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Precursors and Possible Effects of Psychological
Stress
The term stress can be used to refer to a
generalised somatic response, involving hor
monal activity, which renders an individuai
ready to react to a wide range of events. With
continued stress there can resuft a wide range
of patho/ogica/ deve/opments, including phys
ical and psychological symptoms. This paper
wi/1 review the socia! and psycho/ogicaf factors
which appear to increase the stress response
and wi/1 a/so examine some of the physicaf
consequences of exposure to stress-inducing
agents. Emphasis wi/1 be given to the possi
bilities that stress may result from common
experiences of living in modem complex so
ciety. Individuai differences need to be consid
ered as moderators of stress, and afso the
means whereby peop/e may be taught to cope
with stress.
This paper is concerned with the psychological and the soc1al factors which bave been posited as playmg a role in the induction in an individuai of the physiological state of stress. The impact of physical events, which may be encountered frequently in oc cupational settings and include noise, beat and noxious fumes will not be considered. Instead, a range of expe riences, also encountered m occupa tional settings, to include socia! disharmomes, financ1al crises, com petition, pressure to meet deadlines and unemployment, will be empha sized. To an extent the kind of stress to be considered can be construed as arising in and from middle-class, white-collar types of occupation; it ignores, largely, the blue-collar types of stress which arise at the coal-face, at the production line or in the ship yard. This is not to imply that the latter type of occupational stress is
less important than the former. In terms of actual phys1cal damage, ob jectively measured, such stress may be more pervasive. The measurement of the psychological stress agents which are prevalent is an 1mportant problem and one which is stili, to some extent, neglected. What may be the physical and psy chological concomitants of the stress of employment and of unemployment will be examined, to show how many of our conceptions of stress bave up to now ignored the background levels of stress experienced by people in our society, which has led to a somewhat narrow view of the means whereby stress may be ìnduced within a person.
The Stress Reaction
Despìte its ubiqulty in scientific and common parlance, the term 'stress' has not been adequately defined; it is open-ended and given to almost any interpretation one wishes to put on it.
A large amount of emp1rical work is stil! needed to enumerate the environ mental events, both physical and socia!, which elicit a stress response. Selye (cited in Hinkle 1973) regarded stress as the reaction of an organism to a noxious event. The environmental event is better termed the stressor. Selye found, in animals, that exposure to a wide range of stressors resulted in a three stage response, termed by him the Generai Adaptation Syndrome (GAS). In the first stage, the alarm reaction, there was characteristically the release of catecholamines from the adrenal medulla. This was followed by the release of corticosteroids from the adrenal cortex, under the stimulus of ACTH (adreno-cortico-trophic hor mone) from the anterior pituitory gland. This second stage, the stage of resistance, appeared to be a response by the organism to enable the utili zation of stored resources of energy. In this second stage, however, there
44 The Australian Journal of Physrotherapy. Voi 30, No.2, Aprii, 1984
also seemed to be an aggravation of the body's inflammatory reaction and a reduction of immunological re- sponses. Thus there was an enhanced response to any infection and a re- duced resistance to that infection. Fol- lowing longer exposure to the stressor the pathology of the alarm reaction was irreversibly re-established, with death following. The effects of exposure to stressor events, in summary, can be placed into two categories. Threat increases the catabolic bodily reactions; the production of ca tech o I amines and cor- ticosteroids increase energy mobiliza- tion, red blood cell production, de- creased repair of cells with high turnover and decreased production of cells for the immune system. There is also a decrease in the anabolic reac- tion. Hormone production associated with the synthesis of energy resources is inhibited. The body utilizes its resource and fails to store further resources. Selye pointed to the stereotyped nature of the GAS to any stimulus. More recent work has, however, shown that the reaction may vary in response to different stimuli (Franken- haeuser 1976, Mason er a! 1976). Where the organism is given the op- portunity to respond actively to a stimulus threat, and not merely pas- sively, there is a greater secretion of noradrenaline, where in the reverse case there is more adrenaline secretion (Frankenhaeuser 1976). Mason et al (1976) have shown that in humans strong, aversive stimulation, such as heat, noise and exertion, which stim- ulate catecholamine production, fails to produce cortisol, provided that any subjective feelings of evaluation and competition are minimized. Given the crucial role of cortisol production in the 'second stage* of the GAS, inhib- iting the immunological reaction, the psychological factors involved in stres- sor presentation would seem to be highly important. In the study of stress in society there is almost certainly
some common factor of threat, or of the likelihood of evaluation or com- petition present. A potentially patho- logical stress syndrome is evoked by psychosocial stressors, which may not necessarily be the case with physical stimuli. Work on such topics with human as against animal subjects, alerts one to the subjective reaction of the or- ganism to the stimulus event. The manner in which the stimulus is categorized, and the nature of the response which is available to the organism to cope with the stimulus appear to be important mediating fac- tors relating exposure to subsequent pathology. In considering the paths whereby stress may result in some form of illness, there are at least two. The decreased immunological function may increase the susceptibilty of the organism to any pathogen which is present. It seems unlikely that any specific illness will result from expo- sure to any specific stressor (Cassel 1974). The exposure of a population to a wide range of stressors will in- crease the probability of illness, in a variety of forms. To an extent this view renders the hypothesis that stress is related with illness virtually unfal- sifiable. Any illness, however minor, which manifests itself can be seen to relate to any stressor exposure. There are recent suggestions, however, that specific conditions, particularly var- ious forms of cancer, may be identified with exposure to specific stress con- ditions (Fox 1981). Stress may be related to general somatic disorders, however, directly through the actions of bodily hor- mones. The action of the pituitary gland to increase the level of ACTH acts through a variety of pathways to increase blood pressure. Sodium and water retention is increased, with in- creases in vasoconstriction (itself also increased through the action of noradrenaline) and in blood volume (Sterling and Eyer 1981). Hypertension is a risk factor for a number of
ailments and there may not have to be any external, pathogenic triggering agent to produce the effect, other than the stressors themselves. Similarly, there are means whereby hormonal activity can reduce the capacity of the myocardium to function with low ox- ygen levels (Anderson 1978, Raab
- and increase the rate of depo- sition of atherosclerotic plaque (Stein- berg 1979), both with implications for coronary heart disease. Stressful events may also have direct influence upon the cardiovascular sys- tem, other than through the mediation of hormonal activity. Sudden death in humans, for example, need not be associated with coronary artery disease (Friedman et al 1973). The induction of tachycardia and subsequent arrhythmia has been shown to be induced by stressful events possibly through enhanced sympathetic nerv- ous activity and the withdrawal of parasympathetic influences (Lown et al, 1978, Natelson and Cagin 1979). Repeated exposure to stress could lead to ventricular damage and possibly, eventually, death. Whatever are the pathways, can we improve our understanding of the nature of the stressors? The reaction to a stimulus event may depend upon features of the organism and of the possible response to the stimulus. What may some of these features be?
Characteristics of the
Stressors
Stimuli which are aversive may elicit a brief reaction, but have no long- term effects, provided that these stimuli are predictable. When their occurrence is unpredictable, however, then there may be debilitating short- term and long-term effects (Glass and Singer 1972). Even when the stimulus has been removed, there are measur- able, deleterious effects upon behav- iour and bodily function. More importantly, perhaps, is the fact that a person's belief that he or she can have control over the stimulus can render a potentially stressful stim-
The Australian Journal of Physiotherapy Vol. 30, No. 2, April, 1984 4 5
are compared rather than simply the change scores. Life events and reported physical symptoms are also positively corre- lated in a sample of members of the fire service (Clarke and Innes, 1983). Those who report more events that are psychologically distressing also re- port more physical and psychological symptoms.
Psychological Hassles
While we have evidence that these fairly major life events induce a strain- like reaction, it is also intuitively known that much stress or, at least, subjective feelings of tension result from many, very minor upsets or 'hassles'. We may not lose a child every year, but every year most of us will worry about fixing the gutters, or a leaking pipe, or see yet another hole in the galvanised iron roof. These minor upsets may be a potent, and continual, source of tension. Indeed, it has been demonstrated that such minor hassles are better predictors of physical and psychical complaints than are the life events depicted in the scales just mentioned Our intuitive judgment about the problems of life being largely little ones seems empirically confirmed (Kanner, Coyne, Schaefer and Lazarus* 1981). Hassles may also be the means whereby the major life events come to have their impact. It is not so much that having a baby in itself is stressful, It is the subsequent demands upon time, of having too much to do, that eats away to change a positive, uplift- ing event into a drudge. Since there are very little data on the physiological changes that occur subsequent to any major life events, it is not known what mediates any relationship. Continual monitoring of reactions to hassles may be a fruitful approach to the study of stress and illness. It may be worth pointing out here that the nature of the hassles that are identified as such may depend upon some psychological factors. Continual
hassles from colleagues, or the tele- phone, or house repairs, may tell us a great deal by the strengths or weak- nesses of the individual. Hassles are psychologically loaded. There may be some psychodynamic meaning in some idiosyncratic reactions to particular hassles, although there is a broad consensus about the stress of some particular uses, such as doing jobs around the house (DeLongis, Coyne, Dakof, Folkman and Lazarus 1982).
Cultural and Cohort
Differences
At this point we should consider what has been the major underlying approach to the study of stress. Spe- cifically, there is an emphasis upon the experiences and responses of the individual. We measure a person's reports about his or her life experi- ences. In doing so we take the char- acteristic approach of the medical sciences that an individual's experi- ences do not vary with time or space. But in so doing we are ignoring the general background that pervades all of our experiences but which, by being so pervasive, may not be subjectively reported. By this we mean two things. The first is that we may have a tendency to ignore cultural differences. People raised in different societies may react to various stimuli in different ways, their categorization of events may enable them to define stimuli as less or more stress-inducing. For some, predictability or control may be ex- tremely important factors to enable stress reduction. For others the per- ception of control may not be nearly as important. A general approach, seeing the events in life as controlled by others, may be a much more appropriate one to help cope with events, The second consideration is the pos- sibility of differences within a culture which occur over time. We are all aware of cultural differences when they are pointed out to us. But we are
not as aware of the likelihood of generational or cohort differences. Marital crises, financial crises, death and bereavement happen to us all, and have been happening since time immemorial. But the general back- ground of expectations, of good and bad times, changes and the relative meaning or consequence of an event can thereby change. The way in which a financial crisis or any life event will be defined will be at least partially dependent upon the prevailing world view which accompanies a particular cohort of people. Long term studies (eg Eyer and Sterling 1977) have suggested that stress-related illness can be related to growth in economic factors, with more work leading to more hours of work, overtime and poorer working condi- tions. If there is surplus labour, de- pendent upon the size of cohort into which a person is born, then there is greater stress in employment, due to greater power of the employers and lower power of the unions, and greater stress from the threat of unemploy- ment. The particular relationship between economic stressors and indi- vidual illness will be partially mediated by the size of the cohort into which one is born: it will be possible to make precise predictions only with that in- formation to hand. That such a variable is important is suggested by information which sug- gests a rise, since the 1960s, in the age-specific mortality rate for people in the age ranges 15-24 and 25-34, although there is a slight decline for people 55-64. These former age groups are under increasingly heavy stress due to economic factors. It remains to be seen what happens to them in later years, but there is certainly a case to be made that they will continue to be under stress throughout their life-span and therefore we may see an increase in stress-related illness rather than a decline. We can further explicate this picture by looking at particular life-span events in various cohorts, and relating
The Australian Journal of Physiotherapy Vol 30, No 2, April, 1984 47
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Figure 1: Life-span events in relation to external social and economic events
them to external social and economic events. Figure 1 depicts some of the inter- actions which may affect particular individuals. One can readily conceive the years 20-30 being important for an individual in establishing economic and social independence. Rather than say that such years are static in their effect, however, one must relate them to external events. Being in the work force in the years 1920-30 and trying to establish independence was a very different experience from doing the same thing in the years 1960-70. Just to emphasise the point, con- sider the years of the so-called (mid- hfe crisis', circa 40-50. The generation having that in the 1960s had both the financial opportunity to indulge and the past experience of greater security and fewer earlier challenges. A cohort born in the years 1940-50, may not have the same period of economic stability to react to the mid-life crisis in the same way. Elder and Liker (1982) examined the impact upon women of the experience
of economic hardship during the Great Depression in America. There were clear effects of economic hardship upon health and adjustment forty years later in a cohort of women entering the year 1930 as young moth- ers. As one would expect, however, adding further complications, the effects were greater upon the women who entered the years of the Depres- sion in lower socio-economic groups. Personal economic resource will mit- igate some effects of general economic changes. But as times get harder, and as things seem not to be under personal control, then stress is likely to increase and can manifest itself m a wide variety of somatic disorders.
Individual Differences in
Reaction
Mention of personal resources leads us to the last factor to be considered here, namely the extent to which in- dividuals may differ in their suscep- tibility to stressors. In doing so we will consider the possibility that people vary in their degree of hardiness or
stamina with respect to a range of stressors, as well as a more specific responsiveness to particular forms of stress. We will also briefly consider how people may be trained to cope with stress rather than rely simply upon their own resources. Psychologists have always been in- terested in the extent to which people differentially react to stress. Emphasis has usually been on how people break- down under stress. At the beginning of World War II psychiatrists were unanimous in their predictions that bombing raids would produce mass hysteria and general mental break- down. The subsequent failure of such outcomes to eventuate, with indeed a decline m general psychiatric admis- sions, was surprising to many. It was also largely ignored and psychology continued to look for evidence of the ravages of fear upon susceptible in- dividuals, rather than for evidence of courage to cope (Rachman 1978). The characteristic manner of psy- chological investigation into suscepti- bility to stress is to identify a particular set of psychological characteristics which, when in combination with the external stimulus event, produce an elevated reaction to that event. Probably the most well-known fac- tor which has been related to a stress- related physical illness is the Type A coronary-heart disease (CHD) behav- iour pattern (eg Innes 1981). Early intuitions that a person who mani- fested heart disease showed a partic- ular syndrome of behaviour were sup- ported in a number of studies, best exemplified by the Western Collabo- rative Group Study (Roseman et al 1975). In this study, followed up over a period of eight and a half years, a group of men were interviewed to establish their characteristic behaviour pattern, and their health status was subsequently examined. Men showing the Type A pattern were twice as likely to die of myocardial infarction and report symptoms of angina than were men who did not show the pattern, even when other risk factors such as
48 The Australian Journal of Physiotherapy Vol 30, No 2, April, 1984
events and physical and psychological symptoms. In a sample of older people in the work-force we get a different relationship. So there may be other personality characteristics which may make a person liable to suffer from stressful events. But resistance to illness may be related to the presence of character- istics rather than merely due to the absence of features. A belief of one's own work, that one's skills and values and feelings are important, has been shown to be a powerful predictor of an absence of illness (Kobasa, Maddi and Puccetti 1982). Too much of such a belief, however, could lead to the same compulsion and challenge which leads to CHD in the Type A person. What is more to the point is a knowl- edge of when it is worth giving up. When one's resources can be seen to be incapable of dealing with a problem and that retirement from the problem is the most sensible way to deal with it, that is the sign of the personality that may deal with a stressful event. For a time psychological research emphasised the training of coping re- sponses to deal actively with a stressor. Either through action, or by some kind of re-evaluation or re-definition of a response, it was believed stress could be reduced. We are not denying that such reactions can be beneficial. But more recently it can be seen that positive denial or avoidance of a prob- lem can be beneficial. The benefits of denial may be seen to reside in two types of response to a problem. There is dealing with the problem itself, or there is dealing with the emotional response to the problem. Distancing oneself from the emotional arousal, thinking about something else, having a drink, can in some respects reduce the arousal and alleviate the stress. Not always, not for every problem, but it can help (Lazarus and Launier 1978). One of the side-benefits of exercise in helping to alleviate stress may pro- vide such a mechanism. Exercise can act to improve body tone, so that
there is a greater capacity to deal with problems and also, in a sense, keep a body in a chronically higher level of arousal, so that rapid swings and shifts are less likely. Exercise, however, also directs attention away from the im- mediate problem and hence there is a reduction of the immediate emotional significance of a problem. Action as well as passivity, denial as well as attack, these are coping responses which may help to alleviate the dysphoric aspects of stress and render less likely the negative physical consequences. The events which are stressful and the factors which govern a response to them are complex and our grasp upon their inter-relation- ships is at present very tenuous and superficial. Investigations into the na- ture of stressors, the bodily character- istics of people, their culture and into the means whereby reactions to stres- sors may be modified all need to be made before we can begin to have an image of what stress is and how it may be alleviated. A person who is ill, or who is at risk of illness, may be so because of chronic and acute exposure to a variety of physical and psycho-social stres- sors. The capacity of a person may be such that stress may not be debi- litating, but even in the hardy person a continual build-up of stress may eventually precipitate a problem. In the treatment of ailments which have a psychosomatic, or psycho-social component, an exploration of the range of stresses experienced may be an important adjunct to a standard case history. If we believe stress to be a part of modern living, then perhaps in our treatment of patients an ac- ceptance of its role in illness may benefit that treatment.
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lnnes JM and Holubowycz OT (1982), Stressful life events in the development of alcohol dependence in women, Anzaas Conference, Macquane University Jenkins CD, Zyzanski SJ and Rosenman RH (1978), Coronary-prone behavior One pattern or several^7 Psychosomatic Medicine, 40, 25- 43, Jenkins CD et al (1977), Social insecurity and coronary-prone Type A responses as identifiers of severe atherosclerosis, Journal of Consulting and Clinical Psychology, 45, 1060- Kanner AD, Coyne JC, Schaefer C and Lazarus RS (1981), Comparison of two modes of stress measurement- Daily hassles and uplifts versus major life events, Journal of Behavioral Med- icine, 4, 1- Kobasa, SC, Maddi SR and Puccetti MC (1982), Personality and exercise as buffers in the stress- illness relationship, Journal of Behavioral Med- icine, 5, 391- Lazarus RS and Launier R (1978), Stress-related transactions between person and environment
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