Psychological Stress and Health

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Psychological Stress and Health

• Sheldon Cohen
• Carnegie Mellon University

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WHAT IS STRESS?
Depends who you ask..
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• EpidemiologicalObjective Event
• Requires change/adaptation
• Consensual negative impact
• Demand/Control

• PsychologicalPerceived Threat
• Demands exceed ability to cope
• Experience of stress

• BiologicalSNS Activation (or vagal withdrawal)
• or HPA Activation
• e.g., BP, HR, Skin Conductance,
• HR variability, Cortisol

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HOW DOES STRESS ? DISEASE?
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Environmental Demands (Stressors of Life Events)
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
Negative Emotional Response
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
Negative Emotional Response
Activation of SNS HPA
Poor Health Practices Adherence
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
Negative Emotional Response
Direct Innervation of CNS and Physiological
Systems
Activation of SNS HPA
Poor Health Practices Adherence
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
Negative Emotional Response
Direct Innervation of CNS and Physiological
Systems
Activation of SNS HPA
Poor Health Practices Adherence
Disease Related Physiological Changes (e.g.
immune, cardiovascular)
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
Negative Emotional Response
Direct Innervation of CNS and Physiological
Systems
Activation of SNS HPA
Poor Health Practices Adherence
Disease Related Physiological Changes (e.g.
immune, cardiovascular)
Increased Risk of Physical and Psychological
Disease
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Environmental Demands (Stressors of Life Events)
Demands Appraised as Stressful (Perceived Stress)
Negative Emotional Response
Direct Innervation of CNS and Physiological
Systems
Activation of SNS HPA
Poor Health Practices Adherence
Disease Related Physiological Changes (e.g.
immune, inflammatory, cardiovascular)
Increased Risk of Physical and Psychological
Disease
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Psychological Stress is NOT

• Psychiatric disorders
• clinical depression, anxiety disorders or PTSD
• Personality characteristics
• hostility, extraversion, neuroticism

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Common Measures of Objective Events Stressful
Life Events

• Nonspecific
• Major Stressful Life Events Scales
• Life Event Interviews (e.g., LEDS, SEPRATE)
• Specific Events
• Bereavement
• Divorce
• Natural Disasters
• Caregiving
• Job Loss
• Job Classification (demand/control)

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EXAMPLE Major Stressful Life Events Scales(Item
Examples)

• Death of a spouse or partner
• Death of a child
• Separation or divorce
• Serious problems at work or school
• Arrested or involved in court case
• Being robbed
• Natural disaster or house fire
• Involvement in a serious accident
• Fired at work
• Business Readjustment

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Psychological (appraised) Stress
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What is Stress Appraisal?
Appraisal depends of stimulus situation
psychological characteristics of individual

• Primary Appraisal Is this a threat?
• Threat (potential for harm)
• Harm/loss (damage done)
• Challenge (opportunity for growth, mastery, gain)

Secondary Appraisal-- Can I cope with
it? Problem-focused coping Emotional-focused
coping
Lazarus, R. S., Folkman, S. (1984) Stress,
appraisal coping.
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Common Measures of Perceived Stress

• Global Perceived Stress
• Demand/Coping (control)
• Experiential (negative impact, feel stressed)
• Domain Specific
• Work Stress
• Experiential
• Demand/Control
• Effort/Reward
• Marital or Family Stress

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EXAMPLE Perceived Stress Scale

• How often felt nervous and stressed
• How often felt on top of things
• How often felt unable to control things
• How often felt that your demands exceed your
  ability to cope

Cohen, S., Kamarck, T., Mermelstein, R. (1983).
Journal of Health and Social Behavior, 24,
385-396.
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EXAMPLE Job Strain Model(perceptions of
demand/decision latitude)
Persons who perceive that they work in
environments that involve high demand and allow
little latitude or flexibility to meet those
demands may develop job strain. Job Demands Was
your job hectic? Was your job psychologically
demanding? Decision Latitude Could you make at
least one private phone call about 10 minutes or
longer during working hours? Could you receive a
private visitor for about 10 minutes during
working hours? Do you have control over how to
complete your work? When to complete work?
Karasek et al. (1981) Am J Public Health
Landsbergis, et al. (2000). Occupational
Medicine State of the Art Reviews, vol. 15.
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Common Measures of Negative Affect

• Anxiety, Depression, Anger
• Undifferentiated Negative Affect
• (Suls Bunde, 2005 Bleil et al, 2008)

Is trait affect chronic stress or dispositional?
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EXAMPLE Negative Affect (POMS)

• Sad Depressed Unhappy

On-edge Nervous Tense
Hostile Resentful Angry
Maybe undifferentiated affect
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Acute versus Chronic Stress

• No agreed upon interval at which an acute event
  becomes chronic

• Hypothesis 1 the longer the stressful experience
  the greater the health risk

• Hypothesis 2 acute stress can trigger disease
  events among persons with underlying disease
  (e.g., asthma, CAD)

• Hypothesis 3 acute stress is most likely to
  trigger events in the context of a chronic
  stressor

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Does the duration of the stressor matter?
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Cohen et al. (Health Psychology, 1998)
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How Many of Us Get Hurt by Stress?

• Most people adapt, most of the time

We don't know how much of the slack in prediction
is due to (a) buffering/modifiers, or (b)
imperfect measurement of initiating
circumstances.
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What is the evidence (morbidity and mortality
studies)?

• Depression
• CHD
• HIV/AIDS
• Infectious Diseases
• Wound Healing
• Rheumatoid Arthritis
• Asthma

Cohen, Janicki-Deverts Miller, JAMA 2007
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Psychological Stress and Depression

• Major life events occur 50-80 of the time within
  3-6 months of onset (control comparisons are
  about 20-30).

• Approximately 20-25 of people with major
  stressful events break down with depression.

• Loss of close others is a particularly potent
  stressful event in triggering major depression.

• The association between early onsets and major
  life stress changes over repeated depressive
  episodes.

Hammen, Annual Review of Clinical Psych, 2005
Mazure, Clinical Psychology, 1998
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Psychological Stress and CHD Risk Job Stress
50 increase in CVD risk associated with high
levels of work stress
When work stress is defined as

• low control at work, particularly when coupled
  with high levels of work demand
• The perception of organizational injustice
• An imbalance between the effort people put into
  work and the rewards they gain

(Hemingway Marmot, BMJ 1999 Kivmaki et al.,
Scand J Work Enviornment Health 2006 Rozansky et
al. Circulation, 1999)
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Psychological Stress and CHD Risk Acute Stress

• Increasing evidence of acute stress triggering
  clinical events
• (MI, Cardiac arythmia, sudden death)
• For example 9/11, Northridge earth quake, SCUD
  Missile attacks, Self-reported negative emotions
  (anger) in ambulatory studies
• Long-term CVD risk is increased among those
  experiencing traumatic events (e.g., loss of a
  child) and emotional, physical or sexual
  abuse.

(Krantz McCeney, Ann Rev Psychol 2002
Everson-Rose Lewis. Ann Rev Public Health,
2005)
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Psychological Stress and CHD Risk Depressed
Anxious Affect

• Depressive symptoms and future CHD and
  progression of CHD has been documented in
  multiple studies
• This effect is stronger when CHD is measured as
  angina, but studies in patients of death and
  documented MI also are supportive.
• Reasonable evidence that anxiety predicts sudden
  cardiac death in men.
• Depression, anxiety and anger may represent a
  general (nonspecific) disposition that puts
  persons at risk for heart disease.

Kubzansky Kawachi in Social Epidemiology, 2000
Suls Bunde, Psychol Bull. 2005 Hemingway
Marmot, BMJ 1999 Rozansky et al. Circulation,1999
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Psychological Stress and Infectious Disease
ACUTE URIs

• Epidemiology and viral-challenge studies greater
  risk for those with major life events or
  perceived stress.
• Some evidence that the longer stressors last the
  greater the risk.
• Social conflicts with friends and family fellow
  workers and un- and under-employment are potent
  stressors

Miller, G. Cohen, S. (2005). Infectious
disease and PNI. In K. Vedhara M. Irwin
(eds.), Human PNI. Oxford Press.
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with Colds
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3-4
5-6
7- 8
9-10
11-12
Psychological Stress Index
Cohen, Tyrrell Smith, New England Journal of
Medicine, 1991
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Cohen et al. Health Psychology (1998)
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Psychological Stress and Infectious Disease
LATENT INFECTIONS

• Oral Genital Herpes

Persistent but not short-term stressors are
associated with recurrence.
Effects may be mediated by respiratory infections
Miller, G. Cohen, S. (2005). Infectious
disease and PNI. In K. Vedhara M. Irwin
(eds.), Human PNI. Oxford Press.
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Psychological Stress and Infectious Disease
LATENT INFECTIONS

• HIV/AIDS
• Among HIV positive men, each additional
  moderately severe event increases progression to
  AIDS

Stressful life events have been associated with
disease progression and decreased survival in
HIV individuals
Some evidence for bereavement and depressed
affect as risks for disease progression and
mortality in HIV
Pereira, D. B. Penedo, F. J. (2005). PNI and
chronic viral infection HIV infection. In K.
Vedhara M. Irwin (eds.), Human PNI. Oxford
Press.
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Who Gets Hurt by Stress?Stress-Buffers or
Vulnerability Factors
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Demographic Buffers

• Age
• Socioeconomic Status
• Race/Ethnicity

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Personality Buffers

• Composite indices of Stress-Protective Resources
• Psychosocial Assets
• Hardiness (control, commitment challenge)

• Interpersonal Factors
• Social skills
• Social interests
• Anomie (alienation)

Cohen Edwards, Advances in the Investigation of
Psychological Stress, 1989
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Personality Buffers

• Intrapersonal Factors
• Generalized Expectancies of Control
• Type A Behavior Pattern
• Coping Styles
• Coping Flexibility and Complexity
• Arousal and Sensation Seeking
• Self-esteem
• Private Self-Conciousness
• Stress-Reactivity

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Coping Resources as Buffers

• Skills and abilities (e.g., analytic, mechanical)
• Social (people who can provide support)
• Physical (health stamina)
• Tangible Resources (money)
• Psychological (self-efficacy, perceived control)
• Institutional, Cultural Political (agencies,
  social groups)
• Finding Meaning (finding meaning, Bower JCCP,
  66, 979-986)

S. Folkman et al. (1991) In Eckenrode (ed), The
social context of coping.
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How do buffers work?
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SummaryBuffering/Vulnerability

• It is a diverse literature (many possible
  buffers) and it is not (to my knowledge)
  currently reviewed.
• Most studies of stress and health do not test for
  buffering or provide appropriate tests

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SummaryBuffering/Vulnerability

• Because testing for interactions is not standard,
  negative findings may not be reported.
• A large sample is required to test (with
  sufficient power) the interaction predicted by
  stress-buffering.

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Stress Health Some Final Issues

• Some impressive demonstrations of associations
  between stress and disease.
• Hint about the role of vulnerability
  factors/especially social support
• Interpretable literatures limited to few major
  diseases

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Some Issues (continued)

• A lack of studies addressing behavioral and
  physiological mediators accounting for links
  between stress and disease
• Limited work defining important parameters of
  stressful events or perceived stress
• Types of Stressors
• Control and Predictability of Stressors
• Stressor Duration

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THE END

• Stressed is just desserts spelled backwards