Psychology and health: Stress and health – Article summary

Stress occurs when demands are appraised as exceeding a person’s resources to cope. Stressors are external and internal events that may trigger a stress response. Stressors can be external or internal (1), can be acute or chronic (2) and can be traumatic or role strain (3). Stress responses are the various ways people respond to a stressor. Responses can be cognitive (1), behavioural (2), affective (3) and physiological (4). There is not always a strong association between these responses.

The fight-flight response includes the sympathetic branch of the autonomic nervous system as a fast first-wave response. It also includes the endocrine pathways of the hypothalamic-pituitary-adrenal (HPA) axis as a slower, second-wave response. The SNS prepares the body for immediate action by stimulating the adrenal medulla to produce adrenaline and noradrenaline. The HPA axis activates the hypothalamus to release corticotrophin which sets of other endocrine events leading to the release of cortisol and other hormones from the adrenal cortex. Cortisol is a critical stress hormone.

Normally, the presence of cortisol in the bloodstream causes the hypothalamus to stop producing corticotrophin. This means that the cortisol levels will naturally go back to natural levels. However, after a prolonged period of stress, the HPA axis can become dysregulated and result in chronically elevated levels of cortisol. This has long-term negative health effects (e.g. accumulation of abdominal fat).

Physiological responses to stressors vary according to the characteristics of the situation. There are stronger physiological responses in novel, unpredictable and uncontrollable situations. Perceived control is important for the experience of stress. However, some situations are uncontrollable and perceived control can not be obtained in these situations and attempts at obtaining it may lead to more stress.

Stress responsivity refers to how people respond physiologically to stress. It is genetically determined but the early environment is critical in altering and shaping our physical and behavioural responses to stressors. Foetal programming refers to infants being more responsive to stressors because the mother was very responsive to stressors during pregnancy. Children who are more responsive to stressors have the best or worst health outcomes depending on whether they are raised in a positive or negative environment.

The tend and befriend response refers to a response to a stressor where one tends to their offspring and seeks out others for safety and comfort. This is more commonly displayed in females. Oxytocin in conjunction with endogenous opioids is at the basis of this affiliative response to stressors. This hormone is involved in affiliative behaviours and attachment to others. Oxytocin is associated with reduced physiological stress responses and psychological distress. Tend and befriend responses could buffer against long-term negative impact of stressors of health through oxytocin. Physical responses to stressors differ according to circumstances, the individual and the social context.

The SNS increases the immune system activity. The HPA axis suppresses some immune activity through the production of cortisol which has an anti-inflammatory effect and reduces the number of white blood cells and the release of cytokines. Immune responses vary according to whether the stressor is acute (1), a brief naturalistic stressor (2), a sequence of stressors (3) or a chronic, long-term stressor (4). Short stressors lead to an acute increased immune response. There is a focus on protection against injury. This is very quick and the immune system quickly returns to base levels. Brief stressors (i.e. couple of days) influence the function of the immune system with a focus on protection against infection. Chronic stressors have a negative effect on almost all aspects of immune functioning.

The interactional approach states that the response to stressors depends on the interaction between the person and the environment. According to this approach, there are three processes of appraisal:

1. Primary appraisal
   This refers to evaluating the demands of the situation.
2. Secondary appraisal
   This refers to evaluating the resources and ability to cope.
3. Reappraisal
   This refers to reappraising the stressor after applying a coping strategy.

Prolonged stress results in increased episodes of infectious illnesses, cardiovascular disease, slower wound healing and worsens autoimmune conditions. There is also an association between stress and poor mental health. It is difficult to establish the pathways between stress and health because of individual variation in responses to stressors (1), it is not possible to say whether an illness is due to stress (2) and the effect of stress on health can be due to behavioural, emotional and physical responses to stressors (3).

Allostasis refers to the process of regulating our physiological state to achieve stability and is done through physiological systems (e.g. HPA axis). These changes are adaptive in the short-term. However, frequent activation of these systems leads to high allostatic load which can lead to an imbalance in allostatic systems and disease. A prolonged response refers to when physiological systems remain in a continually high state which results in long-term strain on the body.

Resilience refers to people showing swift recovery from stressful events (1), having sustainability of purpose in the face of adversity (2) and growth from adversity (3).

Positive emotions and positive emotional dispositions have a powerful influence on health and are important in resilience. Some types of negative emotions are associated with specific illnesses. People who appraise an event as challenging have smaller cortisol responses than people who appraise it as threatening.

Coping refers to any attempt to to cope with a stressor. Emotion-focused coping refers to coping strategies focused at reducing distress. Problem-focused coping refers to coping strategies focused at dealing with the problem. Approach coping strategies try to deal with the situation proactively. Avoidant coping strategies try to avoid the problem.

Coping strategies that enable a person to feel more in control increase positive emotions and decrease negative emotions. It is associated with resilience and better health. Which coping style is best depends on the situation.

Negative relationships are some of the most potent stressors. Social relationships also shape the way people respond to stressors. Positive parenting improces resilience in children. Stronger social relationships increase survival rate of diseases. The presence of another person can reduce SNS and HPA axis activation but this depends on the nature of the relationship (1), culture (2) and gender (3). It might be that the effect of support on health is due to knowing that other people are close and available to support us should we need it, rathe than the actual support.

There are three main symptoms of stress burnout:

1. Emotional exhaustion
   This refers to feelings of physical exhaustion, being depleted and worn out.
2. Depersonalization
   This refers to having an unfeeling, impersonal approach to co-workers or patients, cynicism and a lack of engagement with the job or people.
3. Reduced personal accomplishment
   This refers to a poor sense of effectiveness, involvement, commitment, engagement and a poor belief in one’s ability to change or improve work patterns or environment.

Burnout can be conceptualized on a continuum from work engagement to burnout. Engagement is characterized by high levels of vigour, dedication and absorption. It is associated with good performance. Burnout is a problem common among healthcare professionals. High levels of burnout are associated with poor job satisfaction (1), intention to change job (2), sick leave (3), younger age (4), being male (5) and use of addictive substances (6).

The risk of burnout operates at individual level (i.e. lifestyle and coping) (1), the individual and the environment (i.e. social support structures, relationships) (2) and the organizational level (i.e. organization of work, design) (3). Interventions aimed to prevent burnout should be aimed at all three levels. Burnout is more likely in jobs that involve a high workload (1), a lack of control (2), insufficient rewards (3), an absence of fairness (4), value conflicts (5) and a poor sense of community (6).

Most stress management interventions aim to reduce arousal and build coping skills so the person is able to manage stress better. Stress management can be focused on physical and mental relaxation (e.g. mindfulness) and can be focused on cognition and behaviour (e.g. psychoeducation). Stress management has positive effects on psychological outcomes but the impact on physical outcomes is mixed.

Resilience refers to a dynamic, evolving process of positive attitudes and effective coping strategies. It consists of attitudes and perspectives (1), balance and prioritization (2), practice management style (3) and supportive relations (4). Many stress management strategies are aimed at increasing resilience.