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2 Stress, Trauma, and Related Disorders Chapter Objectives After reading this chapter, you should be able to do the following:

• Define stress and explain where it comes from. • Discuss the ways that stress affects psychological and physical health, and understand the causes of post-traumatic stress disorder. • Explain why some people are more prone to suffer from the effe cts of stre ss than others. • Explain methods that can be used to help people better cope with stress. Tom Merton/OJO Images/Getty Images get81325_02_c02.indd 25 12/5/13 3:57 PM Section 2.1 Stress: Origins, Definitions, and Theories 2.1 Stress: Origins, Definitions, and Theories The word stress is used widely in both psychological writing and the popular press, so widely in fact that its meaning is not always clear. This chapter examines the concept of stress from the historical, biological, social, and psychological perspectives.

Stress is used to refer to both a cause (a “stressful” job, for example) and an effect (“I am feeling stressed”). Our understanding of what stress is and how it affects us has changed and evolved throughout history.

Origins: 460 BCE–1600s Hippocrates often referred to the effects of the emotions on health. For example, the ancient Greek teachers advised doctors to maintain a calm demeanor lest their pati\ ents become frightened. Showing fear, they believed, would exacerbate a patient’s symptoms. Aristotle added anger as another emotion that, like fear, could cause ill- ness. For centuries, doctors con- tinued to believe in a causative link between strong negative emotions and illness, but this connection was broken in the Renaissance by the European philosopher Rene Descartes, who argued that the body and the esprit (French for “soul” or “mind”) were separate entities that communicated through the pineal gland found at the base of the brain. This philosophical position has come to be known as Cartesian dualism.

Later Years: 1800s–1900s The classical view began to reemerge in the middle of the 19th century when doctors first began to observe an illness called neurasthenia (“nerve weakness”\ ; Abbey & Garfinkel, 1991). The symptoms of neurasthenia included fatigue, aches and pains, \ sore throat, and some low-grade fever. No physiological cause for neurasthenia was uncovered; it was blamed on hard work, striving for success, and changing sex roles. Neurasthenia is impor - tant, however, because its attribution to psychosocial causes provided the groundwork for Sigmund Freud’s claim that the physical symptoms of hysteria were the bodily manifesta - tions of emotional traumas experienced in early childhood. Hemera/Thinkstock When doctors maintain a calm demeanor, their patients also remain calm. Many ancient Greek teachers believed that showing fear may worsen a patient’s symptoms. get81325_02_c02.indd 26 12/5/13 3:57 PM CHAPTER 2 Section 2.1 Stress: Origins, Definitions, and Theories According to Freud, childhood emotional traumas leave a residue of psychic energy that can be “converted” into physical symptoms. Indeed, followers of Fr\ eud often referred to hysteria manifested by physical symptoms as conversion hysteria. Note that hysterical symptoms often mimic those associated with physical disorders (such as blindness, deaf - ness, and paralysis), but Freud did not consider hysterical patients to be physically sick (although prominent neurologists such as Charcot disagreed).

Psychosomatic Medicine The field that came to be known as psychosomatic medicine received a considerable boost in scien - tific respectability from the work of the Harvard physiologist Walter Cannon. According to Can - non, organisms (people) faced with a threatening stimulus mobilize their physiological resources to combat or escape the threat (“fight or flight”; Cannon, 1939). Cannon called the physiological response to threat the emergency reaction (or alarm reaction) and showed that it is controlled by the sympathetic nervous system (see Figure 2.1) and by hormones secreted mainly by the adre - nal glands. Once the person has safely escaped or defeated the cause of the threat, the emergency reaction dissipates. However, if the threat per - sists, the emergency reaction may begin to affect a person’s health.

The emergency reaction described by Cannon is the body’s way of coping with immediate threats.

However, the emergency reaction cannot persist indefinitely. Long-term or frequently recurring threats cause the body to gradually wear out. Dete - rioration takes place in a series of stages described by the medical physiologist Hans Selye as general adaptation syndrome, or GAS (Selye, 1950). © Bettmann/CORBIS According to Walter Cannon, individuals undergo a physiological response when faced with a threatening stimulus and use these physiological resources to combat or escape the threat. Cannon called the physiological response the emergency reaction or alarm reaction. get81325_02_c02.indd 27 12/5/13 3:57 PM CHAPTER 2 Section 2.1 Stress: Origins, Definitions, and Theories Nonspecific Stress Theory The GAS begins with a stressor that produces an emergency reaction. Following the emer- gency reaction, the person enters a “resistance” stage. If the emergency reaction can be described as the mobilization of the body’s defenses, then the resistance stage is similar to all-out war. During the resistance stage, the person uses its physiological resources to min - imize tissue damage. At the same time, the adrenal glands release corticosteroids (“stress hormones”), which further increase blood sugar for energy while reducing inflamma - tion and pain. Body functions that are not directly related to avoiding harm (reproduc- tion, digestion, growth) are gradually shut down. This only works for a time, however. If the threat persists, the body’s defenses become progressively depleted. In the final stage, called exhaustion, illness becomes likely.

Any form of external pressure can trigger GAS. People who have particularly demanding jobs (such as the U.S. president, ER doctors, or EMTs) may experience the first stages of GAS every day. We can cope with moderate levels of stress, but extreme stress causes us to break down and become ill (Jiang, Babyak, Krantz, et al., 1996). Selye’\ s view of the GAS is depicted in Figure 2.1. get81325_02_c02.indd 28 12/5/13 3:57 PM CHAPTER 2 Section 2.1 Stress: Origins, Definitions, and Theories Figure 2.1: Selye’s general adaptation syndrome (GAS) Causes may include:

Exhaustion of lipid reserves Inability to produce glucocorticoids Cumulative damage to vital o rgans Alarm Phase Sympathetic system activation and epinephrine release:

1. Mobilization of glucose reser ves 2. Changes in circulation 3. Increases in heart and respiratory rates 4. Increased energy use by all cells “Fight or flight” Immediate, short-term response to crisis Resistance Phase 1.

Mobilization of remaining energy reser ves Adipose tissue releases lipids Skeletal muscles release amino acids 2. Elevation of blood glucose concentrations Liver synthesizes glucose from amino acids and lipids 3. Conservation of glucose Peripheral tissues break down lipids to obtain energy Long-term metabolic adjustments occur Exhaustion Phase Collapse of vital s ystems Death From: Frederic Martini, Fundamentals of anatomy and physiology, Prentice-Hall, 1989, p. 494. Reprinted by permission of Pearson Learning, Upper Saddle River, NJ.

Selye preferred to use the word stressor to refer to causes, reserving the word stress for the results produced by a stressor. Over the years, the boundaries of what constitutes a stressor have been gradually extended. Stressors have come to include not only physical threats, but also emotional experiences (divorce, for example), unpleasant internal states (fatigue), and the subjective feeling of being under pressure. With such a broad definition, practically anything can be a stressor, but all stressors are related in one very important way—they have the potential to trigger a strong emotion leading to a GAS.

Selye believed that the effects of stress are nonspecific. The same physiological response leads to widely different conditions. To explain why people develop different illnesses in get81325_02_c02.indd 29 12/5/13 3:57 PM CHAPTER 2 Section 2.2 Sources of Stress response to stress, Selye postulated that genetic weaknesses, inadequate diet, infectio\ ns, and other individual differences mediate the effects of stress. The specific mechanisms by which stress interacts with these mediating factors to produce illness are discussed next.

2.2 Sources of Stress To summarize our discussion of stress so far, stress and physical illness go together. This is true not just for traditional psychosomatic conditions such as peptic ulce\ r but for meta- bolic conditions such as diabetes as well. This section describes some c\ ommon sources of stress and uses diabetes to show how stress affects physical health as well as mental health.

Catastrophes When asked to imagine the psychological and social causes of stress, most people immedi - ately think of large-scale cataclysmic events: floods, earthquakes, airplane accidents. A cata - clysmic event is dreaded more than a common disease that affects one person at a time, even when the common disease kills more people. This excessive fear of horrific events seems to have negative effects on health. One reason for the extreme stress produced by cataclysmic events is their unpredictability. Most of us go through life with optimistic attitudes. We act as if disasters only happen to others. When we are asked about the probability of having a car accident, going bankrupt, or dying young, most of us rate our luck as better than average (Darke & Friedman, 1997). We seem to share an illusion of invulnerability (“Bad things won’t happen to me”). Catastrophes (a momentous tragic event that can be a moment of very bad luck to a moment where the per- son’s life or livelihood is ruined or ended) shatter this protective illusion; they show us how tenu - ous our good luck really is. This is why catastrophes frighten us more than more common killers such as diabetes. It is also why horrific experiences that threaten people’s lives may produce symptoms long after the original event (see the discussion of post- traumatic stress disorder [PTSD] later in this chapter).

Important Life Events Most stressors are fairly common—job loss, bereavement, divorce. These types of events can lead to what the DSM–5 calls adjustment disorders, psychological disorders marked by anxiety, depression, withdrawal, and overall impairments in psychological function - ing. These common life events also have the power to make people physica\ lly ill, or per - haps even lead to death.

One of the first researchers to study the relationship between life events and illness in a systematic way was the psychiatrist Adolf Meyer (1886–1950), who was an early adherent Associated Press Photos/Ted S. Warren, Pool The possibility of horrific events engenders immense stress or fear in many people, largely due to their unpredictability. get81325_02_c02.indd 30 12/5/13 3:57 PM CHAPTER 2 Section 2.2 Sources of Stress of Freud. To study the effects of stress, Meyer devised the “life-chart” technique. He would draw a time line (a graph of dates) with a person’s illnesses on on\ e side and significant life events on the other. Meyer claimed that illnesses often appeared just after significant life changes (especially job loss and separation).

Over the years, considerable evidence has been amassed to support Meyer ’s claim. For example, long-term unemployment has been found to be related to various illnesses, including heart disease, cirrhosis of the liver (probably from overuse of alcohol), hyper- tension, various psychiatric conditions, and suicide (McKee-Ryan, Song, Wanberg, & Kinicki, 2005). Unemployment reduces self-esteem and makes people dependent on oth - ers (McKee-Ryan et al., 2005).

Meyer ’s work influenced Thomas Holmes, a medical doctor who became interested in the relationship between life events and illness (Holmes & Rahe, 1967). Holmes routinely asked patients about their personal experiences before they had become ill. Like Meyer, he found a relationship between life changes and illness. By studying medical charts, Holmes produced a list of life events that seemed most often to precede illness. Holmes assumed that any life change, positive or negative, could produce stress if it required an adjustment in the way a person had previously lived.

Following Holmes, scientists have repeatedly demonstrated the role of stressful life events in various physical and mental illnesses (Thoits, 2010). Despite these findings, the rela- tionship between life-stress and illness should be interpreted with caution. When stress - ors such as traumas and chronic negative events are measured, the impacts they make on physical and mental health are quite substantial (Thoits, 2010). Moreover, as we have fre - quently seen, even strong correlations cannot be taken as evidence that life-stress causes illness. They could just as easily mean that illness causes life-stress.

Everyday Hassles The average day is full of has - sles. Daily annoyances plague all of us: spending time in rush- hour traffic, waiting at the bank, dealing with noisy neighbors, getting caught in the rain or snow, losing the house keys. If we are lucky, we also have posi - tive experiences: visiting with friends, performing well at school or at work, dining out.

Daily hassles can take their toll.

For example, busy urban white- collar workers, who are exposed to many more daily annoyances than their rural counterparts, are considerably more likely to suffer from headaches, peptic Medioimages/Photodisc/Thinkstock Everyday hassles, like rush hour traffic, can take their toll on the human body. Urban workers are more likely to experience hypertension, peptic ulcers, and headaches, whereas rural inhabitants are less likely to suffer from these ailments. get81325_02_c02.indd 31 12/5/13 3:57 PM CHAPTER 2 Section 2.2 Sources of Stress ulcers, and hypertension. The inflammation that causes so much pain to a\ rthritis sufferers is exacerbated by daily hassles (Irwin, Davis, & Zautra, 2008). Pregnant women whose lives are full of hassles are more likely to have premature and low-birth-weight babies than are women with more relaxed personal lives (Littleton, Bye, Buck, & Amacker, 2010).

Studies of those with diabetes have shown a positive correlation between the perceived severity of daily hassles and blood sugar levels (Sultan, Epel, Sachon,\ Valliant, & Harte- mann-Heurtier, 2008).

Chronic Illness So far, stress has been viewed as a response to external life events and hassles. However, a chronic illness such as diabetes may itself be a significant source of stress (Franks, Lucas, Parris-Stephens, Rook, & Gonzalez, 2010). For those with diabetes, frequent absences from class or work and concern about future diabetes-related medical conditions are facts of life. Additionally those with insulin-dependent diabetes need to constantly wa\ tch their sugar intake, be alert to their insulin levels, and monitor their regular insulin dosages.

When one adds all of these to a perhaps already too busy life, stress can result.

Chronic Pain and Headaches Although pain is not itself an illness, it has the capacity to affect every aspect of our lives.

The acute pain that accompanies a toothache or an illness or injury can \ keep us from thinking about anything else. This type of severe pain can affect immune system function - ing (Chapman, Tuckett, & Song, 2008). Fortunately, healing usually ensures that acute pain will subside over time. In contrast, chronic pain persists indefinitely. Often, this type of pain leads to depression (Hawker et al., 2011). More than 25% of Americans are esti - mated to suffer from some form of chronic pain (Kingsbury, 2008). Americans spent about $2.6 billion on over-the-counter pain medications and another nearly $14 billion on outpa - tient analgesics in 2004 (the most recent data available; Kingsbury, 2008).

Although chronic pain often has a physiological trigger, it may be exacerbated by stress. In severe cases, chronic pain may even be considered a psychological dis- order. For example, the DSM- IV-TR (APA, 2000) contained “Pain Disorder.” The diagnos- tic criteria for this disorder included severe pain that is not feigned and that causes distress or impairment in social, occu - pational, or other areas of func - tioning. Most importantly, the diagnosis required that psycho - logical factors (especially stress) played an important role in the Christopher Robbins/Digital Vision/Thinkstock Chronic pain or illness has the capacity to impact every facet of a person’s life. get81325_02_c02.indd 32 12/5/13 3:57 PM CHAPTER 2 Section 2.2 Sources of Stress onset, severity, exacerbation, or maintenance of the pain. The validity of the diagnosi\ s of pain disorder is a controversial subject. Some authors have claimed that it is too inclusive and may lead to over diagnosis (Fishbain, 1996). Because of the controversy Pain Disorder was removed from the DSM-5 and was replaced with Somatic Symptom Disorder, with Predominant Pain (APA, 2013). Regardless, all agree that pain is made worse by stress.

We also know that individuals may react very differently to the same level of pain: Some may continue work and social activities; others may drop out of life completely (Jensen, Schmidt, Pedersen, & Dahl, 1991). Those who cope well are optimistic, have good sup- port networks, and feel in control of their lives (Gil, Williams, Keefe, & Beckham, 1990; Lackner, Carosella, & Feuerstein, 1996). These characteristics also describe people\ who are resistant to stress.

One of the most common forms of chronic pain is headaches. More than half the popula - tion—and perhaps as many as 60% of people—experience headaches each year (Stovne\ r et al., 2007). Over the years, complicated classification systems have \ been developed to characterize different types of headaches, but the two most common are tension and migraine. Tension headaches were traditionally thought to result from tense muscles in the neck and head, whereas migraines are thought to be caused by the contraction and dilation of blood vessels in the head. Migraines are more severe than tension headaches, often requiring a day or more to resolve. However, some research suggests that the dif- ferences between the two types of headaches are not so clear-cut; both types of head - aches seem to be associated with the same physiological phenomena (Stovner et al., 2007).

Therefore, it is possible that migraines and tension headaches have similar etiologies but that migraines represent a more severe form of headache.

Psychological variables moderate pain in two ways: through inhibition of pain impulses and by the production of chemicals called endogenous opioids (endorphins). In its s\ im - plest form, psychological inhibi - tion can be construed as shut- ting the “gate” that allows pain stimuli to be transmitted to the brain (Melzack & Wall, 1982).

According to the gate control theory, pain stimuli are trans- mitted to the brain via the dor - sal horns of the spinal column, which serve as a kind of gate.

Pain stimuli open the gate, but inhibitory signals sent by the brain can close the gate and keep pain stimuli from reach- ing the brain. This seems to be what happens when soldiers are injured in battle; some do not feel any pain until after the battle is over (Melzack & Wall, 1982). Science Photo Library/SuperStock This illustration displays the molecular composition of tramadol, a class of drugs called opiate agonists. Tramadol is administered to relieve pain and is also available in extended release capsules to treat patients with chronic pain who need continuous, long-term treatment. get81325_02_c02.indd 33 12/5/13 3:57 PM CHAPTER 2 Section 2.3 Effects of Stress Endorphins are chemicals produced by the body which, like opiates (heroin, for instance), can serve to reduce pain. There is some evidence that people who cope well with their pain produce higher levels of endorphins than those who fail to cope (Bandura,\ O’Leary, Taylor, et al., 1987). It seems possible that, in addition to the endorphins,\ we may also have specialized chemical pain-reduction systems (Chapman et al., 2008).

2.3 Effects of Stress To understand the complex web of interactions between external stressors and the stress produced by chronic illness, we need to take a closer look at the precise mechanisms by which stress exerts its effects on physical and psychological health. Specifically, we shall examine two ways in which stress affects health: (a) the direct effects of stress on physi- ological functioning and (b) the indirect effects of stress on health-relevant behaviors.

Direct Physiological Effects of Stress As we have seen in the discussion of the general adaptation syndrome, stress has direct effects on physiological functioning. In Figure 2.2, stress causes the release of certain hor - mones, which increases the rate of blood clotting, raises respiration and blood pressure, and prepares the body for exertion.

The direct effects of stress on physiological functioning have also been implicated in car - diac arrests (heart attacks) and strokes (blood clots that destroy brain tissue). According to Sapolsky (1992, 1993), the corticosteroid hormones produced by the GAS have both beneficial and harmful effects. They reduce inflammation and inhibit pain, but they may also weaken neurons, especially in the hippocampus. In the short term, the body produces special proteins to protect neurons and other cells from hormone damage, but their effec - tiveness weakens with prolonged or repeated stress (Marcuccilli & Miller, 1994). Once the hippocampus has been weakened, it can no longer play its moderating role, and the stress response becomes difficult to “turn off.” get81325_02_c02.indd 34 12/5/13 3:57 PM CHAPTER 2 Section 2.3 Effects of Stress Figure 2.2: Corticosteroid release in response to stress Hypothalamus CRF Posterior pituitary Anterior pituitary Glucocorticoids(corticosteroids) ACTH Ad renal gland Kidney Stressor When the brain perceives a stressor, the hypothalamus releases CRF (corticotropin releasing factor) and other hormones. The CRF triggers the release of ACTH (adrenocorticotropic hormone, or corticotrophin) in the anterior pituitary. The ACTH travels in the bloodstream to the adrenal glands, where it triggers the release of corticosteroids.

From: Robert Sapolsky, Why Zebras Don’t Get Ulcers: An Updated Guide to Stress, Stress Relat\ ed Diseases, and Coping , W.H. Freeman, 1998, p. 33. Reprinted by permission. get81325_02_c02.indd 35 12/5/13 3:57 PM CHAPTER 2 Section 2.3 Effects of Stress Indirect Effects of Stress on Health Effects of Stress on Cognition Stress exerts profound effects on memory, judgment, and other aspects of cognition (Broadbent, Baddeley, & Reason, 1990; Christianson, 1992). Studies of airline pilots, for example, have shown that as they become increasingly stressed, they become less alert.

They have attention lapses and become easily distracted. Stress does seem to be a factor for pilot burnout (Fanjoy, Harriman, & DeMik, 2010).

The effects of stress are insidious because they are not immediately apparent to the indi- vidual concerned. Even when they were slow to respond to their instrument readings, pilots believed they were as efficient as they were when not under stress.

However, stress tends to affect information-processing capacity in complex ways (Lee & Goto, 2011). Stress does not always lead to poor decision-making. Moderate amounts of anxiety (such as that produced by an upcoming performance, for example) may actually serve to focus attention on essential information. However, high levels of stress can shrink information-processing capacity to the point where important information is ignored.

Studies of airline pilots have found them more likely to read their instruments incorrectly when flying in bad weather. Presumably, this is because coping with a storm produces stress (Broadbent, 1973).

The Stress-Illness Cycle As already noted, illness can be a source of stress. It can interfere with cognitive and emotional functioning and exacerbate the effect of external stressors. Illness can also pro - duce stress through its effects on social function - ing. Some illnesses produce stress because they are perceived as a sign of weakness. For example, people with liver disease resulting from the over - use of alcohol and people with AIDS resulting from intravenous drug use are often stigmatized and shunned because their illness is perceived as self-inflicted (Weiner, 1993), and this stigmatiza - tion can cause stress.

Clinical psychologists need to be sensitive to the many ways in which physical, social, and psycho - logical factors interact. Helping people requires that we somehow prevent the tendency for stress and illness to feed off one another. However, before we examine how this might be accom - plished, we need first to examine why some people seem better able to withstand stress than others. Specifically, we need to understand differ - ences in coping skills.

Let’s examine the case study of William Cole. Digital Vision/Thinkstock Illness can be a source of stress and sometimes produces stress through its effects on social functioning. For example, people with liver disease due to the overuse of alcohol may be shunned because others perceive their illness as self-inflicted. get81325_02_c02.indd 36 12/5/13 3:57 PM CHAPTER 2 Section 2.3 Effects of Stress Case Study: William Cole University Hospital Psychology Service CONFIDENTIAL Consultation Note Psychologist:

Dr. Stewart Berg Referral: Dr. M. Jankowitz Reason for Referral: The client was brought to the Emergency Room in a diabetic coma. He responded well to medical treatment, but he seemed withdrawn and complained of chronic head- aches. Dr. Jankowitz requested advice about the patient’s state of mind and about the potential for his mental state to affect his illness.

Behavioral Observations: William Cole is an 18-year-old African American male. He is of average height but rather thin. He was neatly dressed and clean shaven. He entered my office slowly and hesi- tantly. Although he cooperated by answering questions, he volunteered little and seemed withdrawn. He avoided making eye contact, and his facial expression was tense. He frequently held his forehead in his hand.

History:

William is a first-year student and the first member of his family to attend college. He is assisted by a student loan and has a job working in the library. His father works in an automobile fac- tory, and his mother is a telephone company employee. They live in Los Angeles and see their son on holidays. He calls home every Sunday.

William reports being an athletic child with a close group of same-sex friends. He first learned that he had diabetes at age 13. His mother took him to the family doctor because he was always tired and thirsty and he urinated frequently. A blood test at the time confirmed the diagnosis. William’s illness could not be controlled by diet. He required daily insulin injections. At first, William would not believe he was sick and resisted treatment. He continued to “hang out” with his friends and to play football and baseball. Eventually, however, he says he “accepted” his illness.

William reports that his mother became his nurse. She made sure that he followed a proper diet, checked his urine for sugar (several times each day), and administered his injections. She posted a chart of glucose test results on the bathroom door. William gradually lost contact with his friends. He says this was because his mother urged him to avoid sports or any other activity where he could get physically hurt.

A combination of diet and insulin kept William’s condition stable for 5 years. The only exceptional inci- dent occurred toward the end of his junior year in high school.

He was preparing for his examinations and was feeling left out because he did not have a date for the junior prom. He felt weak but kept going to school. He fainted in class and, although he quickly revived, was taken to the hospital, where he spent one day.

Since William entered college, he has had no serious diabetic episodes until the current one, although he has had trouble sleeping and has experienced loss of appetite. He claims not to have told any of the other students of his illness. get81325_02_c02.indd 37 12/5/13 3:57 PM CHAPTER 2 Section 2.4 Post-Traumatic Stress Disorder (PTSD) Stress can have a profound psychological effect on the individual, as we will see in the next section where we examine post-traumatic stress disorder (PTSD).

2.4 Post-Traumatic Stress Disorder (PTSD) Post-traumatic stress disorder (PTSD) existed long before the Vietnam War, but it had not been formally identified as a diagnosable condition. In 1980, the newly \ published DSM–III gave the disorder a name. PTSD was defined as an extreme anxiety response to traumatic, life-threatening events that were “outside the range of normal human experience.” By giv - ing Vietnam veterans’ symptoms a name, and by making PTSD a recognized mental condition, the DSM–III legitimized the veter - ans’ (and others who experience extreme trauma) claims for help.

The main symptoms of PTSD are anxiety, the avoidance of stimuli associated with the trauma, flashbacks in which the traumatic event is relived men- tally, and a “numbing” of emo - tional responses (Marx & Sloan, 2005). Not surprisingly, PTSD has been found to affect practi - cally every aspect of everyday life (Burijon, 2007).

PTSD is not limited to veterans who survive a war. PTSD also affects victims of violence, especially rape (Breslau, Davis, Andreski, & Peterson, 1991), as well as those who witness acts of extreme violence such as the 9/11 terror attacks on the World Trade Center in New York City and most likely those who witnessed the Boston Marathon bombing\ s in April 2013. The DSM–5 recognizes that the symptoms of PTSD appear differently in children younger than 6 years old and has a separate subcategory: “Posttraumat\ ic stress disorder for Children 6 years and Younger” (APA, 2013). Within the subcategory “Posttraumatic stress disorder” there are notes within some of the specific criteria differentiating how children older than 6 might manifest specific symptoms. For example, a child’\ s dreams may be frightening but the content of the dreams might be unrecognizable (APA, 2013).

Children who have been abused, for example, often show behavioral changes (an\ outgo - ing child may become reclusive; a quiet child may start acting aggressively). Young chil- dren who have been toilet trained may go back to soiling themselves and be\ d-wetting.

Left untreated, PTSD symptoms can last a lifetime (Potts, 1994). Everett Collection Many soldiers are affected by post-traumatic stress disorder long after the danger of combat is over. get81325_02_c02.indd 38 12/5/13 3:57 PM CHAPTER 2 Section 2.4 Post-Traumatic Stress Disorder (PTSD) Etiology of PTSD Approximately 7% of the population has PTSD (Burijon, 2007). In order to qualify for diag- nosis, PTSD symptoms must be present for at least one month (most of the DSM–5 disor- ders require that symptoms be present at least six months). In addition, if the diagnostic criteria are not met until, minimally, six months after the event’s occurrence (though some symptoms may be present), the specifier “With delayed expression” is used (APA, 2013).

Unlike most psychological disorders, the etiology of PTSD is defined in its diagnostic criteria—it is caused by experiencing, either directly or indirectly, an extraordinarily stressful, traumatic event. Given a severe enough trauma, even well-adjusted people may develop PTSD (Clark, Watson, & Mineka, 1994). Yet, most people manage to escape even the most terrifying events with no signs of an anxiety disorder (Rachman, 1991). What protects such people? What makes others succumb? The usual answer to these\ questions is that some people are more vulnerable than others. They may have pre-existing psycho - logical disorders or a family history of psychological disorder (Breslau et al., 1991; Flach, 1990). Vulnerable people may inherit a disposition to develop PTSD (Andreasen, 1995; Koenen et al., 2003; True, Rice, Eisen, & Heath, 1993). There is evidence that people with PTSD have higher levels of stress hormones than others (Burijon, 2007), although the evi - dence is vague (Bachmann, Sedgley, Jackson, Gibson, Young, & Torphy, 2005). Certainly, people who develop PTSD seem to have strong emotional reactions to life’s problems (Burijon, 2007).

We should not discount the important role played by a person’s social environment.

Consider, for example, the finding that PTSD is more common among African American and Hispanic Vietnam War veterans than among white veterans, especially white offi- cers. Does this mean that, compared with white officers, African American and Hispanic enlisted men are less hardy, more autonomically responsive, and more prone to emotion- focused coping? Not necessarily. Forces outside the individual, such as poor social sup- port, may also play an etiological role in post-traumatic stress disorder (Charuvasta & Cloitre, 2008). get81325_02_c02.indd 39 12/5/13 3:57 PM CHAPTER 2 Section 2.4 Post-Traumatic Stress Disorder (PTSD) Figure 2.3: Post-traumatic stress disorder A model of the causes of PTSD.

From “Posttraumatic Stress Disorder” by T.M. Keane & D.H. Barlow (2002), in Anxiety and Its Disorder: The Nature and Treatment of Anxiety and Panic, by D.H. Barlow, 2nd ed. New York: Guilford Press. Copyright 2002 by Guilford Press. Reprinted by perm\ ission. get81325_02_c02.indd 40 12/5/13 3:57 PM CHAPTER 2 Section 2.4 Post-Traumatic Stress Disorder (PTSD) Therapeutic Treatment for PTSD With the publication of the DSM–III, mental health professionals began to devote increas - ing attention to PTSD. Trauma victims were encouraged to discuss their troubles in groups made up of victims of similar traumas. It is generally accepted tha\ t the social sup - port provided by these groups is an important ingredient of successful therapy (Lifton, 2005). However, group discussions alone may not always be sufficient. Other therapeutic interventions may also be needed. The most common behavioral intervention is exposure (Koch & Haring, 2008). Victims are helped to confront their memories of the traumatic event so that their anxiety can be extinguished. Flooding, systematic de\ sensitization, cog - nitive restructuring, and stress-management training are also used to help clients over - come their anxiety and to teach them how to cope with anxiety-provoking situations that may arise in the future (Foa, Rothbaum, Riggs, & Murdock, 1991).

Some research has reported successful treatment of PTSD using a technique called eye movement desensitization and reprocessing (EMDR), in which people are asked to visu - alize images of the traumatic event (Russell, Silver, Rogers, & Darnell, 2007). Once the images are clear, clients are required to follow the movements of the clinician’s finger (or a pencil) with their eyes while holding their head still. Because \ it is a relatively new type of intervention, the effectiveness of EMDR has been controversial, and early research results are inconclusive. Some believe the exposure itself and not the eye movement may be responsible for the success with this treatment method (Lamprecht, Kohnke, Lempa, Sack, Matzke, & Munte, 2004). A growing body of research aims to determine the legiti - macy and efficacy of this approach.

Drug Treatment for PTSD The FDA has approved only two medications for PTSD treatment: the SSRIs Paxil (par - oxetine) and Zoloft (sertraline). They seem to help alleviate anxiety\ and panic attacks, making other PTSD symptoms more manageable (Golier, Legge, & Yehuda, 2007). The primary method of treating PTSD remains psychotherapy.

Early Intervention and Prevention of PTSD The prevention of PTSD requires early intervention. For soldiers, this means instituting treatment at the first sign of stress (Samter et al., 1993). Many victims of trauma never get treatment. For example, rape victims rarely seek psychological help in the period imme - diately following the rape (Patterson, Greeson, & Campbell, 2009). They do not see them - selves as psychologically disturbed but as victims of a crime that they \ would rather forget.

Unfortunately, sometimes the police, lawyers, and the press make sure that the attack is never far from mind. Some victims may even find themselves being blamed for the attack.

The stress can build up until it produces a stress disorder (Falsetti, Resnick, Dansky, et al., 1995). Police reactions often seem to influence how rape victims feel, possibly affecting the severity of PTSD (Maddox, Lee, & Barker, 2011). It is at this point that victims seek assistance. get81325_02_c02.indd 41 12/5/13 3:57 PM CHAPTER 2 Section 2.6 Illness of the Mind or the Body: A Dubious Distinction 2.5 Acute Stress Disorder The DSM–5 recognizes another disorder associated with trauma: acute stress disorder.

Similar to PTSD, this disorder occurs in response to traumas, but acute stress disorder is diagnosed when the symptoms typically occur immediately after the trauma\ . The symp - toms must last for minimally three days and no longer than a month after the trauma to qualify for this diagnosis (APA, 2013). The symptoms of acute distress disorder are similar to those for PTSD: persistent re-experiencing of the trauma through flashbacks, intru - sive thoughts, and nightmares. A person experiencing acute stress disorder may avoid reminders of the trauma and may feel numb or detached, or report feeling as if he or she is in a dreamlike state. Although it is a short-term response to trauma, people with acute distress disorder are at risk for continuing to experience post-traumatic stress symptoms for many additional months.

2.6 Illness of the Mind or the Body: A Dubious Distinction Diabetes may not seem particularly relevant to abnormal psychology because it is a phys - ical disease. Traditionally, abnormal psychologists have limited their interest in physi - cal diseases to the so-called psychophysiological or psychosomatic disorders (psycho = mind, somatic = body)—disorders in which psychological factors produce “real” physical diseases, such as peptic ulcer, asthma, hypertension, and headaches. Psychosomatic con - ditions were thought to differ from other physical illnesses because psychological factors played a significant role in their etiology. Asthma, for example, was attributed to loss or separation, ulcers to stress-producing jobs, headaches to helplessness, and hypertension was supposedly the result of repressed anger. In recent years, it has become increasingly clear that this approach to physical illness is too simplistic. For example, we now know that many peptic ulcers are the result of a bacterial infection that thrives on stress, which results in a physical condition (peptic ulcer). This is a perfect example of the diathesis- stress model of psychopathology discussed in Chapter 1.

Because of the interplay between physiological and psychological factors\ , distinguishing between pure physical illnesses and those with psychological components is now widely recognized as artificial and futile. Social and psychological factors affect all illnesses, from the common cold to cancer, from hernia to heart disease, from skin rashes to diabetes.

Those studying behavioral medicine examine the interaction between psychology and physiology, seeking to learn how psychological factors (1) make people susceptib\ le (or resistant) to illness, (2) alter the course of an illness, (3) influ\ ence compliance with medical treatment, and (4) affect health-related behavior. Today’s serious illnesses tend more and more to be the result of behavioral choices—smoking, using drugs, and drinking alco - hol to excess (Oyama & Andrasik, 1992). Understanding and preventing illness-causing behaviors such as smoking have the potential to do more to improve public health than building any number of new hospitals. The disciplines contributing to behavioral medi - cine are depicted in Figure 2.4. get81325_02_c02.indd 42 12/5/13 3:57 PM CHAPTER 2 Section 2.6 Illness of the Mind or the Body: A Dubious Distinction Figure 2.4: Disciplines contributing to behavioral medicine Biologicalsciences (biochemistry, immunology) Pro fessional studies (nursing, physical therapy) Social sciences (anthropolog y, sociology) Psyc hological and behavioral sciences Medical sciences (patholog y, radiology) Behavioral Medicine Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 5.9, p. 217.

Early versions of the DSM included a variety of “psychosomatic” disorders. These no longer appear in the DSM-5, which refers instead to “psychological factors affecting other medical conditions.” This diagnosis is applied when psychological fac\ tors appear to cause, exacerbate, or delay recovery from a medical condition or when psychological factors interfere with treatment. The DSM–5 also acknowledges that causality can go both ways.

In other words, medical conditions can produce or exacerbate psychological problems.

The DSM–5 includes several diagnoses that recognize the interaction between psychologi - cal variables and physical illness (for example, “sexual dysfunction due to a general medi - cal condition”). However, these diagnoses hardly do justice to the complex interactions that take place between psychological factors and health. get81325_02_c02.indd 43 12/5/13 3:57 PM CHAPTER 2 Section 2.7 Factors That Modify the Effects of Stress Psychological interventions, such as the provision of social support, are often aimed at helping clients to comply with their treatment regimen, thereby limiting complications.

Thus, interventions designed to address psychological factors such as social isolation not only have direct psychological effects but also help to reduce the severity of the physi- ological disease. Improved physical health, in turn, affects psychological well-being by reducing depression and social isolation. This is a typical pattern. Psychological an\ d phys - iological variables continuously interact, one set of variables affecting and being affected by the other. The aim of this chapter is to illustrate psychology’s role in understanding and treating psychological disorders as well as in fostering health. (See Part 2 of the Wil - liam Cole case study in your e-book.) 2.7 Factors That Modify the Effects of Stress Coping means finding effective ways to adapt to the problems and difficulties presented by stress. In general, successful coping is marked by compliance with the treatment regime, by acceptance of the limitations and challenges of the illness, a\ nd by attempting to lead as “normal” a life as possible. Unsuccessful coping is evidenced by poor treatment compliance, shame, and social isolation.

Poor compliance is not surprising in chronic conditions, especially those in which the treat - ment regime is complicated. However, noncompliance also occurs when treatment is sim - ple. For example, among women who have had breast cancer, fewer than half follow their doctors’ recommendations for simple breast self-examinations (Taylor, Lichtman, Wood, et al., 1984). Because compliance is essential to long-term health, con\ siderable research has been devoted to clarifying why patients fail to comply with the recommended treatment.

This research has identified several important factors (e.g., people comply better\ with clear instructions; warm doctor-patient relationships facilitate compliance), but the most important factor seems to be the way in which people appraise the stress produced by ill - ness (Miller, Shoda, & Hurley, 1996). Some people deny being sick, others make a hobby out of it. Denial reduces compliance, whereas obsessive attention to one’s health increases compliance. In this section, we will see that treatment compliance depends on learning to cope with stress.

Appraisals The effects of a stressor depend to a large extent on how the stressor is perceived. Thus, the first step in coping is to appraise the stress-producing situation (Taylor & Aspinwall, 1996). The appraisal of life events results in emotional, physiological, and behavioral responses that interact with one another in complex ways to determine how\ people cope with illness (Figure 2.5). get81325_02_c02.indd 44 12/5/13 3:57 PM CHAPTER 2 Section 2.7 Factors That Modify the Effects of Stress Figure 2.5: Life events Life events Hassles Catastrophies Illness Appraisalof event Emotional responses Physiological responses Behavioral responses The effects of life events depend on how they are appraised.

Adapted from Schwartz, S. 2000. Abnormal Psychology: A Discovery Approach. Mountain View, CA: Mayfield Publishing Company, Fig 5.9, p. 217.

According to Richard Lazarus (1993), there are two types of appraisal: primary and sec - ondary. In primary appraisal, the individual assesses the personal implications of an event.

Events may be appraised as irrelevant, beneficial, or stress-inducing. Secondary appraisal is concerned with what, if anything, should be done. If an event is appr\ aised as stress- inducing, the individual may then appraise the harm done and decide how to prevent a future recurrence. If the harm has not yet been done, appraisal may take the form of how to avoid or minimize harm. Appraisals often include a comparison of costs and benefits.

Cognitive appraisals need not be so calculated or rational; they do not \ even have to be conscious. However, at some level, our response to stress is always based on our personal perception of external events.

Denial is a primitive form of coping, but it can sometimes be useful. If an illness is untreat - able, denying the facts may help the ill person make the most of what li\ fe remains. On the other hand, if a condition can be helped by a change in behavior, denial may make matters worse. A less extreme form of denial is to admit that one has an illness but to minimize its seriousness. Again, if treating life-threatening illnesses as minor annoyances allows a person to lead a fuller life than would otherwise be the case, a little \ denial is probably a good thing. However, if carried too far, denial can lead people to ignore the limitations imposed by illness—and possibly to take unwise health risks.

In contrast to those who minimize their illness, some people cope by bec\ oming obsessed with their condition. They devote a lot of their energy to managing their disease. If their obsessiveness increases their quality of life, then it is a reasonable way of coping. On the other hand, if their extreme concern with their health causes other activities and relation- ships to suffer, then it is not a successful way of coping. Instead of controlling their illness, obsessive people may wind up achieving the opposite; they may find that \ their illness controls them. What is required is a happy medium between minimization and obses- sive attention that provides a balance between controlling illness and not letting it take over one’s life. Lazarus and his colleagues (Folkman & Lazarus, 1990; Lazarus, 1993) call get81325_02_c02.indd 45 12/5/13 3:57 PM CHAPTER 2 Section 2.7 Factors That Modify the Effects of Stress denial and obsessiveness emotion-focused coping. The goal of emotion-focused coping is to manage feelings to make ourselves feel better (Doron, Stephan, Maiano, & Le Scanff, 2011). Problem-focused coping, on the other hand, involves making a plan of action and dealing directly with the stressor (Doron et al., 2011). For example, when faced with a dif - ficult final exam, emotion-based coping could take the form of avoiding \ thinking about the exam in order to reduce anxiety. In contrast, problem-focused coping would involve formulating a schedule for studying and a procedure for self-assessment.

It is important to know when to apply different types of coping. Relying on emotion- focused coping when problem-focused coping could result in a better outcome leads to sad results. However, problem-focused coping works only when a person has the ability to remedy the situation by taking some action. When events are not in a person’s control, problem-focused coping may lead to frustration and more stress. When action is futile, it makes more sense to rely on emotion-focused coping.

Why do some people manage to cope successfully with their illness, whereas others never seem to be able to adjust? At least part of the answer lies in the coping resources available to the individual.

Social Support Coping is not simply a matter for the person who is ill. It involves fam\ ily members and friends as well. Some family members try to distance themselves from the ill relative (per - haps to avoid the pain of a loved one’s suffering). Others derive enhanced self-esteem from helping the individual cope (Kovacs & Feinberg, 1982). Provided that it does not lead to overprotectiveness and dependency, the latter attitude is more helpful to someone attempting to come to grips with a chronic illness.

Given that all family members are affected by one member ’s chronic illness, it is not sur - prising that family conflict affects how well chronically ill people cope (Wertlieb, Jacobson, & Hauser, 1990). People with diabetes who live in harmonious families seem to have bet - ter control of their blood sugar than do those who live in distressed or unhappy families.

It should be noted, however, that some studies have failed to find a strong relationship between family harmony and diabetic control (Gowers, Jones, Kiana, 1995; Kovacs, Kass, Schnell, et al., 1989). One possible reason for the discrepant results is the reliance on self- report. Members of dysfunctional families may be reluctant to admit that disharmony exists.

To be effective, however, social support must be appropriate for a person’s stage of devel - opment. For example, daily questioning (“Have you had your insulin t\ his morning?”) improves treatment compliance in young children but actually makes it worse in adoles - cents, who resent this intrusion on their autonomy and independence (Idalski-Carcone, Ellis, Weisz, & Naar-King, 2011).

Social support contributes to health in several ways. First, by providing acceptance, social ties may help maintain self-esteem. Second, friends provide help in times of trou - ble and sympathetic ears for the expression of painful feelings. Third, members of self- help groups are important sources of new information about the disease and its control. get81325_02_c02.indd 46 12/5/13 3:57 PM CHAPTER 2 Section 2.7 Factors That Modify the Effects of Stress Of course, it is always possible that people who are sick with- draw from social contact. In such cases, illness has affected their social life rather than the other way around. We should not expect miracles from strong social support, however. Social support does not act in a vac- uum. As described in the next section, individual differences and external social events can moderate the effects of social support. There may even be times when social support is not beneficial, as explained in the next Highlight. Individual Characteristics Stress affects people in markedly different ways; an event that has a devastating effect on one person may hardly affect another. This section looks at some of the reasons for these individual differences: knowledge, hardiness, self-esteem, locus of control, and attributions.

Knowledge At first glance, coping with treatment may appear to be simply a matter of knowledge. We reason that once the patient knows what needs to be done and why, compliance should follow. Knowing what to do (and why) does not guarantee healthy behavior. One reason that knowledge does not guarantee healthy behavior is that the illusion of invulnerability discussed earlier leads most of us to minimize the probability of bad outcomes. Medi - cal students and students of clinical psychology are exceptions. They tend to err in the opposite direction, exaggerating their susceptibility to illness. They may even deve\ lop the signs and symptoms of the diseases they study (known as a psychosom\ atic reaction or a somatic symptom disorder). This was discussed in Chapter 1 and is called medical student syndrome. Overestimating one’s susceptibility to illness is just as misleading and \ maladaptive as minimizing it. In both cases, knowledge does not guarante\ e appropriate behavior. iStockphoto/Thinkstock During times of illness, friends may offer a sympathetic ear or help maintain self-esteem. get81325_02_c02.indd 47 12/5/13 3:57 PM CHAPTER 2 Section 2.7 Factors That Modify the Effects of Stress Highlight: When Social Support Increases Stress To be of value, social support must work to facilitate positive goals. Friends who want to take you out for a pizza the night before an important exam may think they are being supportive, but the outcome of their behavior may be that you fail the exam.

A compelling demonstration of the potential costs of social support may be found in a study by Baumeister and Steinhilber (1984). These researchers examined baseball World Series records from 1924 to 1982 and basketball semifinal and championship series for the years 1967 to 1982. They were particularly interested in the success of the home team. Teams playing at their home field or stadium have an audience of sup- porters to cheer them on. This is a form of “social sup- port” that is usually interpreted as giving the home team an advantage over the visitors. Overall, the statistics confirmed this advantage. Both baseball and basketball teams are more successful in front of their fans. However, this advantage was evident only early in the season. End-of-season championships, such as the World Series, produced quite the opposite results. Home teams were more likely to lose. The pressure of playing in front of fans, of not wanting to lose at home, may cause a team to “choke.” Teams actually performed better without the social support provided by their hometown crowds. See Baumeister (1995) and Wallace, Baumeister, and Vohs (2005) for more support of these findings. © Joseph Sohm/Visions of America/Corbis Teams playing at their home field receive “social support” from their fans, and this is often considered an advantage over the visiting team. Hardiness People who withstand stress when their coworkers, friends, and relatives break down may possess certain protective personality traits. Optimists, for example, tend to with - stand stress better than pessimists. Around examination time, optimistic students report less fatigue and fewer colds, aches, and pains than their pessimistic pe\ ers. Hardiness is a particular form of optimism (Bernard, Hutchinson, Lavin, & Pennington, 1996; Kobasa, Hilker, & Maddi, 1979). Hardy people are committed to their work and believe that they have at least partial control over events. They view change as a challenge and an oppor - tunity to grow. They downplay the importance of setbacks by putting them in the per - spective of an entire life. When stress occurs, hardy people try to cope by addressing the specific problem in a positive way (Williams, Wiebe, & Smith, 1992). There is also some evidence that hardiness and optimism are inherited dispositions (Caprara, Steca, Alessan - dri, Abela, & McWhinnie, 2009 ). These findings are certainly worth further investigation, but we should be careful not to overemphasize them. Most of all, we should avoid char - acterizing people who fall ill as lacking healthy personality traits. get81325_02_c02.indd 48 12/5/13 3:58 PM CHAPTER 2 Section 2.7 Factors That Modify the Effects of Stress Self-Esteem Being different, not being able to do the same things as others, takes its toll on self-esteem.

Low self-esteem, in turn, leads to a discrepancy between a person’s real and ideal self.

Humanists attribute many psychological problems to a discrepancy between one’s real and ideal selves. Not every ill person has low self-esteem of course. Ho\ wever it is all too common among individuals who seek therapy and at the least can possibly \ create more stress in one’s life. For example while some might think that an intelle\ ctually gifted child has a huge advantage over many other children in her class, many do not understand that it is often difficult for these children to “fit in,” as they are seen as different by their peers. This can lower their self-esteem and may lead to these children feeling out of place or ostracized.

Locus of Control Adults are usually considered responsible enough to comply with treatment. However, not all people accept this responsibility. In theory, at least, people who have an external locus of control—who believe that external forces are more likely to determine what hap - pens to them than their own actions—should be less likely to adhere to a treatment regime than those who have an internal locus of control (Lefcourt, 1992). People who have an internal locus of control believe that their life’s outcomes are under their control and occur because of their actions, not because of external factors out of t\ heir control.

Studies of locus of control have produced a mixed picture (May, 1991; Wertlieb et al., 1990). Some report an external locus of control among chronically ill people; some do not.

One possible reason for the discrepant results is the reciprocal effect of health status on locus of control.

Despite uncertainties about the precise relationship between locus of control and illness, there is ample evidence that feeling in control helps reduce stress. Feelings of control come from three factors: familiarity, predictability, and controllability. Familiarity reduces stress by making us more aware of what to expect. This is why your first job interview is likely to elicit a greater alarm reaction than your second or third. Predictability exerts an effect on stress independent from familiarity. In a demonstration of the effects of pre - dictability, laboratory rats produced a more intense autonomic reaction to unpredictable electric shock than to shocks of exactly the same voltage occurring on a\ predictable sched - ule (Weiss, 1977). Indeed, animals who received unpredictable shocks developed peptic ulcers at a much greater rate than did rats who received predictable shocks. Providing the animals with a way of avoiding or shutting off the shock reduces the stress response even further. This last finding suggests that controllability also determines a stressor ’s effect (Tsuda, Ida, Satoh, et al., 1989). Similar effects have been found among older people placed in nursing homes without their consent (Rodin, 1986). They decline rapidly and die sooner than people who are allowed to choose for themselves where they will live and to determine their own daily activities. get81325_02_c02.indd 49 12/5/13 3:58 PM CHAPTER 2 Section 2.8 Helping People Cope Health Beliefs and Attributions Instead of focusing on a global belief such as internal or external locu\ s of control, some researchers have studied the relationship between more specific beliefs and treatment compliance. For example, among those with diabetes, adherence to the treatment regime may be related to specific beliefs about themselves and their illness (May, 1991). Some of these beliefs include • susceptibility (“I will not develop complications.”) • severity (“Diabetes is not really all that serious.”) • the benefits of compliance (“If I don’t stick to the regime all of the time, it won’t hurt me in the long run.”) • the costs of compliance (“My injections keep me from going out at night.”) It is not surprising that health beliefs were better predictors of adherence than of blood sugar levels. Even when adherence is perfect, blood sugar levels may vary depending on numerous physiological and emotional factors (Brownlee-Duffeck, Peterson, Simonds, et al., 1987).

One unusual result of the study by Martha Brownlee-Duffeck and her colleagues was their finding that, among adolescents, those who perceived their illness as severe (and their susceptibility to complications as high) had poorer adherence to treatment than did those who minimized their illness. This relationship was exactly the opposite of the one the researchers expected to find. One explanation is that people who do not adhere to treatment are just being realistic. They know that with their severe illness they are more likely to develop complications, so why waste their effort? This explanation implies that health beliefs may both affect behavior and be affected by behavior (May, 1991).

2.8 Helping People Cope Practically every type of psychological treatment has been applied to helping people cope with stress, chronic pain, and the management of illnesses such as diabetes (Bradley, 1994; Rubin & Peyrot, 1992; Shillitoe & Christie, 1990). The main aim is to reduce stress, thereby reducing pain and preventing illness or exacerbations of illness. The general term stress management has come to be applied to the various approaches to reducing stress (Lehrer & Woolfolk, 1993). Some treatments take a direct approach, teaching relaxation and other stress-reduction skills. Others take an indirect approach. They attempt to change cogni- tions and behaviors, which may, in turn, lead to better health through better diabetic man - agement. Every coping process and every coping resource are potential candidates for intervention. Thus, psychologists may try to build a person’s self-esteem, provide social support, or even reorient a person’s locus of control from external to internal. get81325_02_c02.indd 50 12/5/13 3:58 PM CHAPTER 2 Section 2.8 Helping People Cope Stress Reduction Through Relaxation One popular and effective method of stress reduction is Edmund Jacobson’s (1938) pro- gressive muscle relaxation technique. Individuals are instructed to alternately tense and relax different groups of muscles. For example, focusing on the muscles of the lower arm, the individual would make a fist and then relax it. The person then continues to move throughout the rest of the body, focusing on different muscle groups until the entire body is relaxed. The goal is to make individuals aware of muscle tension and to give them practice in relaxing different muscle groups. When muscle tension is not a promi - nent symptom, therapists may use alternate relaxation techniques, such as transcendental meditation, in which the person focuses attention on quietly repeating a specific syllable (the man - tra), or hypnosis. In each case, the underlying rationale is that relaxation is incompatible with stress. Individuals who learn to relax in stress - ful situations should have fewer and less-intense alarm reactions. Fewer alarm reactions mean less strain on the heart, the nervous system, and the immune system.

In one now classic demonstration of the power of relaxation, middle-aged heart attack survivors were randomly assigned to one of two conditions (Friedman & Ulmer, 1984). One group received advice from cardiologists about exercise, medi - cations, and diet. The second group received the same advice plus continuing counseling on how to relax (eat slowly, smile at others and laugh at yourself, admit mistakes, and take time to enjoy life). The two groups were followed for 3 years.

During that period, members of the relaxation group had only half the number of heart attacks as the first group. Friedman and Ulmer note that “no drug, food, or exercise program ever devised, not even a coronary bypass surgical program, could match the protection against recurrent heart attacks” of simply learning to relax (p. 141). iStockphoto/Thinkstock There are various methods to reduce stress, such as Jacobson’s progressive muscle relaxation technique or transcendental meditation. When individuals can relax in stressful situations, there are fewer or less-intense alarm reactions and less strain on the body’s nervous and immune systems. get81325_02_c02.indd 51 12/5/13 3:58 PM CHAPTER 2 Section 2.8 Helping People Cope Figure 2.6: Stress relief Watch TV Listen to music Take bath or shower Go for a walkExercise Scream at others Have sex Drink alcoholic beverage Activity Pe rcentage Who Perform Activity When Stressed 10 0 90 80 70 60 50 40 30 20 10 0 75% 67%61% 57% 38% 38%33% 22% What do people do to relieve stress? According to one large survey, most watch television or listen to music.

Adapted from Corner, R. J. 2007. Abnormal Psychology. 6e. NY: Worth Publishers.

Evidence shows that relaxation training given to patients undergoing treatment for vari - ous diseases, including cancer, made them less fatigued and depressed and more likely to finish the treatment course (Demiralp, Oflaz, & Komurcu, 2010). The benefits of relax- ation training are not limited to people being treated for an illness. Employers have found that offering training in relax - ation and other aspects of stress management at the workplace can improve employee per - formance (Quick, Murphy, & Hurrell, 1992). In highly stress - ful environments, whole com - munities have benefited from such training (Ingham & Ben- nett, 1990; Rutter, Quine, & Chesham, 1993). Comstock Images/Thinkstock Some heart attack survivors participated in counseling sessions on how to relax and were advised to eat slowly, smile at others, laugh at themselves, and take time to enjoy life. get81325_02_c02.indd 52 12/5/13 3:58 PM CHAPTER 2 Section 2.8 Helping People Cope Biofeedback Biofeedback has been used as an adjunct to stress-management programs (Hovanitz & Wander, 1990; Shahidi & Salmon, 1992). Biofeedback is a technique that trains\ people to improve their health by controlling certain bodily processes that normally happen involun- tarily, such as heart rate, blood pressure, and muscle tension. Electrodes are attached to the person’s skin and the results are displayed on a monitor. For example, biofeedback has been used to try to reduce the muscle tension that seems to accompany some headaches, and to lower blood pressure. However, initial claims for biofeedback—that it might be a cure for migraines, hypertension, peptic ulcers, and many other conditions—\ are now clearly seen to have been exaggerated (Miller, 1974). Biofeedback has beneficial effects in some conditions for some people, but, when used alone, the benefit of biofeedback for relieving stress and reducing symptoms is probably no greater than that provided by relaxation training. However, biofeedback is more effective when combined with relaxation and other therapies (Blanchard, 1992; Gauthier, Cote, & French, 1994).

Research has indicated that exercise, both aerobic and resistance training, reduces the anxiety and depression often associated with stress (Singh, Clements, & Flatarone, 1997; Martinsen, 1990; Martinsen, Hoffart, & Solberg, 1989) and can be as effective as conventional pharmacotherapy (Blu - menthal et al., 2007). Numerous studies show that those who exercise live longer and spend fewer days in the hospital than those who do not (Paffen - barger, Hyde, Wing, & Hsjeh, 1986). Of course, it is always possible that people who are sick do not feel like exercising. As we have frequently seen, it is difficult to separate cause and effect when deal - ing with correlational data.

Behavioral and Cognitive-Behavioral Treatment All aspects of behaviorism, including modeling, behavioral contracting, \ and condition - ing, may be used to help people develop new coping skills. For example, people with diabetes who fear needles are likely to miss injections. Helping them to overcome this fear through desensitization (any decrease in reactions or sensitivity to a stimulus or stimuli), for instance, would benefit them by helping them comply with treatment. Reward-based programs, in which those with diabetes are rewarded for keeping to their diets or their schedules for monitoring blood sugar, can have a similar effect.

Given the evidence from human and animal studies suggesting that immune functioning is decreased by stress, psychological interventions have also targeted the immune system.

Using a wide variety of therapeutic techniques, including relaxation, hypnosis, exercise, conditioning, and cognitive therapy, psychologists have been able to increase the level of immune functioning (Kiecolt-Glaser & Glaser, 1992; Zakowski, Hall, & Baum, 1992). Of course, the problem of clinical significance that affects the field in general also applies to © Getty Images/Jupiterimages/Comstock/Thinkstock Both aerobic exercise and resistance training can reduce anxiety and depression commonly associated with stress. get81325_02_c02.indd 53 12/5/13 3:58 PM CHAPTER 2 Section 2.8 Helping People Cope treatment studies. Specifically, it has still not been demonstrated that increasing immune system function has a direct beneficial effect on health. (Keep in mind that, apart from AIDS, most infections increase immune function, yet this increased production of white blood cells is hardly an indicator of good health.) Family Interventions Stress and illness have profound effects not just on physical functioning but also on psy- chological and social identity (Kaplan, 1996; Morse & Johnson, 1991). \ Suffering affects a person’s self-concept, and it subjects other family members to a burden that may require different family members to take on different caregiver roles. The spouse of someone receiv - ing painful chemotherapy, for example, must cope not only with caring for the patient, but also with other family matters, and with fears for the patient’s futu\ re. Sometimes, family therapy is required to help families deal with the burden of one member ’s illness. Self-help groups for patients and their families are often useful sources of social support.

Environmental and Community Interventions Because trauma and stressor-related disorders often result from threatening environments, community interventions can sometimes be as effective as individual treatment. For exam - ple, increased police patrols reduce the stress that comes from living in high-crime areas, antipoverty programs reduce the stress that comes from poverty, and employment pro- grams help to reduce the stress created by job loss. Combinations of behavioral and cogni - tive interventions have also been used to modify a community’s health\ -relevant behaviors.

For example, people at high risk for illness may be taught strategies to minimize the risks while, at the same time, learning how to avoid dangerous behaviors (Bennett, Wallace, Car - roll, & Smith, 1991). See the following Highlight for some ways to cope with your own stress. Highlight: Self-Help in Coping With Stress Even without psychological interventions, there are some things you can do to help yourself cope with stress.

1. Appraise the situation . Isolate the problem. Find out as much as you can about the stressor, its causes, and its correlates. Consider alternate actions.

2. Examine your appraisal . Is it realistic? Avoid catastrophizing. If you have failed an examination, is it really the end of the world? Perhaps you can try again. A study plan may help. Even if you cannot erase the failure, you may find you are better at something else. Catastrophizing leads to stress. Realistic appraisals lead to calm but hopeful acceptance.

3. Be aware of your defenses. Are you denying reality? Are you rationalizing?

4. Reduce stress and practice coping skills . Learn to relax. Talk to friends. Exercise. Eat and sleep well. Join self-help groups where appropriate.

5. Take the necessary actions, but do not be impulsive . Consider possible actions, and list the pros and cons of each. Do not be impulsive. Do not take an action just because of the need to do something. However, once you have decided what to do, then do it. Procrastination just pro- duces more stress.

6. Remain flexible . Adaptive behavior means not being locked into any course of action. You must be willing to change direction when the situation warrants it. get81325_02_c02.indd 54 12/5/13 3:58 PM CHAPTER 2 Chapter Summary No matter which psychological intervention is used, sociocultural factors must be taken into account (Radley, 1993). We cannot begin to help people cope with stress and illness until we first understand how they perceive stress and illness (Dasen, Berry, & Sartorius, 1988). Special efforts must be made to target these groups and their beliefs if prevention is to be successful.

Chapter Summary • In the past, a small number of conditions were labeled psychosomatic or psycho - physiological (ulcer, asthma, headaches, hypertension). Today, this distinction between illnesses with and without psychological components is considered artificial. Psychological factors play a role in all illnesses. • The opposite is also true: all illnesses have psychological effects. The recipro - cal effects of stress and illness are best understood using a “stress and coping” model. That is, the effects of various stressors on health are mediated by coping, which, in turn, depends on an individual’s coping resources. • Early theories in the field of psychosomatic medicine postulated a specific connection between certain personalities and certain diseases. These theories claimed that specific unconscious conflicts produced specific diseases. • It is difficult to prove that a personality type or psychological conflict actually causes a disease. Stress • Selye’s general adaptation syndrome, or GAS, was an elaboration of Cannon’s emergency reaction. There are three stages: emergency (or alarm), resistance (dur - ing which the person uses all of its physiological resources to minimize tissue dam - age), and, finally, the exhaustion stage (in which illness and injury become likely). • Selye used the word stressor to refer to external threats to well-being that could trigger a GAS. Strong or repeated stress causes the body’s defenses to crumble, making illness likely. Sources of Stress • Stress can arise from developmental transitions, from catastrophes, from life events, and from everyday hassles. Direct Effects of Stress on Health • Stress has been shown to weaken the nervous system, making it more prone to injury from incidents such as stroke. • Stress also reduces the effectiveness of the immune system. • The effects of stressors may be mediated by individual differences. Indirect Effects of Stress on Health • In addition to its direct physiological effects, stress affects health indirectly by interfering with health-relevant behaviors. Stress affects memory, judgment, and other aspects of cognition. get81325_02_c02.indd 55 12/5/13 3:58 PM CHAPTER 2 Chapter Summary Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder • The main symptoms of PTSD are anxiety, avoidance of stimuli associated with the trauma, flashbacks, and a “numbing” of emotional responses. The DSM–5 recognizes that the symptoms of PTSD may be different in children and has dif- ferent diagnostic criteria for children under 6. • PTSD is caused by exposure to an extraordinarily stressful, traumatic event. • Acute stress disorder is diagnosed when the symptoms occur immediately after the exposure to the trauma and must last at least three days to a month after the exposure to the trauma. • The most common behavioral intervention for PTSD is exposure. Other methods of treating PTSD include flooding, systematic desensitization, cognitive restruc- turing, and stress-management training. • Sometimes assertiveness training is needed to teach people (rape victim\ s, for example) how to deal with their anger. • Cognitive processing therapy, a therapy program developed specifically for the post-traumatic stress of victims of sexual assault, combines aspects of exposure- based therapy with cognitive restructuring. • Eye movement desensitization and reprocessing (EMDR) has also been used to treat PTSD. • Antidepressant medication may also help reduce some of the symptoms of post- traumatic stress disorder. • The prevention of PTSD requires early intervention following a traumatic event. Coping with Stress: Types of Appraisals • Primary appraisal involves an assessment of the implications of an event\ for the individual. Events may be appraised as irrelevant, beneficial, or stress-inducing. • Secondary appraisals are concerned with what, if anything, should be done. Cog - nitive appraisals need not be rational or even conscious. • Response to stress is always based on our appraisal (conscious or unconscious) of the threat and our perception of how to deal with it. Emotion-Focused Versus Problem-Focused Coping • Emotion-focused coping is aimed at managing feelings. • Problem-focused coping attempts to challenge stressors directly by making a plan of action and dealing with the source of stress. • Problem-focused coping works best when a person has the ability to remedy the situation by taking some action. Coping Resources • Some people manage to cope successfully with their illness, whereas others never seem to be able to adjust. Part of the answer lies in the coping resources available to the individual. • Social support provides a source of help in times of trouble and gives people a way of expressing their painful feelings to one another. • Other factors that affect coping include knowledge (about health practices), har - diness, high self-esteem, locus of control, and health beliefs. get81325_02_c02.indd 56 12/5/13 3:58 PM CHAPTER 2 Key Terms Helping People Deal With Stress and Illness • The most widely applied intervention strategy for helping people cope wi\ th stress is relaxation. The underlying rationale is that teaching people how to use relaxation to reduce the intensity and frequency of emergency reactions and GASs will reduce their stress. • Fewer GASs mean less strain on the heart, the nervous system, and the im\ mune system. • Exercise, biofeedback, behavior modification, self-help groups, and many other interventions have all been found useful in helping people cope with stress. Critical Thinking Questions 1. What are your views on the theory that psychological processes can cause physi - cal symptoms? 2. Discuss how you best cope with stress. Do you think that these techniques would work well for your friends? Why or why not? 3. Discuss how, in your view, denial can help or hinder people coping with serious illness and stress. 4. Give your views on why we cannot make a diagnosis of PTSD until the symp\ - toms have been present for at least one month. Is this really enough time to recover from a traumatic event? 5. We will see how important social support systems are in helping people cope with mental illness. Why are social support systems important in helping people cope with stress and stressful situations? 6. One issue mentioned in this chapter is that some people with insulin-dep\ endent diabetes are afraid of injections. Let’s presume you had a good friend in this exact scenario. What techniques would you use to help him or her overcome this fear? Key Terms acute stress disorder A short-term response to a traumatic event with symp- toms similar to post-traumatic stress disorder. The onset of symptoms occurs immediately after the trauma and lasts minimally three days to no longer than four weeks after the trauma. adjustment disorders Psychological disorders marked by anxiety, depression, withdrawal, and overall impairments in psychological functioning. behavioral medicine The study of the interaction between psychology and physiology. biofeedback A technique that trains people to improve their health by control- ling certain bodily processes that normally happen involuntarily, such as heart rate, blood pressure, and muscle tension. conversion hysteria What Freudians often referred to as hysteria manifested by physical symptoms. coping Finding effective ways to adapt to the problems and difficulties presented by stress. desensitization Any decrease in reactions or sensitivity to a stimulus or stimuli. get81325_02_c02.indd 57 12/5/13 3:58 PM CHAPTER 2 Key Terms emergency (alarm) reaction The body’s physiological response to threat. emotion-focused coping The goal is to manage feelings to make ourselves feel better. external locus of control When an indi- vidual believes that their problems are caused by external events and thus cannot be controlled by their behaviors. general adaptation syndrome (GAS) When long-term or frequently recurring threats cause the body to gradually wear out. Deterioration takes place in a series of stages called the GAS. hardiness A particular form of optimism. internal locus of control When an individ- ual believes that their problems are caused by internal forces and thus their behaviors lead to the events that occur in their lives. migraines Neuralgia thought to be caused by the contraction and dilation of blood vessels in the head. post-traumatic stress disorder (PTSD) An anxiety disorder that typically occurs after being exposed to a traumatic event such as war or violence; symptoms include anxi- ety, the avoidance of stimuli associated with the trauma, flashbacks in which the traumatic event is relived mentally, and a “numbing” of emotional responses. problem-focused coping Involves making a plan of action and dealing directly with the stressor.

psychophysiological or psychosomatic disorders Disorders in which psychologi- cal factors produce “real” physical diseases. stress Usually refers to both a cause (a “stressful” job, for example) and an effect (for example, “I am feeling stressed”). stress management Refers to the various approaches to reducing stress. stressor Cause(s) of stress. tension headaches Neuralgia traditionally thought to result from tense muscles in the neck and head. get81325_02_c02.indd 58 12/5/13 3:58 PM CHAPTER 2