaniasty, & La Greca, 2010). People with a trait we call hardiness tolerate stress exceptionally well or seem to thrive on it (Kobasa, 1979; Leyro, Zvolensky, & Bernstein, 2010; Maddi, 2008; Zvolensky, Vulanovic, Bernstein, & Leyro, 2010). They also feel that they control their own destinies and are confident about being able to cope with change (Kessler, Price, & Wortman, 1985; S. E. Taylor, 2003). Conversely, individuals who have little confidence that they can master new situations and can exercise control over events feel powerless and apathetic (C. Peterson, Maier, & Seligman, 1993b). Even when change offers new opportunities for taking charge of their situation, they remain passive.
Psychologists are also interested in resilience: the ability to "bounce back," recovering one's self-confidence, good spirits, and hopeful attitude after extreme or prolonged stress (Beasley, Thompson, & Davidson, 2003; Bonanno, Galea, Bucciarelli, & Vlahov, 2006; Whitelock, Lamb, & Rentfrow, 2013). In one study, half of the people in a sample of those who were actually inside the World Trade Center at the time of the terrorist attacks showed only mild, short-lived symptoms of stress (Bonanno et al., 2010). Resilience may partially explain why some children who grow up in adverse circumstances (such as extreme poverty, dangerous neighborhoods, abusive parents, or exposure to drugs and alcohol) become well-adjusted adults, whereas others remain troubled - and frequently get into trouble - throughout their lives (Bonanno, 2004; Feinauer, Hilton, & Callahan, 2003; Leifer, Kilbane, & Kalick, 2004; Richaud, 2013). By studying resilient children, it may be possible to develop effective intervention programs that other children could use to reduce the impact of adverse environments (Chen, 2012; Richaud, 2013). Similarly, in 2010 the U.S. Army initiated a Comprehensive Soldier Fitness (CSF) program designed to enhance resilience among soldiers, family members and civilians in the Department of the Army. It works by assessing resiliency strengths, providing online self-help modules based on the results of the assessment, training master resilience trainers, and requiring resilience training at every Army leader development school (Casey, 2011). This is a ground-breaking program based on the belief that resilience can be learned. Researchers are monitoring the program closely to determine whether, in fact, it is effective (Lester, McBride, Bliese, & Adler, 2011). The entire January, 2001, issue of American Psychologist was devoted to describing this program in depth.
COPING WITH STRESS
Whatever its source, stress requires that we cope - that is, it requires us to make cognitive and behavioral efforts to manage psychological stress. There are many different ways of coping with stress, but two general types of adjustment stand out: direct coping and defensive coping.
Direct Coping
Direct coping refers to intentional efforts to change an uncomfortable situation. Direct coping tends to be problem oriented and to focus on the immediate issue. When we are threatened, frustrated, or in conflict, we have three basic choices for coping directly: confrontation, compromise, or withdrawal.
Consider the case of a woman who has worked hard at her job for years, but has not been promoted. She learned that she has not advanced due to her stated unwillingness to temporarily move to a branch office in another part of the country to acquire more experience. Her unwillingness to move stands between her and her goal of advancing in her career. She has several choices, which we will explore.
Confrontation
Acknowledging that there is a problem for which a solution must be found, attacking the problem head-on, and pushing resolutely toward the goal is called confrontation. This might involve learning new skills, enlisting other people's help, finding other things, or just trying harder. Or it might require steps to change either oneself or the situation. The woman who wants to advance her career might try to persuade her boss that even though she has never worked in a branch office, she nevertheless has acquired enough experience to handle a better job in the main office.
Confrontation may also include expressions of anger. Anger may be effective, especially if we really have been treated unfairly and if we express our anger with restraint instead of exploding in rage.
Compromise
Compromise is one of the most common and effective ways of coping directly with conflict or frustration. We often recognize that we cannot have everything we want and that we cannot expect others to do just what we would like them to do. In such cases, we may decide to settle for less than we originally sought. For example, the woman might agree to take a less desirable position that doesn't require relocation.
Withdrawal
In some circumstances, the most effective way of coping with stress is to withdraw from the situation. The woman whose promotion depends on temporarily relocating might quit her job and join another company. When we realize that our adversary is more powerful than we are, that there is no way we can effectively modify ourselves or the situation, that there is no possible compromise, and that any form of confrontation would be self-defeating, withdrawal is a positive and realistic response. However, withdrawal may be a mixed blessing. Perhaps the greatest danger of coping by withdrawal is that the person will come to avoid all similar situations. The woman who did not want to take a job at her company's branch office might not only quit her present job, but might withdraw entirely from the work world leaving her in a poor position to take advantage of an effective alternative if one should come along.
Defensive Coping
Thus far, we have discussed coping with stress that arises from recognizable sources. But there are times when we either cannot identify or cannot deal directly with the source of our stress. For example, you return to a parking lot to discover that your car has been damaged. In other cases, a problem is so emotionally threatening that it cannot be faced directly: Perhaps someone close to you is terminally ill, or after 4 years of hard work, you have failed to gain admission to medical school and may have to abandon your plan to become a doctor.
In such situations, people may turn to defense mechanisms as a way of coping. Defense mechanisms are techniques for deceiving oneself about the causes of a stressful situation to reduce pressure, frustration, conflict, and anxiety. The self-deceptive nature of such adjustments led Freud to conclude that they are entirely unconscious, but not all psychologists agree. Often we realize that we are pushing something out of our memory or are otherwise deceiving ourselves. For example, all of us have blown up at someone when we knew we were really angry at someone else. Whether defense mechanisms operate consciously or unconsciously, they provide a means of coping with stress that might otherwise be unbearable.
Denial
Denial is the refusal to acknowledge a painful or threatening reality. Although denial can be a positive response in some situations, it clearly is not in other situations. Frequent drug users who insist that they are merely "experimenting" with drugs are using denial.
Repression
The most common mechanism for blocking out painful feelings and memories is repression, a form of forgetting to exclude painful thoughts from consciousness. Soldiers who break down in the field often block out the memory of the experiences that led to their collapse (P. Brown, van der Hart, & Graafland, 1999).
Denial and repression are the most basic defense mechanisms. In denial, we block out situations that we can't handle; in repression, we block out unacceptable impulses or stressful thoughts. These psychic strategies form the basis for several other defensive ways of coping.
Projection
If a problem cannot be denied or completely repressed, we may be able to distort its nature so that we can handle it more easily through projection: the attribution of one's repressed motives, ideas, or feelings onto others. A corporate executive who feels guilty about the way he rose to power may project his own ruthless ambition onto his colleagues. He simply is doing his job, he believes, whereas his associates are all crassly ambitious and consumed with power.
Identification
The reverse of projection is identification: taking on the characteristics of someone else, so that we can vicariously share in that person's triumphs and overcome feeling inadequate. The admired person's actions, that is, become a substitute for our own. A parent with unfulfilled career ambitions may share emotionally in a son's or daughter's professional success. Identification is often used as a form of self-defense in situations in which a person feels utterly helpless, for example, in a hostage situation. To survive, victims sometimes seek to please their captors and may identify with them as a way of defensively coping with unbearable and inescapable stress. This is called the "Stockholm Syndrome" (Cassidy, 2002), after four Swedes who were held captive in a bank vault for nearly a week, but defended their captors upon release.
Regression
People under stress may revert to childlike behavior through a process called regression. Some psychologists say people regress because an adult cannot stand feeling helpless. Conversely, children feel helpless and dependent every day, so becoming more childlike can make total dependency or helplessness more bearable. Regression is sometimes used as a manipulative strategy, too, albeit an immature and inappropriate one. Adults who cry or throw temper tantrums when their arguments fail may expect those around them to react sympathetically, as their parents did when they were children.
Intellectualization
Intellectualization is a subtle form of denial in which we detach ourselves from our feelings about our problems by analyzing them intellectually and thinking of them almost as if they concerned other people. Parents who start out intending to discuss their child's difficulties in a new school and then find themselves engaged in a sophisticated discussion of educational philosophy may be intellectualizing a very upsetting situation. They appear to be dealing with their problems, but in fact they are not, because they have cut themselves off from their disturbing emotions.
Reaction Formation
The term reaction formation refers to a behavioral form of denial in which people express, with exaggerated intensity, ideas and emotions that are the opposite of their own. Exaggeration is the clue to this behavior. The man who extravagantly praises a rival may be covering up jealousy over his opponent's success.
Displacement
Displacement involves the redirection of repressed motives and emotions from their original objects to substitute objects. A classic example is the person who has an extremely frustrating and stressful day at work and then yells at his wife and children when he gets home.
Sublimation
Sublimation refers to transforming repressed motives or feelings into more socially acceptable forms. Anger and aggressiveness, for instance, might be channeled into competitiveness in business or sports. A strong and persistent desire for attention might be transformed into an interest in acting or politics.
Does defensive coping mean that a person is immature, unstable, or on the edge of a "breakdown"? Is direct coping adaptive, and is defensive coping maladaptive? Not necessarily (Cramer, 2000; Hart, 2014; Rhodewalt & Vohs, 2005). In some cases of prolonged and severe stress, lower level defenses such as denial may not only contribute to our overall ability to adjust but also may be essential to survival. Over the long run, however, defense mechanisms are maladaptive if they interfere with a person's ability to deal directly with a problem or they create more problems than they solve.
Socioeconomic, Cultural, and Gender Differences in Coping with Stress
Consider the impact of socioeconomic status on stress and coping. In poor neighborhoods, addressing even the basic tasks of living is stressful. Thus, poor people have to deal with more stress than people who are financially secure (M. A. Barnett, 2008; Gallo, de los Monteros, & Shivpuri, 2009). Moreover, people in lower socioeconomic classes often have fewer means for coping with hardship and stress - fewer people to turn to and fewer community resources to draw on for support during stressful times (Gallo et al., 2009; Hammack, Robinson, Crawford, & Li, 2004). While some research shows that a lifetime of moderate adversity is associated with greater ability to cope with stress (Seery, Leo, Lupien, Kondrak, & Almonte, 2013), a lifetime of severe stress coupled with fewer options for coping has a profound effect on people in lower socioeconomic classes (Kasper et al., 2008).
Studies have also found that the way individuals cope with stress varies for people from different cultural backgrounds. For example, when stressed, most European Americans seek explicit social support from their friends, such as discussing the source of their stress and seeking advice and emotional solace. In contrast Asian Americans are generally more reluctant than European Americans to seek explicit social support because they are concerned about the potential negative relationship consequences that may occur if they disclose the source of their stress. Instead, they are more likely to seek implicit social support which involves simply being in close contact with others, without disclosing the source of their stress (H. S. Kim, Sherman, & Taylor, 2008; S. E. Taylor, Welch, Kim, & Sherman, 2007).
Research also indicates that when faced with equally stressful situations, men and women often use different coping strategies (Bellman, Forster, Still, & Cooper, 2003; Kort-Butler, 2009; Patton & Goddard, 2006). Women are more likely than men to evaluate the stressful situation positively, to gather information in order to reduce uncertainty, to engage in distracting activities, and turn to prayer. Men are more likely to keep their feelings to themselves, avoid thinking about the situation, and engage in problem-solving to reduce the stress (Spence, Nelson, & Lachlan, 2010). Women under stress are also more likely than men to tend to their young and to seek contact and support from others (particularly other women) rather than to behave aggressively. This "tend-and-befriend" response may be linked to the hormone oxytocin, which is linked to maternal behavior and social affiliation. Under stress, both males and females secrete oxytocin, but the male hormone testosterone seems to reduce its effect, whereas the female hormone estrogen amplifies it (S. E. Taylor, 2006). A new line of research suggests that the tend-and-befriend response may also be the result of evolutionary adaptations. In simple terms, when our hunter-gatherer ancestors were threatened with danger, it may have been most adaptive for the species if the men responded with aggression and women responded by guarding the children and seeking social support from others (S. E. Taylor et al., 2000; S. E. Taylor, 2006; Turton & Campbell, 2005; Volpe, 2004).
HOW STRESS AFFECTS HEALTH
Experiencing too much stress over a long period can contribute to physical problems as well as psychological ones (Kendall-Tackett, 2010; McEwen, 2013; Pressman, Gallagher, & Lopez, 2013). For example, being discriminated against because of one's sex, religion, sexual orientation, or skin color is often a life-long source of stress (Fuller-Rowell, Evans, & Ong, 2012; Jackson, Knight, & Rafferty, 2010; Lick, Durso, & Johnson, 2013). Research shows that perceived discrimination is linked to mental health problems (depression, distress, anxiety) as well as physical health problems (high blood pressure, poor health, obesity, substance abuse) (Hatzenbeuhler, 2009; Okazaki, 2009; Pascoe & Richman, 2009). Health psychology focuses on how the mind and body interact. Specifically, health psychologists seek to understand how psychological factors influence wellness and illness. Numerous studies have found that people suffering from acute or chronic stress are likely to be more vulnerable to everything from the common cold to an increased risk for heart disease (S. Cohen et al., 1998; R. O. Stanley & Burrows, 2008; L. M. Thornton, 2005). New research is uncovering the biological mechanisms that link stress to lowered immunity and poor health. The challenge for health psychologists is to find ways to prevent stress from becoming physically and emotionally debilitating, and to promote healthy behavior and well-being.
Physicians and psychologists agree that stress management is an essential part of programs to prevent disease and promote health. To understand how our body responds to stress, recall how the sympathetic nervous system reacts when you are intensely aroused: heart begins to pound, your respiration increases, you develop a queasy feeling in your stomach and your glands start pumping stress hormones such as adrenaline and norepinephrine into your blood. Other organs also respond; for example, the liver increases the available sugar in the blood for extra energy, and the bone marrow increases the white blood cell count to combat infection.
The noted physiologist Walter Cannon (1929) first described the basic elements of this sequence of events as a fight-or-flight response, because it appeared that its primary purpose was to prepare an animal to respond to external threats by either attacking or fleeing from them. The adaptive significance of the fight-or-flight response in people was obvious to Cannon, because it assured the survival of early humans when faced with genuine danger. However, Cannon also observed that this same physiological mobilization occurred regardless of the nature of the threat.
Extending Cannon's theory of the fight-or-flight response, the endocrinologist Hans Selye (1907-1982) contended that we react to physical and psychological stress in three stages that he collectively called the general adaptation syndrome (GAS) (Selye, 1956, 1976). The three stages, alarm, resistance, and exhaustion, describe the body's natural response to stressors.
Stage 1, alarm reaction, is the first response to stress. It begins when the body recognizes that it must fend off some physical or psychological danger. Activity of the sympathetic nervous system is increased and the body is ready to meet the danger. At the alarm stage, we might use either direct or defensive coping strategies. If neither of those approaches reduces the stress, we eventually enter the second stage of adaptation.
During Stage 2, resistance, physical symptoms and other signs of strain appear. We intensify our use of both direct and defensive coping techniques. If we succeed in reducing the stress, we return to a more normal state. But if the stress is extreme or prolonged, we may turn in desperation to inappropriate coping techniques and cling to them rigidly, despite evidence that they are not working. When that happens, physical and emotional resources are further depleted, and signs of psychological and physical wear and tear become even more apparent.
In the third stage, exhaustion, we draw on increasingly ineffective defense mechanisms in a desperate attempt to bring the stress under control. Some people lose touch with reality and show signs of emotional disorder or mental illness. Others show signs of "burnout," including the inability to concentrate, irritability, procrastination, and a cynical belief that nothing is worthwhile (Y. Li & Hou, 2005; Maslach & Leiter, 1997). Physical symptoms such as skin or stomach problems may erupt, and some victims of burnout turn to alcohol, drugs, or overeating to cope with the stress-induced exhaustion. While these unhealthy behaviors may help to reduce stress and preserve mental health in the short-term, they have long-term health consequences (Jackson et al., 2010). If the stress continues, the person may suffer irreparable physical or psychological damage or even death. In our everyday lives, stressors may be present over long periods of time. As a result, your body may remain on alert for a long time as well. Since the human body is not designed to be exposed for long periods to the powerful biological changes that accompany alarm and mobilization, when stress is prolonged, we are likely to experience some kind of physical disorder.
In extreme cases of stress, such as witnessing a terrifying event, some people may develop an anxiety disorder called Post Traumatic Stress Disorder (PTSD).
Stress and Heart Disease
Stress is a major contributing factor in the development of coronary heart disease (CHD), the leading cause of death and disability in the United States (Allan & Fisher, 2011). A great deal of research has been done, for example, on people who exhibit the Type A behavior pattern - that is, who respond to life events with impatience, hostility, competitiveness, urgency, and constant striving (M. Friedman & Rosenman, 1959).
Type A people are distinguished from more easygoing Type B people. The two cardiologists who first identified the characteristics of Type A personalities were convinced that this behavior pattern was most likely to surface in stressful situations. A number of studies have shown that Type A behavior does indeed predict CHD (Carmona, Sanz, & Marin, 2002; Myrtek, 2007). For example, when Type A personalities were subjected to harassment or criticism, their heart rate and blood pressure were much higher than those of Type B personalities under the same circumstances (Griffiths & Dancaster, 1995; Lyness, 1993). Both high heart rate and high blood pressure are known to contribute to CHD.
There is also considerable evidence that chronic anger and hostility predict heart disease (Mohan, 2006; R. B. Williams, 2001). For example, people who scored high on an anger scale were 2.5 times more likely to have heart attacks or sudden cardiac deaths than their calmer peers (Janice Williams et al., 2000).
Depression, too, appears to increase the risk of heart disease and premature death (Mitka, 2008; Rugulies, 2002). In fact, recent studies have identified a personality type that incorporates the precise elements of depression that are most predictive of heart disease. Called Type D, or Distressed Personality, it is characterized by depression, negative emotions, and social inhibition. The Type D personality is linked to heart disease because when stressed, people with a type D personality produce excessive amounts of cortisol, which damages the heart and blood vessels over time (Deary et al., 2010; Denollet, 2005; Huang, Yao, Huang, Guo, & Yang, 2008; Sher, 2004).
Because long-term stress increases the likelihood of developing CHD, reducing stress has become part of the treatment used to slow the progress of hardening of the arteries, which can lead to a heart attack. A very low-fat diet and stress-management techniques, such as yoga and deep relaxation, have been effective in treating this disease (Langosch, Budde, & Linden, 2007; Ornish et al., 1998). Counseling designed to diminish the intensity of time urgency and hostility in patients with Type A behavior has also been moderately successful in reducing the incidence of CHD (M. Friedman et al., 1996; Kop, 2005).
Stress and the Immune System
Scientists have long suspected that stress also affects the functioning of the immune system. Recall that the immune system is strongly affected by hormones and signals from the brain. The field of psychoneuroimmunology (PNI) studies the interaction between stress on the one hand and immune, endocrine, and nervous system activity on the other (Byrne-Davis & Vedhara, 2008; Dougall & Baum, 2004; Irwin, 2008). Chronic stress - from caring for a sick spouse or elderly parent (Norton, 2010), living in poverty (Schetter et al., 2013), depression (Kiecolt-Glaser & Glaser, 2002; Oltmanns & Emery, 1998), or even living with a spouse with cancer (Mortimer, Sephton, Kimerling, Butler, Bernstein, & Spiegel, 2005) - has been linked to suppressed functioning of the immune system (Irwin, 2002). To the extent that stress disrupts the functioning of the immune system, it can impair health (S. Cohen & Herbert, 1996; Walls, 2008).
Increased stress has been shown to increase susceptibility to influenza in both mice and humans (E. A. Murphy et al., 2008; Tseng, Padgett, Dhabhar, Engler, & Sheridan, 2005) and upper respiratory infections, such as the common cold (S. Cohen, 1996; S. Cohen et al., 2002). For example, volunteers who reported being under severe stress and who had experienced two or more major stressful events during the previous year were more likely to develop a cold when they were exposed to a cold virus (S. Cohen, Tyrell, & Smith, 1991). A control group of volunteers who reported lower levels of stress were less likely to develop cold symptoms even though they were equally exposed to the virus. People who report experiencing a lot of positive emotions (for example, happiness, pleasure, or relaxation) are also less likely to develop colds when exposed to the virus than those who report a lot of negative emotions (for example, anxiety, hostility, or depression) (S. Cohen, Doyle, Turner, Alper, & Skoner, 2003a).
Psychoneuroimmunologists have also established a possible relationship between stress and cancer (Herberman, 2002). Stress does not cause cancer, but due to the extent that stress impairs the immune system, cancerous cells may be better able to establish themselves and spread throughout the body. Establishing a direct link between stress and cancer in humans is difficult. For obvious reasons, researchers cannot conduct controlled experiments with human participants. Some early research showed a correlation between stress and incidence of cancer (McKenna, Zevon, Corn, & Rounds, 1999; A. O'Leary, 1990), but more recent research has not confirmed these findings (Maunsell, Brisson, Mondor, Verreault, & Deschenes, 2001). In addition, although several new cancer drugs work by boosting the immune system, even this does not necessarily mean that damage to the immune system makes you more vulnerable to cancer (Azar, 1999). Thus, the jury is out on whether stress contributes to cancer in humans (Reiche, Morimoto, & Nunes, 2005).
Regardless, many medical practitioners now agree that psychologists can play a vital role in improving the quality of life for cancer patients (Joanna Smith, Richardson, & Hoffman, 2005). For example, women faced with the diagnosis of late-stage breast cancer understandably experience high levels of depression and mental stress. Many physicians now routinely recommend that their breast-cancer patients attend group therapy sessions, which are effective in increasing the quality of life, reducing depression, mental stress, hostility, insomnia, and the perception of pain (Giese-Davis et al., 2002; Goodwin et al., 2001; Quesnel, Savard, Simard, Ivers, & Morin, 2003; Witek-Janusek et al., 2008). Some initial reports also showed that breast cancer patients who attended group therapy sessions actually had an increased survival rate (Spiegel & Moore, 1997), although more recent investigations have not supported this claim (DeAngelis, 2002; Edelman, Lemon, Bell, & Kidman, 1999; Goodwin et al., 2001).
STAYING HEALTHY
Stress may be part of life, but there are proven ways to reduce the negative impact of stress on your body and your health. The best method, not surprisingly, is to reduce stress. A healthy lifestyle can also prepare you to cope with the unavoidable stress in your life.
Reduce Stress
Scientists do not have a simple explanation for the common cold, much less cancer. But they do have advice on how to reduce stress and stay healthy (Hays, 2014).
Calm Down
Exercise is a good beginning. Running, walking, biking, swimming, or other aerobic exercise lowers your resting heart rate and blood pressure, so that your body does not react as strongly to stress and recovers more quickly. Exercise is also part of a healthy lifestyle. Moreover, numerous studies show that people who exercise regularly and are physically fit have higher self-esteem than those who do not; are less likely to feel anxious, depressed, or irritable; and have fewer aches and pains, as well as fewer colds (Annesi, 2005; Biddle, 2000; Nguyen-Michel, Unger, Hamilton, & Spruijt-Metz, 2006; Sonstroem, 1997).
Research has also shown that expressive writing can alleviate stress and help one cope with a difficult situation. While it is unclear if writing about our feelings provides a safe outlet for our emotions, or helps us focus our thoughts on finding solutions, dozens of research studies have shown that expressing one's feelings in writing can be an effective way to reduce stress (Pennebaker & Chung, 2007; Smyth, Hockemeyer, & Tulloch, 2008). Expressive writing has even been shown to be of value when used as a therapeutic technique, reducing the symptoms of depression and stress in women suffering from intimate partner violence (Koopman, Ismailji, Holmes, Classen, Palesh, & Wales, 2005).
Relaxation training is another stress buster. A number of studies indicate that relaxation techniques lower stress (Pothier, 2002) and improve immune functioning (Andersen, Kiecolt-Glaser, & Glaser, 1994; Antoni, 2003). Relaxation is more than flopping on the couch with the TV remote, however. Healthful physical relaxation requires lying quietly and alternately tensing and relaxing every voluntary muscle in your body - from your head to your toes - to learn how to recognize muscle tension, as well as to learn how to relax your body. Breathing exercises can have the same effect: If you are tense, deep, rhythmic breathing is difficult, but learning to do so relieves bodily tension.
Reach Out
A strong network of friends and family who provide social support can help to maintain good health (Haslam, Jetten, Postmes, & Haslam, 2009; Jaremka et al., 2013; Jetten, Haslam, & Haslam, 2011; Kok et al., 2013; Miller, 2014; Uchino, 2009; von Dawans, Fischbacher, Kirschbaum, Fehr, & Heinrich, 2012). Exactly why the presence of a strong social support system is related to health is not fully understood. Some researchers contend that social support may directly affect our response to stress and health by producing physiological changes in endocrine, cardiac, and immune functioning (Uchino, Uno, & Holt-Lunstad, 1999). Whatever the underlying mechanism, most people can remember times when other people made a difference in their lives by giving them good advice (informational support), helping them to feel better about themselves (emotional support), providing assistance with chores and responsibilities or financial help (tangible support), or simply by "hanging out" with them (belonging support) (Uchino et al., 2009).
Religion and Altruism
Health psychologists are also investigating the role religion may play in reducing stress and bolstering health (Freedland, 2004; Joseph, Linley, & Maltby, 2006; W. R. Miller & Thoresen, 2003; Rabin & Koenig, 2002). For example, research has found that elderly people who pray or attend religious services regularly enjoy better health and markedly lower rates of depression than those who do not (Koenig, McCullough, & Larson, 2000). Other studies have shown that having a religious commitment may also help to moderate high blood pressure and hypertension (Bell, Bowie, & Thorpe, 2012; Wilkins, 2005).
It is unclear why there is an association between health and religion (Contrada et al., 2004; K. S. Masters, 2008). One explanation holds that religion provides a system of social support that includes caring friends and opportunities for close personal interactions. As previously described, a strong network of social support can reduce stress in a variety of ways, and in turn, reduced stress is associated with better health. Other possible explanations are that regular attendance at religious services encourages people to help others, which in turn increases feelings of personal control and reduces feelings of depression; that frequent attendance at religious services increases positive emotions; and that most religions encourage healthy lifestyles.
Altruism - reaching out and giving to others because this brings you pleasure - is one of the more effective ways to reduce stress (Vaillant, 2000). Caring for others tends to take our minds off our own problems, to make us realize that there are others who are worse off than we are, and to foster the feeling that we're involved in something larger than our own small slice of life (Allen, Haley, & Roff, 2006). Altruism is a component of most religions, suggesting that altruism and religious commitment may have something in common that helps to reduce stress. Altruism may also channel loss, grief, or anger into constructive action.
Even simple actions can contribute to a sense of well-being and happiness. Expressing gratitude, performing acts of kindness, practicing optimism, and savoring the moment have all been shown to increase subjective well-being (Dunn, Aknin, & Norton, 2014; Lyubomirsky & Layous, 2013).
Learn to Cope Effectively
How you appraise events in your environment - and how you appraise your ability to cope with potentially unsettling, unpredictable events - can minimize or maximize stress and its impact on health.
Proactive coping is the psychological term for anticipating stressful events and taking advance steps to avoid them or to minimize their impact (Aspinwall & Taylor, 1997; Greenglass, 2002). Proactive coping does not mean "expect the worst;" constant vigilance actually increases stress and may damage health. Rather, proactive coping means (as in the Boy Scout motto) "Be prepared." This may include accumulating resources (time, money, social support, and information), recognizing potential stress in advance, and making realistic plans.
In many cases, you cannot change or escape stressful circumstances, but you can change the way you think about things. Positive reappraisal helps people to make the best of a tense or painful situation over which they have little or no control (Jamieson, Mendes, & Nock, 2013; Troy, Shallcross, & Mauss, 2013). A low grade can be seen as a warning sign, not a catastrophe; similarly, a job you hate may provide information on what you really want in your career. Positive reappraisal does not require you to become a "Pollyanna" (the heroine of a novel who was optimistic to the point of being ridiculous). Rather, it requires finding new meaning in a situation, or finding a perspective or insight that you had overlooked (Rosenthal, 2013). Positive reappraisal has also been shown to be an effective technique to help people cope with HIV, by improving the quality of their life and increasing their psychological well-being (Moskowitz, Hult, Bussolari, & Acree, 2009).
One of the most effective, stress-relieving forms of reappraisal is humor (Ayan, 2009). As Shakespeare so aptly put it in The Winter's Tale: "A merry heart goes all the day / Your sad tires in a mile" (Act IV, Scene 3). Journalist Norman Cousins (1981) attributed his recovery from a life-threatening disease to regular "doses" of laughter. Watching classic comic films, he believed, reduced both his pain and the inflammation in his tissues. He wrote: "What was significant about the laughter... was not just the fact that it provides internal exercise for a person flat on his or her back - a form of jogging for the innards - but that it creates a mood in which the other positive emotions can be put to work, too. In short, it helps make it possible for good things to happen." (pp. 145-146).
Some health psychologists agree that a healthy body and a sense of humor go hand in hand (Myers & Sweeney, 2006; Salovey, Rothman, Detweiler, & Steward, 2000; Vaillant, 2000), while others believe that more research is needed before any firm conclusions can be drawn (R. A. Martin, 2002). Most are in agreement, however, that doing what we can to maintain a healthy body helps us both reduce and cope with stress.
Adopt a Healthy Lifestyle
While learning how to avoid and cope with stress is important, the positive psychology movement has prompted many health psychologists to explore other ways to promote good health by adopting a healthier lifestyle. Developing healthy habits - like eating a well-balanced diet, getting regular exercise, not smoking, and avoiding high-risk behaviors - are all important to maintaining health (H. S. Friedman, 2002).
Diet
A good diet of nutritious foods is important because it provides energy necessary to sustain a vigorous lifestyle while promoting healthy growth and development. Although there is some disagreement about what exactly constitutes a well-balanced diet, most experts advise eating a wide variety of fruits, vegetables, nuts, whole-grain breads and cereals, accompanied by small portions of fish and lean meats. Several studies have documented that eating a healthy diet can improve the quality of life, increase longevity, and reduce the risk of heart disease, cancer, and stroke (Trichopoulou, Costacou, Bamia, & Trichopoulos, 2003). Conversely, eating excessive amounts of fatty meats, deep-fried foods, dairy products that are high in cholesterol (such as whole milk and butter), and foods high in sugars (such as soda and candy) are generally considered unhealthy (H. S. Friedman, 2002).
Exercise
The importance of regular aerobic exercise (such as jogging, brisk walking, or swimming) for maintaining a healthy body has been well established. In addition, health psychologists have shown that regular aerobic exercise can also help people cope better with stress, as well as help them feel less depressed, more vigorous, and more energetic. One study, for example, randomly divided mildly depressed college women into three groups. One group participated in regular aerobic exercise, one group received relaxation therapy, and the last group (a control group) received no treatment at all. After 10 weeks, the mildly depressed women in the aerobic activity group reported a marked decrease in their depression when compared to the no-treatment group. The relaxation group also showed benefits from relaxation therapy, but they were not as significant as the group that had engaged in the regular aerobic exercise program (McCann & Holmes, 1984). Numerous other studies have also demonstrated a link between regular exercise, reduced stress, increased self-confidence, and improved sleep quality (Gandhi, DePauw, Dolny, & Preson, 2002; Manger & Motta, 2005).
Since exercise has so many beneficial effects, why is it hard for some people to exercise more often?
Quit Smoking
Fewer Americans smoke today than in the past, and over half of those who did smoke have quit. However, cigarette smoking still poses a serious health threat to the millions of people who continue to smoke (Mody & Smith, 2006). Smoking is linked to chronic lung disease, heart disease, and cancer. In addition, smoking can reduce the quality of life by decreasing lung efficiency.
Interestingly, the tendency to start smoking occurs almost exclusively during the adolescent years. Almost no one over the age of 21 takes up the habit for the first time, but teenagers who seriously experiment with cigarettes or have friends who smoke are more likely to start smoking than those who do not (W. S. Choi, Pierce, Gilpin, Farkas, & Berry, 1997; J. L. Johnson, Kalaw, Lovato, Baillie, & Chambers, 2004). For these reasons, health psychologists realize that initiatives aimed at preventing smoking should primarily focus their efforts on young people (Tilleczek & Hine, 2006).
Most adults who smoke want to quit, but their addiction to nicotine makes quitting very difficult. Fortunately, several alternative methods to help people quit smoking have been developed in recent years. For instance, prescription antidepressant medications such as Zyban, Wellbutrin, and Effexor, which work at the neurotransmitter level, have proved useful in helping people stop smoking. Nicotine substitutes, usually in the form of chewing gum, patches, or inhalers, have also produced encouraging results (Etter, 2009). Many people who are attempting to quit also find that modifying the environment that they have come to associate with smoking is important. For instance, because people often smoke in bars or during coffee breaks, changing routines that signal lighting up can also help. Finally, some people succeed in quitting "cold turkey." they simply decide to stop smoking without any external support or change in their lifestyle. Regardless of how people quit smoking, studies have shown that quitting will generally add years to your life. Hence, doing whatever it takes to stop is worth it.
Avoid High-Risk Behaviors
Every day we make dozens of small, seemingly insignificant choices that can potentially impact our health and well-being. For instance, choosing to wear a seat belt every time you ride in a car is one of the more significant measures to reduce the risk of injury and early death. Similarly, refusing to have unprotected sex reduces your chances of contracting a sexually transmitted disease.
Health psychologists, working with public agencies, are designing intervention programs to help people make safer choices in their everyday lives. For example, John Jemmott and his colleagues (Jemmott, Jemmott, Fong, & McCaffree, 2002) studied the impact of a safer sex program that stressed the importance of condom use and other safer sex practices on a sample of 496 high-risk inner-city African American adolescents. Six months after the program began, a follow-up evaluation of the participants revealed that they reported a lower incidence of high-risk sexual behavior, including unprotected intercourse, than did adolescents who did not participate in the program. Similar results have been obtained in programs designed to prevent drug abuse among adolescents (R. Davies, 2009). Research like this underscores the important role that health psychologists can play in helping people learn to avoid risky behavior and improve their quality of life.
EXTREME STRESS
Extreme stress marks a radical departure from everyday life, such that a person cannot continue life as before and, in some cases, never fully recovers. What are some major causes of extreme stress? What effect do they have on people? How do people cope?
Sources of Extreme Stress
Extreme stress has a variety of sources, ranging from unemployment to wartime combat, from violent natural disaster to rape. More common events, too, can be sources of extreme stress, including bereavement, separation, and divorce.
Unemployment
Joblessness is a major source of stress (Lennon & Limonic, 2010). When the jobless rate rises, there is also an increase in first admissions to psychiatric hospitals, infant mortality, deaths from heart disease, alcohol-related diseases, and suicide (Almgren, Guest, Immerwahr, & Spittel, 2002; Goldman-Mellor, Saxton, & Catalano, 2010; Luo, Florence, Quispe-Agnoli, Ouyang, & Crosby, 2011). One survey taken in September 2009 when unemployment was 10% in the United States, showed that compared to those who were still employed, those without jobs were four times as likely to have serious mental health problems (Mental Health America, 2009). Family strain also increases. "Things just fell apart," one worker said after both he and his wife suddenly found themselves unemployed. Not surprisingly, being unemployed also decreases an individual's sense of well-being and happiness (Creed & Klisch, 2005).
Divorce and Separation
"The deterioration or ending of an intimate relationship is one of the more potent of stressors and one of the more frequent reasons why people seek psychotherapy" (J. Coleman, Glaros, & Morris, 1987, p. 155). After a breakup, both partners often feel they have failed at one of life's most important endeavors, but strong emotional ties often continue to bind the pair. If only one spouse wants to end the marriage, the initiator may feel sadness and guilt at hurting the other partner; the rejected spouse may feel anger humiliation, and guilt over his or her role in the failure. Even if the separation was a mutual decision, ambivalent feelings of love and hate can make life turbulent, often for many years (R. E. Lucas, 2005). Of course, adults are not the only ones who are stressed by divorce (Lansford, 2009). Each year more than 1 million American children are also impacted by their parent's divorce (S. M. Greene, Anderson, Doyle, & Riedelbach, 2006). A national survey of the impact of divorce on children (Cherlin, 1992) found that a majority suffer intense emotional stress at the time of divorce. Although most recover within a year or two, especially if the custodial parent establishes a stable home and the parents do not fight about child rearing (Bing, Nelson, & Wesolowski, 2009), a minority experience long-term problems (Judith Siegel, 2007; Wallerstein, Blakeslee, & lewis, 2000).
Bereavement
For decades, it was widely held that following the death of a loved one, people go through a necessary period of intense grief during which they work through their loss and, about a year later, pick up and go on with their lives. Psychologists and physicians, as well as the public at large, have endorsed this cultural wisdom. But some have challenged this view of loss (Bonanno, Wortman, & Nesse, 2004; Davis, Wortman, Lehman, & Silver, 2000; Wortman & Silver, 1989)
According to Wortman and her colleagues (Bonanno, Boerner, & Wortman, 2008), the first myth about bereavement is that people should be intensely distressed when a loved one dies; this suggests that people who are not devastated are behaving abnormally, perhaps pathologically. Often, however, people have prepared for the loss, said their goodbyes, and feel little remorse or regret. Indeed, they may be relieved that their loved one is no longer suffering. The second myth - that people need to work through their grief - may lead family, friends, and even physicians to (consciously or unconsciously) encouraged the bereaved to feel or act distraught. Moreover, physicians may deny those mourners who are deeply disturbed necessary anti-anxiety or antidepressant medication "for their own good." The third myth holds that people who find meaning in the death, who come to a spiritual or existential understanding of why it happened, cope better than those who do not. In reality, people who do not seek greater understanding are the best adjusted and least depressed. The fourth myth - that people should recover from a loss within a year or so - is perhaps the most damaging. Parents trying to cope with the death of an infant and adults whose spouse or child died suddenly in a vehicle accident often continue to experience painful memories and wrestle with depression years later (S. A. Murphy, 2008). But because they have not recovered "on schedule," members of their social network may become unsympathetic. Unfortunately, the people who need support most may hide their feelings because they do not want to make other people uncomfortable. Often they fail to seek treatment because they, too, believe they should recover on their own.
Not all psychologists agree with this "new" view of bereavement. But most agree that research on loss must consider individual (and group or cultural) differences, as well as variations in the circumstances surrounding a loss (Dobson, 2004; Hayslip & Peveto, 2005; Vanderwerker, & Prigerson, 2004).
Catastrophes
Catastrophes - natural and otherwise - produce certain psychological reactions common to all stressful events. At first, in the shock stage," the victim is stunned, dazed, and apathetic" and sometimes even "stuporous, disoriented, and amnesic for the traumatic event." Then, in the suggestible stage, victims are passive and quite ready to do whatever rescuers tell them to do. In the third phase, the recovery stage, emotional balance is regained, but anxiety often persists, and victims may need to recount their experiences over and over again. In later stages, survivors may feel irrationally guilty because they lived while others died (Mallimson, 2006; Straton, 2004).
Combat and Other Threatening Personal Attacks
Wartime experience often causes soldiers intense and disabling combat stress that persists long after they have left the battlefield. Similar reactions - including bursting into rage over harmless remarks, sleep disturbances, cringing at sudden loud noises, psychological confusion, uncontrollable crying, and silently staring into space for long periods - are also frequently seen in survivors of serious accidents, especially children, and of violent crimes such as rapes and muggings (Fairbrother & Rachman, 2006).
Posttraumatic Stress Disorder
Severely stressful events can cause a psychological disorder known as posttraumatic stress disorder (PTSD) (Galatzer-Levy & Bryant, 2013), particularly if the person has been exposed to multiple traumatic events over their lifetime (Ogle, Rubin, & Siegler, 2014; Ogle, Rubin, Berntsen, & Siegler, 2013; Rubin & Feeling, 2013). Dramatic nightmares in which the victim re-experiences the terrifying event exactly as it happened are common. So are daytime flashbacks, in which the victim relives the trauma. Often, victims of PTSD withdraw from social life and from job and family responsibilities (Kashdan, Julian, Merritt, & Uswatte, 2006). PTSD can set in immediately after a traumatic event or within a short time afterwards. But sometimes, months or years may go by in which the victim seems to have recovered from the experience, and then, without warning, psychological symptoms reappear, then may disappear only to recur repeatedly (Corales, 2005).
The experiences of soldiers have heightened interest in PTSD. For example, between 18.7% and 30.9% of the soldiers who served in Vietnam experienced PTSD at some point afterward (Dohrenwend et al., 2007; E. J. Ozer, Best, Lipsey, & Weiss, 2003). It is estimated that as many as one-third of Iraq war veterans suffer from PTSD. Many veterans of World War II, who are now old men, still have nightmares from which they awake sweating and shaking. The memories of combat continue to torment them after more than half a century (Port, Engdahl, & Frazier, 2001). Recently, therapists have begun to observe a new phenomenon: Veterans who seemed to be healthy and well adjusted throughout their postwar lives suddenly develop symptoms of PTSD when they retire and enter their "golden years" (Sleek, 1998; van Achterberg, Rohrbaugh, & Southwick, 2001).
Soldiers are not the only victims of war. Research has shown that female partners of veterans with PTSD often experience more psychological distress than do the soldiers themselves (Caska & Renshaw, 2011). Moreover, during the 20th century, civilian deaths outnumbered military deaths in most wars. Yet only in the last decade - especially following the tragedy of September 11 terrorist attacks on the World Trade Center and the Pentagon and the devastation of New Orleans by Hurricane Katrina - have medical researchers begun to investigate the psychological and physiological effects of war, tragedy, and terrorism on civilian survivors. For many, the immediate response following a traumatic event is one of shock and denial. Shock leaves victims feeling stunned, confused, and in some cases, temporarily numb. Denial often causes them to be unwilling to acknowledge the impact and emotional intensity of the event. After the initial shock passes, individual reactions to trauma vary considerably, but commonly include: heightened emotionality, irritability, nervousness, difficulty concentrating, changes in sleep patterns, physical symptoms such as nausea, headaches, chest pain, and even depression. Some civilians also experience long-lasting and severe problems, such as exhaustion, hatred, mistrust, and the symptoms of PTSD (Gurwitch, Sitterle, Young, & Pfefferbaum, 2002; Mollica, 2000). For example, in one survey of adults with no previous history of PTSD, 10% of those who witnessed the collapse of the World Trade Center towers on September 11, 2001, developed symptoms of PTSD that were still present five to six years later. Another 10% first developed symptoms of PTSD after several years had passed since the attacks (Brackbill et al., 2009). Among Holocaust survivors, many continued to show symptoms of PTSD decades after the end of WWII (Barel, Van Ijzendoorn, Sagi-Schwartz, & Bakermans-Kranenburg, 2010).
THE WELL-ADJUSTED PERSON
Adjustment is any effort to cope with stress. Psychologists disagree, however, about what constitutes good adjustment. Some think it is the ability to live according to social norms. Thus, a woman who grows up in a small town, attends college, teaches for a year or two, and then settles down to a peaceful family life might be considered well adjusted because she is living by the predominant values of her community.
Other psychologists disagree strongly with this view. They argue that society is not always right. Thus, if we accept its standards blindly, we renounce the right to make individual judgments. For instance, V. E. O'Leary and Bhaju (2006) argue that well-adjusted people enjoy the difficulties and ambiguities of life, treating them as challenges to be overcome.