What are the moderators for stress and illness? - Chapter 12

How can coping be defined?

We have already seen that, according to the transactional model of Lazarus, stress is the result of the unfavorable combination of person and environment. People are able to change either the stressor or its interpretation, so that the situation becomes more positive. This is called coping.

Coping involves many actions and behaviors that are the result of a primary and secondary approach. Coping includes everything that someone does to make the situation more bearable, including the things that ultimately make it more difficult or tedious. Coping can be focused on the emotions that an event or situation entails, but it can also be directly focused on that situation itself. For example, if you are tense because you are going to a new school, you can try to get used to the idea and see the positive sides of it, but you can also address fear directly by talking to someone or by using drugs. use.

Different scientists distinguish different types and numbers of coping strategies, but a few common examples are:

• Seek social support.
• Confronting.
• Make a positive reinterpretation.
• Alcohol or drug use.

Adaptive coping

Problem-focused coping may be more effective if there is something that can be done to change the stressor. According to Lazarus, it is very difficult to determine which coping strategy will work. That simply differs greatly per person but especially per situation. Problem-focused and emotion-focused coping are independent of each other, but ultimately also work together on the overall picture.

Problem-focused coping occurs more often when something can be done to change or keep the stressful event under control.

A psychological way of coping is the 'fighting spirit'. The fighting spirit is characterized by thoughts such as 'I am determined to get through this situation' or 'I am going to overcome this illness'. People who deal with a disease in this way are more likely to fight instead of withdrawing and denying the disease. This method of coping is associated with better long-term disease outcomes in breast cancer. Helplessness and hopelessness is associated with less positive end results.

Meaning-oriented coping is about the values ​​and beliefs of a person and focuses on powers to gain personal and existential meaning within a negative and stressful situation.

Coping goals

Sometimes the coping strategy that someone applies is not at all effective for that situation. What you can ask yourself is 'why does someone use that strategy?' The way in which someone deals with a situation often has a lot to do with the way in which someone has dealt with such situations before, and with what happened then. But what is also very important is what the result is of the coping in the current situation.

A study by Laux and Weber (1991) into quarrels between married couples shows that people have an angry and offensive coping response when they feel that their self-confidence is threatened (or when they feel that this is the case). However, when there is a shared fear of something external, they often use a more encouraging form of coping.

What is the link between stress, personality and illness?

According to Alport (1961) you can define personality as the organization of psychophysical systems in a person that determines someone's characteristics, thoughts and behavior. Such approaches (trait approaches) view personality as a combination of stable dimensions.

Personality traits are an easy aid in stereotyping behavior (such as introverted behavior or type A behavior).

The Big Five

This well-known and popular way of categorizing personality uses the following five dimensions:

• Agreeableness: for example, co-operative.
• Conscientiousness: for example, responsible.
• Extroversion: for example social.
• Neuroticism: for example anxious.
• Openness: for example, openness to new experiences.

These characteristics make it possible for someone to live in a certain way. Every trait has its own associations with certain behavior. Usually they do not lead directly to illness but to certain health behaviors.

Neuroticism

Neuroticism is one of the three personality dimensions identified by Eysenck. It is a personality trait that is relatively unchanging and a broad dimension of the tendency to experience negative emotions and to show associated behaviors and beliefs. Individuals who score high on this trait often have a fear of a situation that is not frightening at all. They often interpret signals from the body as illness or symptoms. It is suggested that individuals who score high on neuroticism are exposed to more negative stressors by their nature. It is also suggested that individuals who score highly on neuroticism tend to use ineffective, emotion-focused coping strategies.

Conscientiousness and other big-five qualities

Conscientiousness is defined as being a responsible person, following social norms, persistent and disciplined. This has positive outcomes on stress and health. It also leads to the use of problem-oriented coping. It is linked to cognitive and evaluative aspects of well-being. Agreeableness is also adaptive because it leads to a flexible coping response to stressors. Extraversion is sometimes positive, but it also leads to more risky behavior such as smoking.

Optimism

Optimism means that someone assumes that desired things are possible, which ensures that people deal more effectively with stressful events and situations. The coping strategies are often better and are also maintained for longer. They are less likely to make internal, stable (it is unchangeable) and global attributions for negative things. Optimistic people often have a problem-oriented approach.

Pessimism is the general, negative view of things that comes with negative expectations and outcomes. Pessimism in young cancer patients is associated with a higher death rate.

What is close to optimism is unrealistic optimism, the idea that bad things happen to other people before you. This is a kind of protection mechanism and also works as a buffer.

It is suggested that people with (for example) diabetes cope better with their disease (and therefore have a more positive course of disease) when they are optimistic. Optimism ensures that someone has the feeling that they can control their illness, so that they adhere better to the diet and medication.

Hardiness

Hardiness is described as rich, varied and rewarding experiences in youth and feelings of commitment, control and challenge. The involvement ensures that potentially stressful situations are seen as meaningful and interesting by people with this appetite. Control means that these people (think they have) influence on their lives and that they see stressors as changeable. Changes are seen as normal or as an opportunity. It is thought that the way these people perceive and experience everything works as a buffer against stress. This buffer has the most effect with extreme stress. It is suggested that the absence of robustness is more important to look at than its presence.

Type A personality

A lot of research has been done on CHD (and its consequences, such as a heart attack) in relation to personality variables and emotions. The research into predisposition for CHD led to the formulation of the concept of type A personality. These type A personalities often show the following behaviors:

• Competitiveness.
• Do (too) much in (too) little time.
• They are easily irritated and quickly unkind or aggressive.
• Impatience.
• Performance-oriented behavior.
• A vigorous way of speaking.

Hostility and anger

Hostility is described as a trait that consists of emotional, behavioral, and cognitive components. The cognitive components are mainly having a cynical view of the world, being negative about many things and having negative expectations. The behavior is characterized by aggressiveness or anger. Anger is seen as a central component that is experienced by the individual and expressed in certain actions and expressions.

Hostile people more often exhibit risky unhealthy behavior, which in itself is a risk factor for, for example, heart disease. They can also benefit less from psychosocial institutions and social support from friends and colleagues. In this way they miss an important buffer for the negative consequences of stressful events. This is called the psychosocial vulnerability hypothesis. In addition, hostile people are more likely to experience stress. Together this makes them very vulnerable to coronary heart disease. Anger is associated with more alcohol consumption and more smoking.

All of these findings are particularly valid for people under 60 years of age, probably because before that time they often come into situations that trigger this personality trait. For example, working life has a large share because people want to work their way up and want financial security. There is competition and people are often busy.

Type C personality

Describing a personality type that makes people vulnerable to CHD encouraged researchers to look for types that are associated with other major causes of death.

Eysenck and Grossarth-Maticek also described personality types and the associated sensitivity:

• Type 1: vulnerability to cancer. This type is characterized by the containment of emotions and the ignorance in dealing with tensions between people, which leads to hopelessness, helplessness and ultimately to depression. The risk of cancer would, according to the researchers, be 120 times as high as in non-type 1 people.
• Type 2: vulnerability to CHD. These people show strong reactions of frustration, anger, hostility and emotional excitement. You can compare this type with the type A persons described above. The risk of CHD would be 25 times greater for this group than for other people.

In 1984, Temoshok described the association between the passive and helpless coping style and the increased chance of a bad outcome of illness. This type was called the type C personality and must meet the following characteristics:

• Cooperative and calming.
• Compliant and passive.
• Stoic.
• Self-sacrificing and unassertive.
• The tendency to inhibit or repress negative emotions.

In the past, many studies have confirmed that these people do indeed have an increased risk of cancer. Larger and methodologically better studies indicate that the link between these people and the development of cancer is limited and weak.

Type D personality

This type would be susceptible to cardiovascular disease prognosis and outcome. These types score high on scales that measure negative affectivity and social inhibition. Social inhibition is avoiding the risk of disappointment and rejection of others in social interaction. These types therefore experience more negative emotions but also contain them, which increases their risk of a heart attack or other cardiovascular event. The effect applies to men and women.

What is the link between stress and cognition?

Observed check

The so-called Locus of Control (LoC), as proposed by Rotter, means that behavior can act as a reward when the responsibility for events is seen as internal and not external. An internal LoC only predicts behavior if the outcome or reward is valuable to that person. According to Rotter, people with an internal LoC take responsibility for what happens to them, while people with an external LoC tend to shift it to environmental factors. This applies to both positive and negative outcomes. These views have a lot of influence on behavior. Someone who thinks that success depends on happiness is likely to make less effort to achieve something.

To associate LoC more specifically with disease outcomes, Wallson described a construct about the Loc with regard to health in 1978. They used a scale that has three categories, namely:

• An internal LoC: I have control over my health.
• An external LoC: no matter what I do, I have no control over my health.
• Powerful others: given my situation, I have to do what the specialists say.

These three types of control awareness are each associated with different types of coping, emotions, and behavior. Some scientists also believe that control awareness can be used to predict disease progression or outcome. The question is, however, which way the causality points. It is not yet possible to say whether optimists have a sense of control, or whether a sense of control makes someone optimistic.

When someone has an unrealistic optimistic thought, if it turns out that the thought was unrealistic, it can lead to the feeling of having failed (perceived failure). This feeling can lead to feelings like helplessness and depression. If someone in such a case would accept the truth and accept that he has no control, it would lead to more useful emotion-focused coping.

What is important is what people (think) have control over. Different types of control are described:

• Behavioral control: the idea that someone's behavior reduces the negative consequences of the event. For example, doing relaxation exercises when blood needs to be taken.
• Cognitive control: the idea that someone has thoughts or thought processes to reduce the negative effects of the stressor. For example, focus your thoughts on something nice in the future if you undergo a painful procedure.
• Control over decisions: when you have the option to choose between two or more options, it feels like you have more control over what is happening. It is then your own choice.
• Information control: the ability to look up information about what has happened or what needs to be done. The more information is available, the better someone can prepare.
• Retrospective control: this means that someone can indicate afterwards where the cause and the responsibility lie of what happened. Giving meaning to something can give a sense of order. For example, someone finds out if their physical disability is the result of a defect in the genes or a complication during birth. In the latter case you place the responsibility externally and some researchers say that this is less adaptive than placing the responsibility internally. But not everyone agrees on this.

Causal attributions are the ways in which a person attributes a cause or an event to feelings or actions of himself or others. There are internal attributions (where the cause is placed on itself) and external attributions (where the cause is placed on others).

There is evidence that social class can influence the level of feeling of control. Following a large-scale study, a distinction was made between mastery ("I can do everything I have in mind") and perceptions or constraints ("other people determine what I can and cannot do"). Mastery was lower and constraints were higher in people from a low social class. The opposite was the case with people from a high social class.

Hope

Hope is defined as a positive motivational state based on a sense of successful energy and plans to achieve a goal. Hope is about the motivation (agency) and the route (pathway) to achieve goals (outcomes), while optimism is about generalized positive outcome expectations.

What is the link between stress and emotions?

Anxiety and depression

Within many studies on the role of negative emotions in the onset of a range of illnesses, anxiety and depression were also examined. The role of depression in increasing likelihood of disease onset, however, is controversial and depends on many factors, including study methods, samples and the specific disease. Depression and anxiety seem to be more implicated in the progression or outcomes of disease.

Several reviews and meta-analyses have reported a significant link between depression and coronary heart disease (CHD) outcomes. A large UK study (Surtees et al. 2008) found that patients diagnosed with major depression were 2.7 times more likely to die from ischemic heart disease. The evidence associating emotions with increased cancer risk is much less consistent. Overall the evidence appears to be in support of depression influencing outcomes of the disease.

how can negative emotions affect health outcome? 

There are various possibilities by which depression and anxiety might affect health outcomes. One pathway is through coping responses. For example, stress may be maintained through rumination, whereby a person will repeatedly think about past events and worry about future events.

The second pathway through which depression may affect health outcomes is indirect, i.e. through behavior. Depression is seen to reduce the likelihood of healthy behaviour or even provoke unhealthy behaviour

Thirdly, there may be physiological pathways with depression that influence health outcomes. The serotonic dysregulation with depression is also responsible for making platelets in the blood more likely to clot.

post-traumatic stress disorder 

PTSD can increase the risk of experiencing further negative events. With PTSD the threat responses of the brain and the sympathetic nervous system are on constant high alert. As a consequence the individual is likely to be at risk for conditions known to be affected by chronic stress.

Coming out for your emotions (emotional disclosure)

Opposite to suppressing emotions is the manifestation of emotions. These two types of dealing with feelings also seem to be opposite in terms of their effect on health. Someone who has done a lot of research into this is Pennebaker. He says that writing about traumatic experiences can have a long-term positive effect on the functioning of the immune system.

Standing up for emotions should not be confused with expressing emotions (expressed emotion). Expressing emotions can involve both negative and positive emotions and is often a form of reducing stress. Expressing emotions has fewer positive effects and sometimes negative ones.

Congestive heart failure is a disorder in which the heart loses its ability to pump blood efficiently through the body. The consequence of this is that many organs do not get enough oxygen and nutrients, so there is a chance that these organs will be damaged and therefore no longer work effectively.

What is the link between social support and stress?

Social support

This possible source of support seems to have a huge impact on health. People with a strong social network live longer and healthier than people who are in social isolation. Social support can really be there, but someone can also feel that he has social support. Social support ensures that someone feels loved and appreciated. Whether someone feels socially supported has an effect on the way in which something bad happens. People who feel socially well supported generally respond with less stress than people who feel alone.

It is clear that social support influences the course of the disease, but a more difficult and dangerous proposition is that social support also influences mortality rates. Various studies (both early and recent and both small and large studies) confirm a relationship between social support and mortality.

How does social support influence a person's health status?

There are two important theories about how social support works:

• Direct effect of social support: regardless of the degree of stress, social support has a positive influence. The absence of social support is also harmful if there is no stress or illness. Social support also has a physical effect. It lowers blood pressure and has a positive effect on the immune system and endocrine systems.
• Social support as a buffer: social support protects people against stress because it acts as a buffer. It influences people's cognitive approach and because it influences someone's coping reaction.

In some cases, social support is actually negative. When someone's social network is very caring, this can lead to dependence.

Women receive and offer more support than men. In addition, women indicate that they have a larger circle of friends. In times of stress, women use the tend and befriend response, where care and support seeking are typical behaviors. In (collectivist) Asian cultures, people seek and expect no support. The group comes first and these individuals do not want to damage relationships by talking about their personal problems. In Western countries, individuals seek enormous support from friends and family.

Social support is also not always seen as support. Sometimes someone thinks his family is too involved or patronizing too much. It can also happen that social support does not fit well with someone's situation. For example, practical support is more useful when an event can be controlled, and emotional support is better when a situation cannot be influenced, such as the death of a dear person.

Finally, research into this subject usually depends on questionnaires that people fill out themselves. The question is therefore whether such lists actually measure the (feeling of) social support, or whether in some cases they actually measure an underlying characteristic.