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Stress, Lifestyle, and Health


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Chapter 14
Stress, Lifestyle, and Health
Figure 14.1 Exams are a stressful, but unavoidable, element of college life. (credit “left”: modification of work by
Travis K. Mendoza; credit “center”: modification of work by “albertogp123”/Flickr; credit “right”: modification of work by
Jeffrey Pioquinto, SJ)
Chapter Outline
14.1 What Is Stress?
14.2 Stressors
14.3 Stress and Illness
14.4 Regulation of Stress
14.5 The Pursuit of Happiness
Few would deny that today’s college students are under a lot of pressure. In addition to many usual
stresses and strains incidental to the college experience (e.g., exams, term papers, and the dreaded
freshman 15), students today are faced with increased college tuitions, burdensome debt, and difficulty
finding employment after graduation. A significant population of non-traditional college students may
face additional stressors, such as raising children or holding down a full-time job while working toward a
Of course, life is filled with many additional challenges beyond those incurred in college or the workplace.
We might have concerns with financial security, difficulties with friends or neighbors, family
responsibilities, and we may not have enough time to do the things we want to do. Even minor
hassles—losing things, traffic jams, and loss of internet service—all involve pressure and demands that can
make life seem like a struggle and that can compromise our sense of well-being. That is, all can be stressful
in some way.
Scientific interest in stress, including how we adapt and cope, has been longstanding in psychology;
indeed, after nearly a century of research on the topic, much has been learned and many insights have been
developed. This chapter examines stress and highlights our current understanding of the phenomenon,
including its psychological and physiological natures, its causes and consequences, and the steps we can
take to master stress rather than become its victim.
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14.1 What Is Stress?
Learning Objectives
By the end of this section, you will be able to:
Differentiate between stimulus-based and response-based definitions of stress
Define stress as a process
Differentiate between good stress and bad stress
Describe the early contributions of Walter Cannon and Hans Selye to the stress research
Understand the physiological basis of stress and describe the general adaptation syndrome
The term stress as it relates to the human condition first emerged in scientific literature in the 1930s, but it
did not enter the popular vernacular until the 1970s (Lyon, 2012). Today, we often use the term loosely in
describing a variety of unpleasant feeling states; for example, we often say we are stressed out when we
feel frustrated, angry, conflicted, overwhelmed, or fatigued. Despite the widespread use of the term, stress
is a fairly vague concept that is difficult to define with precision.
Researchers have had a difficult time agreeing on an acceptable definition of stress. Some have
conceptualized stress as a demanding or threatening event or situation (e.g., a high-stress job,
overcrowding, and long commutes to work). Such conceptualizations are known as stimulus-based
definitions because they characterize stress as a stimulus that causes certain reactions. Stimulus-based
definitions of stress are problematic, however, because they fail to recognize that people differ in how they
view and react to challenging life events and situations. For example, a conscientious student who has
studied diligently all semester would likely experience less stress during final exams week than would a
less responsible, unprepared student.
Others have conceptualized stress in ways that emphasize the physiological responses that occur when
faced with demanding or threatening situations (e.g., increased arousal). These conceptualizations are
referred to as response-based definitions because they describe stress as a response to environmental
conditions. For example, the endocrinologist Hans Selye, a famous stress researcher, once defined stress
as the “response of the body to any demand, whether it is caused by, or results in, pleasant or unpleasant
conditions” (Selye, 1976, p. 74). Selye’s definition of stress is response-based in that it conceptualizes stress
chiefly in terms of the body’s physiological reaction to any demand that is placed on it. Neither stimulus-
based nor response-based definitions provide a complete definition of stress. Many of the physiological
reactions that occur when faced with demanding situations (e.g., accelerated heart rate) can also occur
in response to things that most people would not consider to be genuinely stressful, such as receiving
unanticipated good news: an unexpected promotion or raise.
A useful way to conceptualize stress is to view it as a process whereby an individual perceives and
responds to events that he appraises as overwhelming or threatening to his well-being (Lazarus &
Folkman, 1984). A critical element of this definition is that it emphasizes the importance of how we
appraise—that is, judge—demanding or threatening events (often referred to as stressors); these
appraisals, in turn, influence our reactions to such events. Two kinds of appraisals of a stressor are
especially important in this regard: primary and secondary appraisals. A primary appraisal involves
judgment about the degree of potential harm or threat to well-being that a stressor might entail. A stressor
would likely be appraised as a threat if one anticipates that it could lead to some kind of harm, loss, or
other negative consequence; conversely, a stressor would likely be appraised as a challenge if one believes
that it carries the potential for gain or personal growth. For example, an employee who is promoted to
a leadership position would likely perceive the promotion as a much greater threat if she believed the
promotion would lead to excessive work demands than if she viewed it as an opportunity to gain new
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skills and grow professionally. Similarly, a college student on the cusp of graduation may face the change
as a threat or a challenge (Figure 14.2).
Figure 14.2 Graduating from college and entering the workforce can be viewed as either a threat (loss of financial
support) or a challenge (opportunity for independence and growth). (credit: Timothy Zanker)
The perception of a threat triggers a secondary appraisal: judgment of the options available to cope with
a stressor, as well as perceptions of how effective such options will be (Lyon, 2012) (Figure 14.3). As you
may recall from what you learned about self-efficacy, an individual’s belief in his ability to complete a task
is important (Bandura, 1994). A threat tends to be viewed as less catastrophic if one believes something
can be done about it (Lazarus & Folkman, 1984). Imagine that two middle-aged women, Robin and Maria,
perform breast self-examinations one morning and each woman notices a lump on the lower region of
her left breast. Although both women view the breast lump as a potential threat (primary appraisal), their
secondary appraisals differ considerably. In considering the breast lump, some of the thoughts racing
through Robin’s mind are, “Oh my God, I could have breast cancer! What if the cancer has spread to
the rest of my body and I cannot recover? What if I have to go through chemotherapy? I’ve heard that
experience is awful! What if I have to quit my job? My husband and I won’t have enough money to pay
the mortgage. Oh, this is just horrible…I can’t deal with it!” On the other hand, Maria thinks, “Hmm, this
may not be good. Although most times these things turn out to be benign, I need to have it checked out.
If it turns out to be breast cancer, there are doctors who can take care of it because the medical technology
today is quite advanced. I’ll have a lot of different options, and I’ll be just fine.” Clearly, Robin and Maria
have different outlooks on what might turn out to be a very serious situation: Robin seems to think that
little could be done about it, whereas Maria believes that, worst case scenario, a number of options that
are likely to be effective would be available. As such, Robin would clearly experience greater stress than
would Maria.
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Figure 14.3 When encountering a stressor, a person judges its potential threat (primary appraisal) and then
determines if effective options are available to manage the situation. Stress is likely to result if a stressor is perceived
as extremely threatening or threatening with few or no effective coping options available.
To be sure, some stressors are inherently more stressful than others in that they are more threatening and
leave less potential for variation in cognitive appraisals (e.g., objective threats to one’s health or safety).
Nevertheless, appraisal will still play a role in augmenting or diminishing our reactions to such events
(Everly & Lating, 2002).
If a person appraises an event as harmful and believes that the demands imposed by the event exceed the
available resources to manage or adapt to it, the person will subjectively experience a state of stress. In
contrast, if one does not appraise the same event as harmful or threatening, she is unlikely to experience
stress. According to this definition, environmental events trigger stress reactions by the way they are
interpreted and the meanings they are assigned. In short, stress is largely in the eye of the beholder: it’s not
so much what happens to you as it is how you respond (Selye, 1976).
Although stress carries a negative connotation, at times it may be of some benefit. Stress can motivate
us to do things in our best interests, such as study for exams, visit the doctor regularly, exercise, and
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perform to the best of our ability at work. Indeed, Selye (1974) pointed out that not all stress is harmful.
He argued that stress can sometimes be a positive, motivating force that can improve the quality of
our lives. This kind of stress, which Selye called eustress (from the Greek eu = “good”), is a good
kind of stress associated with positive feelings, optimal health, and performance. A moderate amount of
stress can be beneficial in challenging situations. For example, athletes may be motivated and energized
by pregame stress, and students may experience similar beneficial stress before a major exam. Indeed,
research shows that moderate stress can enhance both immediate and delayed recall of educational
material. Male participants in one study who memorized a scientific text passage showed improved
memory of the passage immediately after exposure to a mild stressor as well as one day following
exposure to the stressor (Hupbach & Fieman, 2012).
Increasing one’s level of stress will cause performance to change in a predictable way. As shown in Figure
14.4, as stress increases, so do performance and general well-being (eustress); when stress levels reach
an optimal level (the highest point of the curve), performance reaches its peak. A person at this stress
level is colloquially at the top of his game, meaning he feels fully energized, focused, and can work with
minimal effort and maximum efficiency. But when stress exceeds this optimal level, it is no longer a
positive force—it becomes excessive and debilitating, or what Selye termed distress (from the Latin dis
= “bad”). People who reach this level of stress feel burned out; they are fatigued, exhausted, and their
performance begins to decline. If the stress remains excessive, health may begin to erode as well (Everly &
Lating, 2002).
Figure 14.4 As the stress level increases from low to moderate, so does performance (eustress). At the optimal
level (the peak of the curve), performance has reached its peak. If stress exceeds the optimal level, it will reach the
distress region, where it will become excessive and debilitating, and performance will decline (Everly & Lating, 2002).
Stress is everywhere and, as shown in Figure 14.5, it has been on the rise over the last several years.
Each of us is acquainted with stress—some are more familiar than others. In many ways, stress feels like a
load you just can’t carry—a feeling you experience when, for example, you have to drive somewhere in a
crippling blizzard, when you wake up late the morning of an important job interview, when you run out
of money before the next pay period, and before taking an important exam for which you realize you are
not fully prepared.
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Figure 14.5 Nearly half of U.S. adults indicated that their stress levels have increased over the last five years
(Neelakantan, 2013).
Stress is an experience that evokes a variety of responses, including those that are physiological (e.g.,
accelerated heart rate, headaches, or gastrointestinal problems), cognitive (e.g., difficulty concentrating
or making decisions), and behavioral (e.g., drinking alcohol, smoking, or taking actions directed at
eliminating the cause of the stress). Although stress can be positive at times, it can have deleterious health
implications, contributing to the onset and progression of a variety of physical illnesses and diseases
(Cohen & Herbert, 1996).
The scientific study of how stress and other psychological factors impact health falls within the realm of
health psychology, a subfield of psychology devoted to understanding the importance of psychological
influences on health, illness, and how people respond when they become ill (Taylor, 1999). Health
psychology emerged as a discipline in the 1970s, a time during which there was increasing awareness
of the role behavioral and lifestyle factors play in the development of illnesses and diseases (Straub,
2007). In addition to studying the connection between stress and illness, health psychologists investigate
issues such as why people make certain lifestyle choices (e.g., smoking or eating unhealthy food despite
knowing the potential adverse health implications of such behaviors). Health psychologists also design
and investigate the effectiveness of interventions aimed at changing unhealthy behaviors. Perhaps one of
the more fundamental tasks of health psychologists is to identify which groups of people are especially at
risk for negative health outcomes, based on psychological or behavioral factors. For example, measuring
differences in stress levels among demographic groups and how these levels change over time can help
identify populations who may have an increased risk for illness or disease.
Figure 14.6 depicts the results of three national surveys in which several thousand individuals from
different demographic groups completed a brief stress questionnaire; the surveys were administered in
1983, 2006, and 2009 (Cohen & Janicki-Deverts, 2012). All three surveys demonstrated higher stress in
women than in men. Unemployed individuals reported high levels of stress in all three surveys, as did
those with less education and income; retired persons reported the lowest stress levels. However, from
2006 to 2009 the greatest increase in stress levels occurred among men, Whites, people aged 45–64, college
graduates, and those with full-time employment. One interpretation of these findings is that concerns
surrounding the 2008–2009 economic downturn (e.g., threat of or actual job loss and substantial loss of
retirement savings) may have been especially stressful to White, college-educated, employed men with
limited time remaining in their working careers.
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Figure 14.6 The charts above, adapted from Cohen & Janicki-Deverts (2012), depict the mean stress level scores
among different demographic groups during the years 1983, 2006, and 2009. Across categories of sex, age, race,
education level, employment status, and income, stress levels generally show a marked increase over this quarter-
century time span.
As previously stated, scientific interest in stress goes back nearly a century. One of the early pioneers in the
study of stress was Walter Cannon, an eminent American physiologist at Harvard Medical School (Figure
14.7). In the early part of the 20th century, Cannon was the first to identify the body’s physiological
reactions to stress.
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Figure 14.7 Harvard physiologist Walter Cannon first articulated and named the fight-or-flight response, the nervous
system’s sympathetic response to a significant stressor.
Cannon and the Fight-or-Flight Response
Imagine that you are hiking in the beautiful mountains of Colorado on a warm and sunny spring day. At
one point during your hike, a large, frightening-looking black bear appears from behind a stand of trees
and sits about 50 yards from you. The bear notices you, sits up, and begins to lumber in your direction. In
addition to thinking, “This is definitely not good,” a constellation of physiological reactions begins to take
place inside you. Prompted by a deluge of epinephrine (adrenaline) and norepinephrine (noradrenaline)
from your adrenal glands, your pupils begin to dilate. Your heart starts to pound and speeds up, you
begin to breathe heavily and perspire, you get butterflies in your stomach, and your muscles become tense,
preparing you to take some kind of direct action. Cannon proposed that this reaction, which he called
the fight-or-flight response, occurs when a person experiences very strong emotions—especially those
associated with a perceived threat (Cannon, 1932). During the fight-or-flight response, the body is rapidly
aroused by activation of both the sympathetic nervous system and the endocrine system (Figure 14.8).
This arousal helps prepare the person to either fight or flee from a perceived threat.
Figure 14.8 Fight or flight is a physiological response to a stressor.
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According to Cannon, the fight-or-flight response is a built-in mechanism that assists in maintaining
homeostasis—an internal environment in which physiological variables such as blood pressure,
respiration, digestion, and temperature are stabilized at levels optimal for survival. Thus, Cannon viewed
the fight-or-flight response as adaptive because it enables us to adjust internally and externally to changes
in our surroundings, which is helpful in species survival.
Selye and the General Adaptation Syndrome
Another important early contributor to the stress field was Hans Selye, mentioned earlier. He would
eventually become one of the world’s foremost experts in the study of stress (Figure 14.9). As a young
assistant in the biochemistry department at McGill University in the 1930s, Selye was engaged in research
involving sex hormones in rats. Although he was unable to find an answer for what he was initially
researching, he incidentally discovered that when exposed to prolonged negative stimulation
(stressors)—such as extreme cold, surgical injury, excessive muscular exercise, and shock—the rats
showed signs of adrenal enlargement, thymus and lymph node shrinkage, and stomach ulceration. Selye
realized that these responses were triggered by a coordinated series of physiological reactions that unfold
over time during continued exposure to a stressor. These physiological reactions were nonspecific, which
means that regardless of the type of stressor, the same pattern of reactions would occur. What Selye
discovered was the general adaptation syndrome, the body’s nonspecific physiological response to stress.
Figure 14.9 Hans Selye specialized in research about stress. In 2009, his native Hungary honored his work with this
stamp, released in conjunction with the 2nd annual World Conference on Stress.
The general adaptation syndrome, shown in Figure 14.10, consists of three stages: (1) alarm reaction, (2)
stage of resistance, and (3) stage of exhaustion (Selye, 1936; 1976). Alarm reaction describes the body’s
immediate reaction upon facing a threatening situation or emergency, and it is roughly analogous to the
fight-or-flight response described by Cannon. During an alarm reaction, you are alerted to a stressor,
and your body alarms you with a cascade of physiological reactions that provide you with the energy to
manage the situation. A person who wakes up in the middle of the night to discover her house is on fire,
for example, is experiencing an alarm reaction.
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Figure 14.10 The three stages of Selye’s general adaptation syndrome are shown in this graph. Prolonged stress
ultimately results in exhaustion.
If exposure to a stressor is prolonged, the organism will enter the stage of resistance. During this stage,
the initial shock of alarm reaction has worn off and the body has adapted to the stressor. Nevertheless, the
body also remains on alert and is prepared to respond as it did during the alarm reaction, although with
less intensity. For example, suppose a child who went missing is still missing 72 hours later. Although
the parents would obviously remain extremely disturbed, the magnitude of physiological reactions would
likely have diminished over the 72 intervening hours due to some adaptation to this event.
If exposure to a stressor continues over a longer period of time, the stage of exhaustion ensues. At this
stage, the person is no longer able to adapt to the stressor: the body’s ability to resist becomes depleted
as physical wear takes its toll on the body’s tissues and organs. As a result, illness, disease, and other
permanent damage to the body—even death—may occur. If a missing child still remained missing after
three months, the long-term stress associated with this situation may cause a parent to literally faint with
exhaustion at some point or even to develop a serious and irreversible illness.
In short, Selye’s general adaptation syndrome suggests that stressors tax the body via a three-phase
process—an initial jolt, subsequent readjustment, and a later depletion of all physical resources—that
ultimately lays the groundwork for serious health problems and even death. It should be pointed out,
however, that this model is a response-based conceptualization of stress, focusing exclusively on the
body’s physical responses while largely ignoring psychological factors such as appraisal and interpretation
of threats. Nevertheless, Selye’s model has had an enormous impact on the field of stress because it offers
a general explanation for how stress can lead to physical damage and, thus, disease. As we shall discuss
later, prolonged or repeated stress has been implicated in development of a number of disorders such as
hypertension and coronary artery disease.
What goes on inside our bodies when we experience stress? The physiological mechanisms of stress
are extremely complex, but they generally involve the work of two systems—the sympathetic nervous
system and the hypothalamic-pituitary-adrenal (HPA) axis. When a person first perceives something
as stressful (Selye’s alarm reaction), the sympathetic nervous system triggers arousal via the release of
adrenaline from the adrenal glands. Release of these hormones activates the fight-or-flight responses to
stress, such as accelerated heart rate and respiration. At the same time, the HPA axis, which is primarily
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endocrine in nature, becomes especially active, although it works much more slowly than the sympathetic
nervous system. In response to stress, the hypothalamus (one of the limbic structures in the brain) releases
corticotrophin-releasing factor, a hormone that causes the pituitary gland to release adrenocorticotropic
hormone (ACTH) (Figure 14.11). The ACTH then activates the adrenal glands to secrete a number of
hormones into the bloodstream; an important one is cortisol, which can affect virtually every organ within
the body. Cortisol is commonly known as a stress hormone and helps provide that boost of energy when
we first encounter a stressor, preparing us to run away or fight. However, sustained elevated levels of
cortisol weaken the immune system.
Figure 14.11 This diagram shows the functioning of the hypothalamic-pituitary-adrenal (HPA) axis. The
hypothalamus activates the pituitary gland, which in turn activates the adrenal glands, increasing their secretion of
In short bursts, this process can have some favorable effects, such as providing extra energy, improving
immune system functioning temporarily, and decreasing pain sensitivity. However, extended release of
cortisol—as would happen with prolonged or chronic stress—often comes at a high price. High levels of
cortisol have been shown to produce a number of harmful effects. For example, increases in cortisol can
significantly weaken our immune system (Glaser & Kiecolt-Glaser, 2005), and high levels are frequently
observed among depressed individuals (Geoffroy, Hertzman, Li, & Power, 2013). In summary, a stressful
event causes a variety of physiological reactions that activate the adrenal glands, which in turn release
epinephrine, norepinephrine, and cortisol. These hormones affect a number of bodily processes in ways
that prepare the stressed person to take direct action, but also in ways that may heighten the potential for
When stress is extreme or chronic, it can have profoundly negative consequences. For example, stress
often contributes to the development of certain psychological disorders, including post-traumatic stress
disorder, major depressive disorder, and other serious psychiatric conditions. Additionally, we noted
earlier that stress is linked to the development and progression of a variety of physical illnesses and
diseases. For example, researchers in one study found that people injured during the September 11, 2001,
World Trade Center disaster or who developed post-traumatic stress symptoms afterward later suffered
significantly elevated rates of heart disease (Jordan, Miller-Archie, Cone, Morabia, & Stellman, 2011).
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Another investigation yielded that self-reported stress symptoms among aging and retired Finnish food
industry workers were associated with morbidity 11 years later. This study also predicted the onset of
musculoskeletal, nervous system, and endocrine and metabolic disorders (Salonen, Arola, Nygård, &
Huhtala, 2008). Another study reported that male South Korean manufacturing employees who reported
high levels of work-related stress were more likely to catch the common cold over the next several months
than were those employees who reported lower work-related stress levels (Park et al., 2011). Later, you
will explore the mechanisms through which stress can produce physical illness and disease.
14.2 Stressors
Learning Objectives
By the end of this section, you will be able to:
Describe different types of possible stressors
Explain the importance of life changes as potential stressors
Describe the Social Readjustment Rating Scale
Understand the concepts of job strain and job burnout
For an individual to experience stress, he must first encounter a potential stressor. In general, stressors can
be placed into one of two broad categories: chronic and acute. Chronic stressors include events that persist
over an extended period of time, such as caring for a parent with dementia, long-term unemployment,
or imprisonment. Acute stressors involve brief focal events that sometimes continue to be experienced
as overwhelming well after the event has ended, such as falling on an icy sidewalk and breaking your
leg (Cohen, Janicki-Deverts, & Miller, 2007). Whether chronic or acute, potential stressors come in many
shapes and sizes. They can include major traumatic events, significant life changes, daily hassles, as well
as other situations in which a person is regularly exposed to threat, challenge, or danger.
Some stressors involve traumatic events or situations in which a person is exposed to actual or threatened
death or serious injury. Stressors in this category include exposure to military combat, threatened or
actual physical assaults (e.g., physical attacks, sexual assault, robbery, childhood abuse), terrorist attacks,
natural disasters (e.g., earthquakes, floods, hurricanes), and automobile accidents. Men, non-Whites, and
individuals in lower socioeconomic status (SES) groups report experiencing a greater number of traumatic
events than do women, Whites, and individuals in higher SES groups (Hatch & Dohrenwend, 2007). Some
individuals who are exposed to stressors of extreme magnitude develop post-traumatic stress disorder
(PTSD): a chronic stress reaction characterized by experiences and behaviors that may include intrusive
and painful memories of the stressor event, jumpiness, persistent negative emotional states, detachment
from others, angry outbursts, and avoidance of reminders of the event (American Psychiatric Association
[APA], 2013).
Most stressors that we encounter are not nearly as intense as the ones described above. Many potential
stressors we face involve events or situations that require us to make changes in our ongoing lives and
require time as we adjust to those changes. Examples include death of a close family member, marriage,
divorce, and moving (Figure 14.12).
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Figure 14.12 Some fairly typical life events, such as moving, can be significant stressors. Even when the move is
intentional and positive, the amount of resulting change in daily life can cause stress. (credit: "Jellaluna"/Flickr)
In the 1960s, psychiatrists Thomas Holmes and Richard Rahe wanted to examine the link between life
stressors and physical illness, based on the hypothesis that life events requiring significant changes in
a person’s normal life routines are stressful, whether these events are desirable or undesirable. They
developed the Social Readjustment Rating Scale (SRRS), consisting of 43 life events that require varying
degrees of personal readjustment (Holmes & Rahe, 1967). Many life events that most people would
consider pleasant (e.g., holidays, retirement, marriage) are among those listed on the SRRS; these are
examples of eustress. Holmes and Rahe also proposed that life events can add up over time, and that
experiencing a cluster of stressful events increases one’s risk of developing physical illnesses.
In developing their scale, Holmes and Rahe asked 394 participants to provide a numerical estimate for
each of the 43 items; each estimate corresponded to how much readjustment participants felt each event
would require. These estimates resulted in mean value scores for each event—often called life change
units (LCUs) (Rahe, McKeen, & Arthur, 1967). The numerical scores ranged from 11 to 100, representing
the perceived magnitude of life change each event entails. Death of a spouse ranked highest on the scale
with 100 LCUs, and divorce ranked second highest with 73 LCUs. In addition, personal injury or illness,
marriage, and job termination also ranked highly on the scale with 53, 50, and 47 LCUs, respectively.
Conversely, change in residence (20 LCUs), change in eating habits (15 LCUs), and vacation (13 LCUs)
ranked low on the scale (Table 14.1). Minor violations of the law ranked the lowest with 11 LCUs. To
complete the scale, participants checked yes for events experienced within the last 12 months. LCUs for
each checked item are totaled for a score quantifying the amount of life change. Agreement on the amount
of adjustment required by the various life events on the SRRS is highly consistent, even cross-culturally
(Holmes & Masuda, 1974).
Table 14.1 Some Stressors on the Social Readjustment
Rating Scale (Holmes & Rahe, 1967)
Life event Life change units
Death of a close family member 63
Personal injury or illness 53
Dismissal from work 47
Change in financial state 38
Change to different line of work 36
Outstanding personal achievement 28
Beginning or ending school 26
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Table 14.1 Some Stressors on the Social Readjustment
Rating Scale (Holmes & Rahe, 1967)
Life event Life change units
Change in living conditions 25
Change in working hours or conditions 20
Change in residence 20
Change in schools 20
Change in social activities 18
Change in sleeping habits 16
Change in eating habits 15
Minor violation of the law 11
Extensive research has demonstrated that accumulating a high number of life change units within a brief
period of time (one or two years) is related to a wide range of physical illnesses (even accidents and athletic
injuries) and mental health problems (Monat & Lazarus, 1991; Scully, Tosi, & Banning, 2000). In an early
demonstration, researchers obtained LCU scores for U.S. and Norwegian Navy personnel who were about
to embark on a six-month voyage. A later examination of medical records revealed positive (but small)
correlations between LCU scores prior to the voyage and subsequent illness symptoms during the ensuing
six-month journey (Rahe, 1974). In addition, people tend to experience more physical symptoms, such
as backache, upset stomach, diarrhea, and acne, on specific days in which self-reported LCU values are
considerably higher than normal, such as the day of a family member’s wedding (Holmes & Holmes, 1970).
The Social Readjustment Rating Scale (SRRS) provides researchers a simple, easy-to-administer way of
assessing the amount of stress in people’s lives, and it has been used in hundreds of studies (Thoits, 2010).
Despite its widespread use, the scale has been subject to criticism. First, many of the items on the SRRS are
vague; for example, death of a close friend could involve the death of a long-absent childhood friend that
requires little social readjustment (Dohrenwend, 2006). In addition, some have challenged its assumption
that undesirable life events are no more stressful than desirable ones (Derogatis & Coons, 1993). However,
most of the available evidence suggests that, at least as far as mental health is concerned, undesirable or
negative events are more strongly associated with poor outcomes (such as depression) than are desirable,
positive events (Hatch & Dohrenwend, 2007). Perhaps the most serious criticism is that the scale does
not take into consideration respondents’ appraisals of the life events it contains. As you recall, appraisal
of a stressor is a key element in the conceptualization and overall experience of stress. Being fired from
work may be devastating to some but a welcome opportunity to obtain a better job for others. The SRRS
remains one of the most well-known instruments in the study of stress, and it is a useful tool for identifying
potential stress-related health outcomes (Scully et al., 2000).
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Go to this site ( to complete the SRRS scale
and determine the total number of LCUs you have experienced over the last year.
Correlational Research
The Holmes and Rahe Social Readjustment Rating Scale (SRRS) uses the correlational research method to
identify the connection between stress and health. That is, respondents’ LCU scores are correlated with the
number or frequency of self-reported symptoms indicating health problems. These correlations are typically
positive—as LCU scores increase, the number of symptoms increase. Consider all the thousands of studies
that have used this scale to correlate stress and illness symptoms: If you were to assign an average correlation
coefficient to this body of research, what would be your best guess? How strong do you think the correlation
coefficient would be? Why can’t the SRRS show a causal relationship between stress and illness? If it were
possible to show causation, do you think stress causes illness or illness causes stress?
Potential stressors do not always involve major life events. Daily hassles—the minor irritations and
annoyances that are part of our everyday lives (e.g., rush hour traffic, lost keys, obnoxious coworkers,
inclement weather, arguments with friends or family)—can build on one another and leave us just as
stressed as life change events (Figure 14.13) (Kanner, Coyne, Schaefer, & Lazarus, 1981).
Figure 14.13 Daily commutes, whether (a) on the road or (b) via public transportation, can be hassles that
contribute to our feelings of everyday stress. (credit a: modification of work by Jeff Turner; credit b: modification of
work by ""/Flickr)
Researchers have demonstrated that the frequency of daily hassles is actually a better predictor of both
physical and psychological health than are life change units. In a well-known study of San Francisco
residents, the frequency of daily hassles was found to be more strongly associated with physical health
problems than were life change events (DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982). In addition,
daily minor hassles, especially interpersonal conflicts, often lead to negative and distressed mood states
(Bolger, DeLongis, Kessler, & Schilling, 1989). Cyber hassles that occur on social media may represent a
new source of stress. In one investigation, undergraduates who, over a 10-week period, reported greater
Facebook-induced stress (e.g., guilt or discomfort over rejecting friend requests and anger or sadness over
being unfriended by another) experienced increased rates of upper respiratory infections, especially if they
Chapter 14 Stress, Lifestyle, and Health 509
had larger social networks (Campisi et al., 2012). Clearly, daily hassles can add up and take a toll on us
both emotionally and physically.
Stressors can include situations in which one is frequently exposed to challenging and unpleasant events,
such as difficult, demanding, or unsafe working conditions. Although most jobs and occupations can
at times be demanding, some are clearly more stressful than others (Figure 14.14). For example, most
people would likely agree that a firefighter’s work is inherently more stressful than that of a florist.
Equally likely, most would agree that jobs containing various unpleasant elements, such as those requiring
exposure to loud noise (heavy equipment operator), constant harassment and threats of physical violence
(prison guard), perpetual frustration (bus driver in a major city), or those mandating that an employee
work alternating day and night shifts (hotel desk clerk), are much more demanding—and thus, more
stressful—than those that do not contain such elements. Table 14.2 lists several occupations and some of
the specific stressors associated with those occupations (Sulsky & Smith, 2005).
Figure 14.14 (a) Police officers and (b) firefighters hold high stress occupations. (credit a: modification of work by
Australian Civil-Military Centre; credit b: modification of work by Andrew Magill)
Table 14.2 Occupations and Their Related Stressors
Occupation Stressors Specific to Occupation (Sulsky & Smith, 2005)
physical dangers, excessive paperwork, red tape, dealing with court system,
coworker and supervisor conflict, lack of support from the public
Firefighter uncertainty over whether a serious fire or hazard awaits after an alarm
little positive feedback from jobs or from the public, unsafe work environments,
frustration in dealing with bureaucracy, excessive paperwork, sense of personal
responsibility for clients, work overload
Teacher Excessive paperwork, lack of adequate supplies or facilities, work overload, lack of
positive feedback, vandalism, threat of physical violence
Nurse Work overload, heavy physical work, patient concerns (dealing with death and
medical concerns), interpersonal problems with other medical staff (especially
Unpredictable and extreme nature of the job, inexperience
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Table 14.2 Occupations and Their Related Stressors
Occupation Stressors Specific to Occupation (Sulsky & Smith, 2005)
Air traffic
Little control over potential crisis situations and workload, fear of causing an
accident, peak traffic situations, general work environment
Clerical and
Little control over job mobility, unsupportive supervisors, work overload, lack of
perceived control
Work overload, conflict and ambiguity in defining the managerial role, difficult work
Although the specific stressors for these occupations are diverse, they seem to share two common
denominators: heavy workload and uncertainty about and lack of control over certain aspects of a job.
Both of these factors contribute to job strain, a work situation that combines excessive job demands and
workload with little discretion in decision making or job control (Karasek & Theorell, 1990). Clearly, many
occupations other than the ones listed in Table 14.2 involve at least a moderate amount of job strain in that
they often involve heavy workloads and little job control (e.g., inability to decide when to take breaks).
Such jobs are often low-status and include those of factory workers, postal clerks, supermarket cashiers,
taxi drivers, and short-order cooks. Job strain can have adverse consequences on both physical and mental
health; it has been shown to be associated with increased risk of hypertension (Schnall & Landsbergis,
1994), heart attacks (Theorell et al., 1998), recurrence of heart disease after a first heart attack (Aboa-Éboulé
et al., 2007), significant weight loss or gain (Kivimäki et al., 2006), and major depressive disorder (Stansfeld,
Shipley, Head, & Fuhrer, 2012). A longitudinal study of over 10,000 British civil servants reported that
workers under 50 years old who earlier had reported high job strain were 68% more likely to later develop
heart disease than were those workers under 50 years old who reported little job strain (Chandola et al.,
Some people who are exposed to chronically stressful work conditions can experience job burnout,
which is a general sense of emotional exhaustion and cynicism in relation to one’s job (Maslach &
Jackson, 1981). Job burnout occurs frequently among those in human service jobs (e.g., social workers,
teachers, therapists, and police officers). Job burnout consists of three dimensions. The first dimension is
exhaustion—a sense that one’s emotional resources are drained or that one is at the end of her rope and has
nothing more to give at a psychological level. Second, job burnout is characterized by depersonalization:
a sense of emotional detachment between the worker and the recipients of his services, often resulting
in callous, cynical, or indifferent attitudes toward these individuals. Third, job burnout is characterized
by diminished personal accomplishment, which is the tendency to evaluate one’s work negatively by, for
example, experiencing dissatisfaction with one’s job-related accomplishments or feeling as though one has
categorically failed to influence others’ lives through one’s work.
Job strain appears to be one of the greatest risk factors leading to job burnout, which is most commonly
observed in workers who are older (ages 55–64), unmarried, and whose jobs involve manual labor. Heavy
alcohol consumption, physical inactivity, being overweight, and having a physical or lifetime mental
disorder are also associated with job burnout (Ahola, et al., 2006). In addition, depression often co-
occurs with job burnout. One large-scale study of over 3,000 Finnish employees reported that half of the
participants with severe job burnout had some form of depressive disorder (Ahola et al., 2005). Job burnout
is often precipitated by feelings of having invested considerable energy, effort, and time into one’s work
while receiving little in return (e.g., little respect or support from others or low pay) (Tatris, Peeters, Le
Blanc, Schreurs, & Schaufeli, 2001).
Chapter 14 Stress, Lifestyle, and Health 511
As an illustration, consider CharlieAnn, a nursing assistant who worked in a nursing home. CharlieAnn
worked long hours for little pay in a difficult facility. Her supervisor was domineering, unpleasant, and
unsupportive; he was disrespectful of CharlieAnn’s personal time, frequently informing her at the last
minute she must work several additional hours after her shift ended or that she must report to work on
weekends. CharlieAnn had very little autonomy at her job. She had little say in her day-to-day duties and
how to perform them, and she was not permitted to take breaks unless her supervisor explicitly told her
that she could. CharlieAnn did not feel as though her hard work was appreciated, either by supervisory
staff or by the residents of the home. She was very unhappy over her low pay, and she felt that many of
the residents treated her disrespectfully.
After several years, CharlieAnn began to hate her job. She dreaded going to work in the morning, and
she gradually developed a callous, hostile attitude toward many of the residents. Eventually, she began to
feel as though she could no longer help the nursing home residents. CharlieAnn’s absenteeism from work
increased, and one day she decided that she had had enough and quit. She now has a job in sales, vowing
never to work in nursing again.
A humorous example illustrating lack of supervisory support can be found in the
1999 comedy Office Space. Follow this link (
officespace) to view a brief excerpt in which a sympathetic character’s insufferable
boss makes a last-minute demand that he “go ahead and come in” to the office on
both Saturday and Sunday.
Finally, our close relationships with friends and family—particularly the negative aspects of these
relationships—can be a potent source of stress. Negative aspects of close relationships can include adverse
exchanges and conflicts, lack of emotional support or confiding, and lack of reciprocity. All of these can
be overwhelming, threatening to the relationship, and thus stressful. Such stressors can take a toll both
emotionally and physically. A longitudinal investigation of over 9,000 British civil servants found that
those who at one point had reported the highest levels of negative interactions in their closest relationship
were 34% more likely to experience serious heart problems (fatal or nonfatal heart attacks) over a 13–15
year period, compared to those who experienced the lowest levels of negative interaction (De Vogli,
Chandola & Marmot, 2007).
14.3 Stress and Illness
Learning Objectives
By the end of this section, you will be able to:
Explain the nature of psychophysiological disorders
Describe the immune system and how stress impacts its functioning
Describe how stress and emotional factors can lead to the development and exacerbation of
cardiovascular disorders, asthma, and tension headaches
In this section, we will discuss stress and illness. As stress researcher Robert Sapolsky (1998) describes,
stress-related disease emerges, predominantly, out of the fact that we so often activate a
physiological system that has evolved for responding to acute physical emergencies, but we turn
it on for months on end, worrying about mortgages, relationships, and promotions. (p. 6)
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The stress response, as noted earlier, consists of a coordinated but complex system of physiological
reactions that are called upon as needed. These reactions are beneficial at times because they prepare us to
deal with potentially dangerous or threatening situations (for example, recall our old friend, the fearsome
bear on the trail). However, health is affected when physiological reactions are sustained, as can happen
in response to ongoing stress.
If the reactions that compose the stress response are chronic or if they frequently exceed normal ranges,
they can lead to cumulative wear and tear on the body, in much the same way that running your air
conditioner on full blast all summer will eventually cause wear and tear on it. For example, the high blood
pressure that a person under considerable job strain experiences might eventually take a toll on his heart
and set the stage for a heart attack or heart failure. Also, someone exposed to high levels of the stress
hormone cortisol might become vulnerable to infection or disease because of weakened immune system
functioning (McEwen, 1998).
Robert Sapolsky, a noted Stanford University neurobiologist and professor, has for
over 30 years conducted extensive research on stress, its impact on our bodies, and
how psychological tumult can escalate stress—even in baboons. Here are two
videos featuring Dr. Sapolsky: one is regarding killer stress
( and the other is an excellent in-depth
documentary ( from National Geographic.
Physical disorders or diseases whose symptoms are brought about or worsened by stress and emotional
factors are called psychophysiological disorders. The physical symptoms of psychophysiological
disorders are real and they can be produced or exacerbated by psychological factors (hence the psycho
and physiological in psychophysiological). A list of frequently encountered psychophysiological disorders
is provided in Table 14.3.
Table 14.3 Types of Psychophysiological Disorders (adapted from Everly &
Lating, 2002)
Type of Psychophysiological Disorder Examples
Cardiovascular hypertension, coronary heart disease
Gastrointestinal irritable bowel syndrome
Respiratory asthma, allergy
Musculoskeletal low back pain, tension headaches
Skin acne, eczema, psoriasis
In addition to stress itself, emotional upset and certain stressful personality traits have been proposed
as potential contributors to ill health. Franz Alexander (1950), an early-20th-century psychoanalyst and
physician, once postulated that various diseases are caused by specific unconscious conflicts. For example,
he linked hypertension to repressed anger, asthma to separation anxiety, and ulcers to an unconscious
Chapter 14 Stress, Lifestyle, and Health 513
desire to “remain in the dependent infantile situation—to be loved and cared for” (Alexander, 1950, p. 102).
Although hypertension does appear to be linked to anger (as you will learn below), Alexander’s assertions
have not been supported by research. Years later, Friedman and Booth-Kewley (1987), after statistically
reviewing 101 studies examining the link between personality and illness, proposed the existence of
disease-prone personality characteristics, including depression, anger/hostility, and anxiety. Indeed, a
study of over 61,000 Norwegians identified depression as a risk factor for all major disease-related causes
of death (Mykletun et al., 2007). In addition, neuroticism—a personality trait that reflects how anxious,
moody, and sad one is—has been identified as a risk factor for chronic health problems and mortality
(Ploubidis & Grundy, 2009).
Below, we discuss two kinds of psychophysiological disorders about which a great deal is known:
cardiovascular disorders and asthma. First, however, it is necessary to turn our attention to a discussion of
the immune system—one of the major pathways through which stress and emotional factors can lead to
illness and disease.
In a sense, the immune system is the body’s surveillance system. It consists of a variety of structures, cells,
and mechanisms that serve to protect the body from invading toxins and microorganisms that can harm
or damage the body’s tissues and organs. When the immune system is working as it should, it keeps us
healthy and disease free by eliminating bacteria, viruses, and other foreign substances that have entered
the body (Everly & Lating, 2002).
Immune System Errors
Sometimes, the immune system will function erroneously. For example, sometimes it can go awry by
mistaking your body’s own healthy cells for invaders and repeatedly attacking them. When this happens,
the person is said to have an autoimmune disease, which can affect almost any part of the body. How
an autoimmune disease affects a person depends on what part of the body is targeted. For instance,
rheumatoid arthritis, an autoimmune disease that affects the joints, results in joint pain, stiffness, and
loss of function. Systemic lupus erythematosus, an autoimmune disease that affects the skin, can result in
rashes and swelling of the skin. Grave’s disease, an autoimmune disease that affects the thyroid gland, can
result in fatigue, weight gain, and muscle aches (National Institute of Arthritis and Musculoskeletal and
Skin Diseases [NIAMS], 2012).
In addition, the immune system may sometimes break down and be unable to do its job. This situation
is referred to as immunosuppression, the decreased effectiveness of the immune system. When people
experience immunosuppression, they become susceptible to any number of infections, illness, and
diseases. For example, acquired immune deficiency syndrome (AIDS) is a serious and lethal disease that is
caused by human immunodeficiency virus (HIV), which greatly weakens the immune system by infecting
and destroying antibody-producing cells, thus rendering a person vulnerable to any of a number of
opportunistic infections (Powell, 1996).
Stressors and Immune Function
The question of whether stress and negative emotional states can influence immune function has
captivated researchers for over three decades, and discoveries made over that time have dramatically
changed the face of health psychology (Kiecolt-Glaser, 2009). Psychoneuroimmunology is the field that
studies how psychological factors such as stress influence the immune system and immune functioning.
The term psychoneuroimmunology was first coined in 1981, when it appeared as the title of a book that
reviewed available evidence for associations between the brain, endocrine system, and immune system
(Zacharie, 2009). To a large extent, this field evolved from the discovery that there is a connection between
the central nervous system and the immune system.
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Some of the most compelling evidence for a connection between the brain and the immune system
comes from studies in which researchers demonstrated that immune responses in animals could be
classically conditioned (Everly & Lating, 2002). For example, Ader and Cohen (1975) paired flavored
water (the conditioned stimulus) with the presentation of an immunosuppressive drug (the unconditioned
stimulus), causing sickness (an unconditioned response). Not surprisingly, rats exposed to this pairing
developed a conditioned aversion to the flavored water. However, the taste of the water itself later
produced immunosuppression (a conditioned response), indicating that the immune system itself had
been conditioned. Many subsequent studies over the years have further demonstrated that immune
responses can be classically conditioned in both animals and humans (Ader & Cohen, 2001). Thus, if
classical conditioning can alter immunity, other psychological factors should be capable of altering it as
Hundreds of studies involving tens of thousands of participants have tested many kinds of brief and
chronic stressors and their effect on the immune system (e.g., public speaking, medical school
examinations, unemployment, marital discord, divorce, death of spouse, burnout and job strain, caring
for a relative with Alzheimer’s disease, and exposure to the harsh climate of Antarctica). It has been
repeatedly demonstrated that many kinds of stressors are associated with poor or weakened immune
functioning (Glaser & Kiecolt-Glaser, 2005; Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002; Segerstrom &
Miller, 2004).
When evaluating these findings, it is important to remember that there is a tangible physiological
connection between the brain and the immune system. For example, the sympathetic nervous system
innervates immune organs such as the thymus, bone marrow, spleen, and even lymph nodes (Maier,
Watkins, & Fleshner, 1994). Also, we noted earlier that stress hormones released during hypothalamic-
pituitary-adrenal (HPA) axis activation can adversely impact immune function. One way they do this is
by inhibiting the production of lymphocytes, white blood cells that circulate in the body’s fluids that are
important in the immune response (Everly & Lating, 2002).
Some of the more dramatic examples demonstrating the link between stress and impaired immune
function involve studies in which volunteers were exposed to viruses. The rationale behind this research
is that because stress weakens the immune system, people with high stress levels should be more likely
to develop an illness compared to those under little stress. In one memorable experiment using this
method, researchers interviewed 276 healthy volunteers about recent stressful experiences (Cohen et al.,
1998). Following the interview, these participants were given nasal drops containing the cold virus (in
case you are wondering why anybody would ever want to participate in a study in which they are
subjected to such treatment, the participants were paid $800 for their trouble). When examined later,
participants who reported experiencing chronic stressors for more than one month—especially enduring
difficulties involving work or relationships—were considerably more likely to have developed colds than
were participants who reported no chronic stressors (Figure 14.15).
Chapter 14 Stress, Lifestyle, and Health 515
Figure 14.15 This graph shows the percentages of participants who developed colds (after receiving the cold virus)
after reporting having experienced chronic stressors lasting at least one month, three months, and six months
(adapted from Cohen et al., 1998).
In another study, older volunteers were given an influenza virus vaccination. Compared to controls, those
who were caring for a spouse with Alzheimer’s disease (and thus were under chronic stress) showed
poorer antibody response following the vaccination (Kiecolt-Glaser, Glaser, Gravenstein, Malarkey, &
Sheridan, 1996).
Other studies have demonstrated that stress slows down wound healing by impairing immune responses
important to wound repair (Glaser & Kiecolt-Glaser, 2005). In one study, for example, skin blisters were
induced on the forearm. Subjects who reported higher levels of stress produced lower levels of immune
proteins necessary for wound healing (Glaser et al., 1999). Stress, then, is not so much the sword that kills
the knight, so to speak; rather, it’s the sword that breaks the knight’s shield, and your immune system is
that shield.
Stress and Aging: A Tale of Telomeres
Have you ever wondered why people who are stressed often seem to have a haggard look about them? A
pioneering study from 2004 suggests that the reason is because stress can actually accelerate the cell biology
of aging.
Stress, it seems, can shorten telomeres, which are segments of DNA that protect the ends of chromosomes.
Shortened telomeres can inhibit or block cell division, which includes growth and proliferation of new cells,
thereby leading to more rapid aging (Sapolsky, 2004). In the study, researchers compared telomere lengths
in the white blood cells in mothers of chronically ill children to those of mothers of healthy children (Epel
et al., 2004). Mothers of chronically ill children would be expected to experience more stress than would
mothers of healthy children. The longer a mother had spent caring for her ill child, the shorter her telomeres
(the correlation between years of caregiving and telomere length was r= -.40). In addition, higher levels of
perceived stress were negatively correlated with telomere size (r= -.31). These researchers also found that
the average telomere length of the most stressed mothers, compared to the least stressed, was similar to what
you would find in people who were 9–17 years older than they were on average.
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Numerous other studies since have continued to find associations between stress and eroded telomeres
(Blackburn & Epel, 2012). Some studies have even demonstrated that stress can begin to erode telomeres
in childhood and perhaps even before children are born. For example, childhood exposure to violence (e.g.,
maternal domestic violence, bullying victimization, and physical maltreatment) was found in one study to
accelerate telomere erosion from ages 5 to 10 (Shalev et al., 2013). Another study reported that young adults
whose mothers had experienced severe stress during their pregnancy had shorter telomeres than did those
whose mothers had stress-free and uneventful pregnancies (Entringer et al., 2011). Further, the corrosive
effects of childhood stress on telomeres can extend into young adulthood. In an investigation of over 4,000
U.K. women ages 41–80, adverse experiences during childhood (e.g., physical abuse, being sent away from
home, and parent divorce) were associated with shortened telomere length (Surtees et al., 2010), and telomere
size decreased as the amount of experienced adversity increased (Figure 14.16).
Figure 14.16 Telomeres are shorter in adults who experienced more trauma as children (adapted from
Blackburn & Epel, 2012).
Efforts to dissect the precise cellular and physiological mechanisms linking short telomeres to stress and
disease are currently underway. For the time being, telomeres provide us with yet another reminder that stress,
especially during early life, can be just as harmful to our health as smoking or fast food (Blackburn & Epel,
The cardiovascular system is composed of the heart and blood circulation system. For many years,
disorders that involve the cardiovascular system—known as cardiovascular disorders—have been a major
focal point in the study of psychophysiological disorders because of the cardiovascular system’s centrality
in the stress response (Everly & Lating, 2002). Heart disease is one such condition. Each year, heart disease
causes approximately one in three deaths in the United States, and it is the leading cause of death in the
developed world (Centers for Disease Control and Prevention [CDC], 2011; Shapiro, 2005).
The symptoms of heart disease vary somewhat depending on the specific kind of heart disease one has,
but they generally involve angina—chest pains or discomfort that occur when the heart does not receive
enough blood (Office on Women’s Health, 2009). The pain often feels like the chest is being pressed or
squeezed; burning sensations in the chest and shortness of breath are also commonly reported. Such
pain and discomfort can spread to the arms, neck, jaws, stomach (as nausea), and back (American Heart
Association [AHA], 2012a) (Figure 14.17).
Chapter 14 Stress, Lifestyle, and Health 517
Figure 14.17 Males and females often experience different symptoms of a heart attack.
A major risk factor for heart disease is hypertension, which is high blood pressure. Hypertension forces
a person’s heart to pump harder, thus putting more physical strain on the heart. If left unchecked,
hypertension can lead to a heart attack, stroke, or heart failure; it can also lead to kidney failure and
blindness. Hypertension is a serious cardiovascular disorder, and it is sometimes called the silent killer
because it has no symptoms—one who has high blood pressure may not even be aware of it (AHA, 2012b).
Many risk factors contributing to cardiovascular disorders have been identified. These risk factors include
social determinants such as aging, income, education, and employment status, as well as behavioral risk
factors that include unhealthy diet, tobacco use, physical inactivity, and excessive alcohol consumption;
obesity and diabetes are additional risk factors (World Health Organization [WHO], 2013).
Over the past few decades, there has been much greater recognition and awareness of the importance
of stress and other psychological factors in cardiovascular health (Nusair, Al-dadah, & Kumar, 2012).
Indeed, exposure to stressors of many kinds has also been linked to cardiovascular problems; in the
case of hypertension, some of these stressors include job strain (Trudel, Brisson, & Milot, 2010), natural
disasters (Saito, Kim, Maekawa, Ikeda, & Yokoyama, 1997), marital conflict (Nealey-Moore, Smith, Uchino,
Hawkins, & Olson-Cerny, 2007), and exposure to high traffic noise levels at one’s home (de Kluizenaar,
Gansevoort, Miedema, & de Jong, 2007). Perceived discrimination appears to be associated with
hypertension among African Americans (Sims et al., 2012). In addition, laboratory-based stress tasks, such
as performing mental arithmetic under time pressure, immersing one’s hand into ice water (known as
the cold pressor test), mirror tracing, and public speaking have all been shown to elevate blood pressure
(Phillips, 2011).
Sometimes research ideas and theories emerge from seemingly trivial observations. In the 1950s,
cardiologist Meyer Friedman was looking over his waiting room furniture, which consisted of upholstered
chairs with armrests. Friedman decided to have these chairs reupholstered. When the man doing the
reupholstering came to the office to do the work, he commented on how the chairs were worn in a unique
manner—the front edges of the cushions were worn down, as were the front tips of the arm rests. It seemed
like the cardiology patients were tapping or squeezing the front of the armrests, as well as literally sitting
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on the edge of their seats (Friedman & Rosenman, 1974). Were cardiology patients somehow different than
other types of patients? If so, how?
After researching this matter, Friedman and his colleague, Ray Rosenman, came to understand that people
who are prone to heart disease tend to think, feel, and act differently than those who are not. These
individuals tend to be intensively driven workaholics who are preoccupied with deadlines and always
seem to be in a rush. According to Friedman and Rosenman, these individuals exhibit Type A behavior
pattern; those who are more relaxed and laid-back were characterized as Type B (Figure 14.18). In a
sample of Type As and Type Bs, Friedman and Rosenman were startled to discover that heart disease was
over seven times more frequent among the Type As than the Type Bs (Friedman & Rosenman, 1959).
Figure 14.18 (a) Type A individuals are characterized as intensely driven, (b) while Type B people are characterized
as laid-back and relaxed. (credit a: modification of work by Greg Hernandez; credit b: modification of work by Elvert
The major components of the Type A pattern include an aggressive and chronic struggle to achieve more
and more in less and less time (Friedman & Rosenman, 1974). Specific characteristics of the Type A pattern
include an excessive competitive drive, chronic sense of time urgency, impatience, and hostility toward
others (particularly those who get in the person’s way).
An example of a person who exhibits Type A behavior pattern is Jeffrey. Even as a child, Jeffrey was
intense and driven. He excelled at school, was captain of the swim team, and graduated with honors from
an Ivy League college. Jeffrey never seems able to relax; he is always working on something, even on
the weekends. However, Jeffrey always seems to feel as though there are not enough hours in the day to
accomplish all he feels he should. He volunteers to take on extra tasks at work and often brings his work
home with him; he often goes to bed angry late at night because he feels that he has not done enough.
Jeffrey is quick tempered with his coworkers; he often becomes noticeably agitated when dealing with
those coworkers he feels work too slowly or whose work does not meet his standards. He typically reacts
with hostility when interrupted at work. He has experienced problems in his marriage over his lack of
time spent with family. When caught in traffic during his commute to and from work, Jeffrey incessantly
pounds on his horn and swears loudly at other drivers. When Jeffrey was 52, he suffered his first heart
By the 1970s, a majority of practicing cardiologists believed that Type A behavior pattern was a significant
risk factor for heart disease (Friedman, 1977). Indeed, a number of early longitudinal investigations
demonstrated a link between Type A behavior pattern and later development of heart disease (Rosenman
et al., 1975; Haynes, Feinleib, & Kannel, 1980).
Subsequent research examining the association between Type A and heart disease, however, failed to
replicate these earlier findings (Glassman, 2007; Myrtek, 2001). Because Type A theory did not pan out
as well as they had hoped, researchers shifted their attention toward determining if any of the specific
elements of Type A predict heart disease.
Extensive research clearly suggests that the anger/hostility dimension of Type A behavior pattern may
be one of the most important factors in the development of heart disease. This relationship was initially
Chapter 14 Stress, Lifestyle, and Health 519
described in the Haynes et al. (1980) study mentioned above: Suppressed hostility was found to
substantially elevate the risk of heart disease for both men and women. Also, one investigation followed
over 1,000 male medical students from 32 to 48 years. At the beginning of the study, these men completed
a questionnaire assessing how they react to pressure; some indicated that they respond with high levels
of anger, whereas others indicated that they respond with less anger. Decades later, researchers found
that those who earlier had indicated the highest levels of anger were over 6 times more likely than those
who indicated less anger to have had a heart attack by age 55, and they were 3.5 times more likely to
have experienced heart disease by the same age (Chang, Ford, Meoni, Wang, & Klag, 2002). From a health
standpoint, it clearly does not pay to be an angry young person.
After reviewing and statistically summarizing 35 studies from 1983 to 2006, Chida and Steptoe (2009)
concluded that the bulk of the evidence suggests that anger and hostility constitute serious long-term risk
factors for adverse cardiovascular outcomes among both healthy individuals and those already suffering
from heart disease. One reason angry and hostile moods might contribute to cardiovascular diseases is
that such moods can create social strain, mainly in the form of antagonistic social encounters with others.
This strain could then lay the foundation for disease-promoting cardiovascular responses among hostile
individuals (Vella, Kamarck, Flory, & Manuck, 2012). In this transactional model, hostility and social strain
form a cycle (Figure 14.19).
Figure 14.19 According to the transactional model of hostility for predicting social interactions (Vella et al., 2012),
the thoughts and feelings of a hostile person promote antagonistic behavior toward others, which in turn reinforces
complimentary reactions from others, thereby intensifying ones’ hostile disposition and intensifying the cyclical nature
of this relationship.
For example, suppose Kaitlin has a hostile disposition; she has a cynical, distrustful attitude toward others
and often thinks that other people are out to get her. She is very defensive around people, even those she
has known for years, and she is always looking for signs that others are either disrespecting or belittling
her. In the shower each morning before work, she often mentally rehearses what she would say to someone
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who said or did something that angered her, such as making a political statement that was counter to
her own ideology. As Kaitlin goes through these mental rehearsals, she often grins and thinks about the
retaliation on anyone who will irk her that day.
Socially, she is confrontational and tends to use a harsh tone with people, which often leads to very
disagreeable and sometimes argumentative social interactions. As you might imagine, Kaitlin is not
especially popular with others, including coworkers, neighbors, and even members of her own family.
They either avoid her at all costs or snap back at her, which causes Kaitlin to become even more cynical
and distrustful of others, making her disposition even more hostile. Kaitlin’s hostility—through her own
doing—has created an antagonistic environment that cyclically causes her to become even more hostile
and angry, thereby potentially setting the stage for cardiovascular problems.
In addition to anger and hostility, a number of other negative emotional states have been linked with
heart disease, including negative affectivity and depression (Suls & Bunde, 2005). Negative affectivity
is a tendency to experience distressed emotional states involving anger, contempt, disgust, guilt, fear,
and nervousness (Watson, Clark, & Tellegen, 1988). It has been linked with the development of both
hypertension and heart disease. For example, over 3,000 initially healthy participants in one study were
tracked longitudinally, up to 22 years. Those with higher levels of negative affectivity at the time the study
began were substantially more likely to develop and be treated for hypertension during the ensuing years
than were those with lower levels of negative affectivity (Jonas & Lando, 2000). In addition, a study of over
10,000 middle-aged London-based civil servants who were followed an average of 12.5 years revealed that
those who earlier had scored in the upper third on a test of negative affectivity were 32% more likely to
have experienced heart disease, heart attack, or angina over a period of years than were those who scored
in the lowest third (Nabi, Kivimaki, De Vogli, Marmot, & Singh-Manoux, 2008). Hence, negative affectivity
appears to be a potentially vital risk factor for the development of cardiovascular disorders.
For centuries, poets and folklore have asserted that there is a connection between moods and the heart
(Glassman & Shapiro, 1998). You are no doubt familiar with the notion of a broken heart following a
disappointing or depressing event and have encountered that notion in songs, films, and literature.
Perhaps the first to recognize the link between depression and heart disease was Benjamin Malzberg
(1937), who found that the death rate among institutionalized patients with melancholia (an archaic
term for depression) was six times higher than that of the population. A classic study in the late 1970s
looked at over 8,000 manic-depressive persons in Denmark, finding a nearly 50% increase in deaths from
heart disease among these patients compared with the general Danish population (Weeke, 1979). By the
early 1990s, evidence began to accumulate showing that depressed individuals who were followed for
long periods of time were at increased risk for heart disease and cardiac death (Glassman, 2007). In one
investigation of over 700 Denmark residents, those with the highest depression scores were 71% more
likely to have experienced a heart attack than were those with lower depression scores (Barefoot & Schroll,
1996). Figure 14.20 illustrates the gradation in risk of heart attacks for both men and women.
Chapter 14 Stress, Lifestyle, and Health 521
Figure 14.20 This graph shows the incidence of heart attacks among men and women by depression score quartile
(adapted from Barefoot & Schroll, 1996).
After more than two decades of research, it is now clear that a relationship exists: Patients with heart
disease have more depression than the general population, and people with depression are more likely to
eventually develop heart disease and experience higher mortality than those who do not have depression
(Hare, Toukhsati, Johansson, & Jaarsma, 2013); the more severe the depression, the higher the risk
(Glassman, 2007). Consider the following:
In one study, death rates from cardiovascular problems was substantially higher in depressed
people; depressed men were 50% more likely to have died from cardiovascular problems, and
depressed women were 70% more likely (Ösby, Brandt, Correia, Ekbom, & Sparén, 2001).
A statistical review of 10 longitudinal studies involving initially healthy individuals revealed that
those with elevated depressive symptoms have, on average, a 64% greater risk of developing heart
disease than do those with fewer symptoms (Wulsin & Singal, 2003).
A study of over 63,000 registered nurses found that those with more depressed symptoms when the
study began were 49% more likely to experience fatal heart disease over a 12-year period (Whang et
al., 2009).
The American Heart Association, fully aware of the established importance of depression in
cardiovascular diseases, several years ago recommended routine depression screening for all heart disease
patients (Lichtman et al., 2008). Recently, they have recommended including depression as a risk factor for
heart disease patients (AHA, 2014).
Although the exact mechanisms through which depression might produce heart problems have not been
fully clarified, a recent investigation examining this connection in early life has shed some light. In an
ongoing study of childhood depression, adolescents who had been diagnosed with depression as children
were more likely to be obese, smoke, and be physically inactive than were those who had not received this
diagnosis (Rottenberg et al., 2014). One implication of this study is that depression, especially if it occurs
early in life, may increase the likelihood of living an unhealthy lifestyle, thereby predisposing people to an
unfavorable cardiovascular disease risk profile.
It is important to point out that depression may be just one piece of the emotional puzzle in elevating
the risk for heart disease, and that chronically experiencing several negative emotional states may be
especially important. A longitudinal investigation of Vietnam War veterans found that depression,
anxiety, hostility, and trait anger each independently predicted the onset of heart disease (Boyle, Michalek,
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& Suarez, 2006). However, when each of these negative psychological attributes was combined into a
single variable, this new variable (which researchers called psychological risk factor) predicted heart
disease more strongly than any of the individual variables. Thus, rather than examining the predictive
power of isolated psychological risk factors, it seems crucial for future researchers to examine the effects
of combined and more general negative emotional and psychological traits in the development of
cardiovascular illnesses.
Asthma is a chronic and serious disease in which the airways of the respiratory system become obstructed,
leading to great difficulty expelling air from the lungs. The airway obstruction is caused by inflammation
of the airways (leading to thickening of the airway walls) and a tightening of the muscles around them,
resulting in a narrowing of the airways (Figure 14.21) (American Lung Association, 2010). Because
airways become obstructed, a person with asthma will sometimes have great difficulty breathing and will
experience repeated episodes of wheezing, chest tightness, shortness of breath, and coughing, the latter
occurring mostly during the morning and night (CDC, 2006).
Figure 14.21 In asthma, the airways become inflamed and narrowed.
According to the Centers for Disease Control and Prevention (CDC), around 4,000 people die each year
from asthma-related causes, and asthma is a contributing factor to another 7,000 deaths each year (CDC,
2013a). The CDC has revealed that asthma affects 18.7 million U.S. adults and is more common among
people with lower education and income levels (CDC, 2013b). Especially concerning is that asthma is on
the rise, with rates of asthma increasing 157% between 2000 and 2010 (CDC, 2013b).
Asthma attacks are acute episodes in which an asthma sufferer experiences the full range of symptoms.
Asthma exacerbation is often triggered by environmental factors, such as air pollution, allergens (e.g.,
pollen, mold, and pet hairs), cigarette smoke, airway infections, cold air or a sudden change in
temperature, and exercise (CDC, 2013b).
Chapter 14 Stress, Lifestyle, and Health 523
Psychological factors appear to play an important role in asthma (Wright, Rodriguez, & Cohen, 1998),
although some believe that psychological factors serve as potential triggers in only a subset of asthma
patients (Ritz, Steptoe, Bobb, Harris, & Edwards, 2006). Many studies over the years have demonstrated
that some people with asthma will experience asthma-like symptoms if they expect to experience such
symptoms, such as when breathing an inert substance that they (falsely) believe will lead to airway
obstruction (Sodergren & Hyland, 1999). As stress and emotions directly affect immune and respiratory
functions, psychological factors likely serve as one of the most common triggers of asthma exacerbation
(Trueba & Ritz, 2013).
People with asthma tend to report and display a high level of negative emotions such as anxiety, and
asthma attacks have been linked to periods of high emotionality (Lehrer, Isenberg, & Hochron, 1993). In
addition, high levels of emotional distress during both laboratory tasks and daily life have been found
to negatively affect airway function and can produce asthma-like symptoms in people with asthma (von
Leupoldt, Ehnes, & Dahme, 2006). In one investigation, 20 adults with asthma wore preprogrammed
wristwatches that signaled them to breathe into a portable device that measures airway function. Results
showed that higher levels of negative emotions and stress were associated with increased airway
obstruction and self-reported asthma symptoms (Smyth, Soefer, Hurewitz, Kliment, & Stone, 1999). In
addition, D’Amato, Liccardi, Cecchi, Pellegrino, & D’Amato (2010) described a case study of an 18-year-
old man with asthma whose girlfriend had broken up with him, leaving him in a depressed state. She had
also unfriended him on Facebook , while friending other young males. Eventually, the young man was
able to “friend” her once again and could monitor her activity through Facebook. Subsequently, he would
experience asthma symptoms whenever he logged on and accessed her profile. When he later resigned not
to use Facebook any longer, the asthma attacks stopped. This case suggests that the use of Facebook and
other forms of social media may represent a new source of stress—it may be a triggering factor for asthma
attacks, especially in depressed asthmatic individuals.
Exposure to stressful experiences, particularly those that involve parental or interpersonal conflicts, has
been linked to the development of asthma throughout the lifespan. A longitudinal study of 145 children
found that parenting difficulties during the first year of life increased the chances that the child developed
asthma by 107% (Klinnert et al., 2001). In addition, a cross-sectional study of over 10,000 Finnish college
students found that high rates of parent or personal conflicts (e.g., parental divorce, separation from
spouse, or severe conflicts in other long-term relationships) increased the risk of asthma onset (Kilpeläinen,
Koskenvuo, Helenius, & Terho, 2002). Further, a study of over 4,000 middle-aged men who were
interviewed in the early 1990s and again a decade later found that breaking off an important life
partnership (e.g., divorce or breaking off relationship from parents) increased the risk of developing
asthma by 124% over the time of the study (Loerbroks, Apfelbacher, Thayer, Debling, & Stürmer, 2009).
A headache is a continuous pain anywhere in the head and neck region. Migraine headaches are a type
of headache thought to be caused by blood vessel swelling and increased blood flow (McIntosh, 2013).
Migraines are characterized by severe pain on one or both sides of the head, an upset stomach, and
disturbed vision. They are more frequently experienced by women than by men (American Academy
of Neurology, 2014). Tension headaches are triggered by tightening/tensing of facial and neck muscles;
they are the most commonly experienced kind of headache, accounting for about 42% of all headaches
worldwide (Stovner et al., 2007). In the United States, well over one-third of the population experiences
tension headaches each year, and 2–3% of the population suffers from chronic tension headaches
(Schwartz, Stewart, Simon, & Lipton, 1998).
A number of factors can contribute to tension headaches, including sleep deprivation, skipping meals, eye
strain, overexertion, muscular tension caused by poor posture, and stress (MedicineNet, 2013). Although
there is uncertainty regarding the exact mechanisms through which stress can produce tension headaches,
stress has been demonstrated to increase sensitivity to pain (Caceres & Burns, 1997; Logan et al., 2001).
In general, tension headache sufferers, compared to non-sufferers, have a lower threshold for and greater
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sensitivity to pain (Ukestad & Wittrock, 1996), and they report greater levels of subjective stress when
faced with a stressor (Myers, Wittrock, & Foreman, 1998). Thus, stress may contribute to tension headaches
by increasing pain sensitivity in already-sensitive pain pathways in tension headache sufferers (Cathcart,
Petkov, & Pritchard, 2008).
14.4 Regulation of Stress
Learning Objectives
By the end of this section, you will be able to:
Define coping and differentiate between problem-focused and emotion-focused coping
Describe the importance of perceived control in our reactions to stress
Explain how social support is vital in health and longevity
As we learned in the previous section, stress—especially if it is chronic—takes a toll on our bodies and can
have enormously negative health implications. When we experience events in our lives that we appraise
as stressful, it is essential that we use effective coping strategies to manage our stress. Coping refers to
mental and behavioral efforts that we use to deal with problems relating to stress, including its presumed
cause and the unpleasant feelings and emotions it produces.
Lazarus and Folkman (1984) distinguished two fundamental kinds of coping: problem-focused coping
and emotion-focused coping. In problem-focused coping, one attempts to manage or alter the problem
that is causing one to experience stress (i.e., the stressor). Problem-focused coping strategies are similar to
strategies used in everyday problem-solving: they typically involve identifying the problem, considering
possible solutions, weighing the costs and benefits of these solutions, and then selecting an alternative
(Lazarus & Folkman, 1984). As an example, suppose Bradford receives a midterm notice that he is failing
statistics class. If Bradford adopts a problem-focused coping approach to managing his stress, he would be
proactive in trying to alleviate the source of the stress. He might contact his professor to discuss what must
be done to raise his grade, he might also decide to set aside two hours daily to study statistics assignments,
and he may seek tutoring assistance. A problem-focused approach to managing stress means we actively
try to do things to address the problem.
Emotion-focused coping, in contrast, consists of efforts to change or reduce the negative emotions
associated with stress. These efforts may include avoiding, minimizing, or distancing oneself from the
problem, or positive comparisons with others (“I’m not as bad off as she is”), or seeking something positive
in a negative event (“Now that I’ve been fired, I can sleep in for a few days”). In some cases, emotion-
focused coping strategies involve reappraisal, whereby the stressor is construed differently (and somewhat
self-deceptively) without changing its objective level of threat (Lazarus & Folkman, 1984). For example,
a person sentenced to federal prison who thinks, “This will give me a great chance to network with
others,” is using reappraisal. If Bradford adopted an emotion-focused approach to managing his midterm
deficiency stress, he might watch a comedy movie, play video games, or spend hours on Twitter to take
his mind off the situation. In a certain sense, emotion-focused coping can be thought of as treating the
symptoms rather than the actual cause.
While many stressors elicit both kinds of coping strategies, problem-focused coping is more likely to
occur when encountering stressors we perceive as controllable, while emotion-focused coping is more
likely to predominate when faced with stressors that we believe we are powerless to change (Folkman &
Lazarus, 1980). Clearly, emotion-focused coping is more effective in dealing with uncontrollable stressors.
For example, if at midnight you are stressing over a 40-page paper due in the morning that you have not
yet started, you are probably better off recognizing the hopelessness of the situation and doing something
Chapter 14 Stress, Lifestyle, and Health 525
to take your mind off it; taking a problem-focused approach by trying to accomplish this task would only
lead to frustration, anxiety, and even more stress.
Fortunately, most stressors we encounter can be modified and are, to varying degrees, controllable. A
person who cannot stand her job can quit and look for work elsewhere; a middle-aged divorcee can find
another potential partner; the freshman who fails an exam can study harder next time, and a breast lump
does not necessarily mean that one is fated to die of breast cancer.
The desire and ability to predict events, make decisions, and affect outcomes—that is, to enact control
in our lives—is a basic tenet of human behavior (Everly & Lating, 2002). Albert Bandura (1997) stated
that “the intensity and chronicity of human stress is governed largely by perceived control over the
demands of one’s life” (p. 262). As cogently described in his statement, our reaction to potential stressors
depends to a large extent on how much control we feel we have over such things. Perceived control
is our beliefs about our personal capacity to exert influence over and shape outcomes, and it has major
implications for our health and happiness (Infurna & Gerstorf, 2014). Extensive research has demonstrated
that perceptions of personal control are associated with a variety of favorable outcomes, such as better
physical and mental health and greater psychological well-being (Diehl & Hay, 2010). Greater personal
control is also associated with lower reactivity to stressors in daily life. For example, researchers in one
investigation found that higher levels of perceived control at one point in time were later associated
with lower emotional and physical reactivity to interpersonal stressors (Neupert, Almeida, & Charles,
2007). Further, a daily diary study with 34 older widows found that their stress and anxiety levels were
significantly reduced on days during which the widows felt greater perceived control (Ong, Bergeman, &
Bisconti, 2005).
Learned Helplessness
When we lack a sense of control over the events in our lives, particularly when those events are threatening,
harmful, or noxious, the psychological consequences can be profound. In one of the better illustrations of
this concept, psychologist Martin Seligman conducted a series of classic experiments in the 1960s (Seligman
& Maier, 1967) in which dogs were placed in a chamber where they received electric shocks from which
they could not escape. Later, when these dogs were given the opportunity to escape the shocks by jumping
across a partition, most failed to even try; they seemed to just give up and passively accept any shocks the
experimenters chose to administer. In comparison, dogs who were previously allowed to escape the shocks
tended to jump the partition and escape the pain (Figure 14.22).
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Figure 14.22 Seligman’s learned helplessness experiments with dogs used an apparatus that measured
when the animals would move from a floor delivering shocks to one without.
Seligman believed that the dogs who failed to try to escape the later shocks were demonstrating learned
helplessness: They had acquired a belief that they were powerless to do anything about the noxious
stimulation they were receiving. Seligman also believed that the passivity and lack of initiative these dogs
demonstrated was similar to that observed in human depression. Therefore, Seligman speculated that
acquiring a sense of learned helplessness might be an important cause of depression in humans: Humans
who experience negative life events that they believe they are unable to control may become helpless. As a
result, they give up trying to control or change the situation and some may become depressed and show lack
of initiative in future situations in which they can control the outcomes (Seligman, Maier, & Geer, 1968).
Seligman and colleagues later reformulated the original learned helplessness model of depression (Abramson,
Seligman, & Teasdale, 1978). In their reformulation, they emphasized attributions (i.e., a mental explanation
for why something occurred) that lead to the perception that one lacks control over negative outcomes are
important in fostering a sense of learned helplessness. For example, suppose a coworker shows up late to
work; your belief as to what caused the coworker’s tardiness would be an attribution (e.g., too much traffic,
slept too late, or just doesn’t care about being on time).
The reformulated version of Seligman’s study holds that the attributions made for negative life events
contribute to depression. Consider the example of a student who performs poorly on a midterm exam. This
model suggests that the student will make three kinds of attributions for this outcome: internal vs. external
(believing the outcome was caused by his own personal inadequacies or by environmental factors), stable vs.
unstable (believing the cause can be changed or is permanent), and global vs. specific (believing the outcome
is a sign of inadequacy in most everything versus just this area). Assume that the student makes an internal
(“I’m just not smart”), stable (“Nothing can be done to change the fact that I’m not smart”) and global (“This
is another example of how lousy I am at everything”) attribution for the poor performance. The reformulated
theory predicts that the student would perceive a lack of control over this stressful event and thus be especially
prone to developing depression. Indeed, research has demonstrated that people who have a tendency to make
internal, global, and stable attributions for bad outcomes tend to develop symptoms of depression when faced
with negative life experiences (Peterson & Seligman, 1984).
Chapter 14 Stress, Lifestyle, and Health 527
Seligman’s learned helplessness model has emerged over the years as a leading theoretical explanation for
the onset of major depressive disorder. When you study psychological disorders, you will learn more about the
latest reformulation of this model—now called hopelessness theory.
People who report higher levels of perceived control view their health as controllable, thereby making
it more likely that they will better manage their health and engage in behaviors conducive to good
health (Bandura, 2004). Not surprisingly, greater perceived control has been linked to lower risk of
physical health problems, including declines in physical functioning (Infurna, Gerstorf, Ram, Schupp, &
Wagner, 2011), heart attacks (Rosengren et al., 2004), and both cardiovascular disease incidence (Stürmer,
Hasselbach, & Amelang, 2006) and mortality from cardiac disease (Surtees et al., 2010). In addition,
longitudinal studies of British civil servants have found that those in low-status jobs (e.g., clerical and
office support staff) in which the degree of control over the job is minimal are considerably more likely
to develop heart disease than those with high-status jobs or considerable control over their jobs (Marmot,
Bosma, Hemingway, & Stansfeld, 1997).
The link between perceived control and health may provide an explanation for the frequently observed
relationship between social class and health outcomes (Kraus, Piff, Mendoza-Denton, Rheinschmidt, &
Keltner, 2012). In general, research has found that more affluent individuals experience better health
mainly because they tend to believe that they can personally control and manage their reactions to life’s
stressors (Johnson & Krueger, 2006). Perhaps buoyed by the perceived level of control, individuals of
higher social class may be prone to overestimating the degree of influence they have over particular
outcomes. For example, those of higher social class tend to believe that their votes have greater sway on
election outcomes than do those of lower social class, which may explain higher rates of voting in more
affluent communities (Krosnick, 1990). Other research has found that a sense of perceived control can
protect less affluent individuals from poorer health, depression, and reduced life-satisfaction—all of which
tend to accompany lower social standing (Lachman & Weaver, 1998).
Taken together, findings from these and many other studies clearly suggest that perceptions of control and
coping abilities are important in managing and coping with the stressors we encounter throughout life.
The need to form and maintain strong, stable relationships with others is a powerful, pervasive, and
fundamental human motive (Baumeister & Leary, 1995). Building strong interpersonal relationships with
others helps us establish a network of close, caring individuals who can provide social support in times
of distress, sorrow, and fear. Social support can be thought of as the soothing impact of friends, family,
and acquaintances (Baron & Kerr, 2003). Social support can take many forms, including advice, guidance,
encouragement, acceptance, emotional comfort, and tangible assistance (such as financial help). Thus,
other people can be very comforting to us when we are faced with a wide range of life stressors, and they
can be extremely helpful in our efforts to manage these challenges. Even in nonhuman animals, species
mates can offer social support during times of stress. For example, elephants seem to be able to sense when
other elephants are stressed and will often comfort them with physical contact—such as a trunk touch—or
an empathetic vocal response (Krumboltz, 2014).
Scientific interest in the importance of social support first emerged in the 1970s when health researchers
developed an interest in the health consequences of being socially integrated (Stroebe & Stroebe, 1996).
Interest was further fueled by longitudinal studies showing that social connectedness reduced mortality.
In one classic study, nearly 7,000 Alameda County, California, residents were followed over 9 years. Those
who had previously indicated that they lacked social and community ties were more likely to die during
the follow-up period than those with more extensive social networks. Compared to those with the most
social contacts, isolated men and women were, respectively, 2.3 and 2.8 times more likely to die. These
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trends persisted even after controlling for a variety of health-related variables, such as smoking, alcohol
consumption, self-reported health at the beginning of the study, and physical activity (Berkman & Syme,
Since the time of that study, social support has emerged as one of the well-documented psychosocial
factors affecting health outcomes (Uchino, 2009). A statistical review of 148 studies conducted between
1982 and 2007 involving over 300,000 participants concluded that individuals with stronger social
relationships have a 50% greater likelihood of survival compared to those with weak or insufficient social
relationships (Holt-Lunstad, Smith, & Layton, 2010). According to the researchers, the magnitude of the
effect of social support observed in this study is comparable with quitting smoking and exceeded many
well-known risk factors for mortality, such as obesity and physical inactivity (Figure 14.23).
Figure 14.23 Close relationships with others, whether (a) a group of friends or (b) a family circle, provide more than
happiness and fulfillment—they can help foster good health. (credit a: modification of work by Nattachai Noogure;
credit b: modification of work by Christian Haugen)
A number of large-scale studies have found that individuals with low levels of social support are at
greater risk of mortality, especially from cardiovascular disorders (Brummett et al., 2001). Further, higher
levels of social supported have been linked to better survival rates following breast cancer (Falagas et al.,
2007) and infectious diseases, especially HIV infection (Lee & Rotheram-Borus, 2001). In fact, a person
with high levels of social support is less likely to contract a common cold. In one study, 334 participants
completed questionnaires assessing their sociability; these individuals were subsequently exposed to a
virus that causes a common cold and monitored for several weeks to see who became ill. Results showed
that increased sociability was linearly associated with a decreased probability of developing a cold (Cohen,
Doyle, Turner, Alper, & Skoner, 2003).
For many of us, friends are a vital source of social support. But what if you found yourself in a situation
in which you lacked friends or companions? For example, suppose a popular high school student attends
a far-away college, does not know anyone, and has trouble making friends and meaningful connections
with others during the first semester. What can be done? If real life social support is lacking, access to
distant friends via social media may help compensate. In a study of college freshmen, those with few face-
to-face friends on campus but who communicated electronically with distant friends were less distressed
that those who did not (Raney & Troop-Gordon, 2012). Also, for some people, our families—especially our
parents—are a major source of social support.
Social support appears to work by boosting the immune system, especially among people who are
experiencing stress (Uchino, Vaughn, Carlisle, & Birmingham, 2012). In a pioneering study, spouses
of cancer patients who reported high levels of social support showed indications of better immune
functioning on two out of three immune functioning measures, compared to spouses who were below the
median on reported social support (Baron, Cutrona, Hicklin, Russell, & Lubaroff, 1990). Studies of other
populations have produced similar results, including those of spousal caregivers of dementia sufferers,
medical students, elderly adults, and cancer patients (Cohen & Herbert, 1996; Kiecolt-Glaser, McGuire,
Robles, & Glaser, 2002).
Chapter 14 Stress, Lifestyle, and Health 529
In addition, social support has been shown to reduce blood pressure for people performing stressful
tasks, such as giving a speech or performing mental arithmetic (Lepore, 1998). In these kinds of studies,
participants are usually asked to perform a stressful task either alone, with a stranger present (who may be
either supportive or unsupportive), or with a friend present. Those tested with a friend present generally
exhibit lower blood pressure than those tested alone or with a stranger (Fontana, Diegnan, Villeneuve, &
Lepore, 1999). In one study, 112 female participants who performed stressful mental arithmetic exhibited
lower blood pressure when they received support from a friend rather than a stranger, but only if the
friend was a male (Phillips, Gallagher, & Carroll, 2009). Although these findings are somewhat difficult to
interpret, the authors mention that it is possible that females feel less supported and more evaluated by
other females, particularly females whose opinions they value.
Taken together, the findings above suggest one of the reasons social support is connected to favorable
health outcomes is because it has several beneficial physiological effects in stressful situations. However,
it is also important to consider the possibility that social support may lead to better health behaviors, such
as a healthy diet, exercising, smoking cessation, and cooperation with medical regimens (Uchino, 2009).
Coping with Prejudice and Discrimination
While having social support is quite beneficial, being the recipient of prejudicial attitudes and discriminatory
behaviors is associated with a number of negative outcomes. In their literature review, Brondolo, Brady,
Pencille, Beatty, and Contrada (2009) describe how racial prejudice and discrimination serve as unique,
significant stressors for those who are the targets of such attitudes and behavior. Being the target of racism is
associated with increased rates of depression, lowered self-esteem, hypertension, and cardiovascular disease.
Given the complex and pervasive nature of racism as a stressor, Brondolo et al. (2009) point out the
importance of coping with this specific stressor. Their review is aimed at determining which coping strategies
are most effective at offsetting negative health outcomes associated with racism-related stress. The authors
examine the effectiveness of three coping strategies: focusing on racial identity to handle race-related stress,
anger expression/suppression, and seeking social support. You’ve learned a bit about social support, so we’ll
focus the remainder of this discussion on the potential coping strategies of focusing on racial identity and anger
Focusing on racial identity refers to the process by which a person comes to feel as if he belongs to a given
racial group; this may increase a sense of pride associated with group membership. Brondolo et al. (2009)
suggest that a strong sense of racial identity might help an individual who is the target of racism differentiate
between prejudicial attitudes/behaviors that are directed toward his group as a whole rather than at him as a
person. Furthermore, the sense of belonging to his group might alleviate the distress of being ostracized by
others. However, the research literature on the effectiveness of this technique has produced mixed results.
Anger expression/suppression refers to the options available as a function of the anger evoked by racial
prejudice and discrimination. Put simply, a target of racist attitudes and behaviors can act upon her anger
or suppress her anger. As discussed by Brondolo et al. (2009), there has been very little research on the
effectiveness of either approach; the results are quite mixed with some showing anger expression and others
showing anger suppression as the healthier option.
In the end, racism-related stress is a complex issue and each of the coping strategies discussed here
has strengths and weaknesses. Brondolo et al. (2009) argue that it is imperative that additional research
be conducted to ascertain the most effective strategies for coping with the negative outcomes that are
experienced by the targets of racism.
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Beyond having a sense of control and establishing social support networks, there are numerous other
means by which we can manage stress (Figure 14.24). A common technique people use to combat stress
is exercise (Salmon, 2001). It is well-established that exercise, both of long (aerobic) and short (anaerobic)
duration, is beneficial for both physical and mental health (Everly & Lating, 2002). There is considerable
evidence that physically fit individuals are more resistant to the adverse effects of stress and recover
more quickly from stress than less physically fit individuals (Cotton, 1990). In a study of more than 500
Swiss police officers and emergency service personnel, increased physical fitness was associated with
reduced stress, and regular exercise was reported to protect against stress-related health problems (Gerber,
Kellman, Hartman, & Pühse, 2010).
Figure 14.24 Stress reduction techniques may include (a) exercise, (b) meditation and relaxation, or (c)
biofeedback. (credit a: modification of work by “UNE Photos”/Flickr; credit b: modification of work by Caleb Roenigk;
credit c: modification of work by Dr. Carmen Russoniello)
One reason exercise may be beneficial is because it might buffer some of the deleterious physiological
mechanisms of stress. One study found rats that exercised for six weeks showed a decrease in
hypothalamic-pituitary-adrenal responsiveness to mild stressors (Campeau et al., 2010). In high-stress
humans, exercise has been shown to prevent telomere shortening, which may explain the common
observation of a youthful appearance among those who exercise regularly (Puterman et al., 2010). Further,
exercise in later adulthood appears to minimize the detrimental effects of stress on the hippocampus
and memory (Head, Singh, & Bugg, 2012). Among cancer survivors, exercise has been shown to reduce
anxiety (Speck, Courneya, Masse, Duval, & Schmitz, 2010) and depressive symptoms (Craft, VanIterson,
Helenowski, Rademaker, & Courneya, 2012). Clearly, exercise is a highly effective tool for regulating
In the 1970s, Herbert Benson, a cardiologist, developed a stress reduction method called the relaxation
response technique (Greenberg, 2006). The relaxation response technique combines relaxation with
transcendental meditation, and consists of four components (Stein, 2001):
1. sitting upright on a comfortable chair with feet on the ground and body in a relaxed position,
2. a quiet environment with eyes closed,
3. repeating a word or a phrase—a mantra—to oneself, such as “alert mind, calm body,”
4. passively allowing the mind to focus on pleasant thoughts, such as nature or the warmth of your
blood nourishing your body.
The relaxation response approach is conceptualized as a general approach to stress reduction that reduces
sympathetic arousal, and it has been used effectively to treat people with high blood pressure (Benson &
Proctor, 1994).
Another technique to combat stress, biofeedback, was developed by Gary Schwartz at Harvard University
in the early 1970s. Biofeedback is a technique that uses electronic equipment to accurately measure a
person’s neuromuscular and autonomic activity—feedback is provided in the form of visual or auditory
Chapter 14 Stress, Lifestyle, and Health 531
signals. The main assumption of this approach is that providing somebody biofeedback will enable the
individual to develop strategies that help gain some level of voluntary control over what are normally
involuntary bodily processes (Schwartz & Schwartz, 1995). A number of different bodily measures have
been used in biofeedback research, including facial muscle movement, brain activity, and skin
temperature, and it has been applied successfully with individuals experiencing tension headaches, high
blood pressure, asthma, and phobias (Stein, 2001).
14.5 The Pursuit of Happiness
Learning Objectives
By the end of this section, you will be able to:
Define and discuss happiness, including its determinants
Describe the field of positive psychology and identify the kinds of problems it addresses
Explain the meaning of positive affect and discuss its importance in health outcomes
Describe the concept of flow and its relationship to happiness and fulfillment
Although the study of stress and how it affects us physically and psychologically is fascinating, it
is—admittedly—somewhat of a grim topic. Psychology is also interested in the study of a more upbeat
and encouraging approach to human affairs—the quest for happiness.
America’s founders declared that its citizens have an unalienable right to pursue happiness. But what
is happiness? When asked to define the term, people emphasize different aspects of this elusive state.
Indeed, happiness is somewhat ambiguous and can be defined from different perspectives (Martin, 2012).
Some people, especially those who are highly committed to their religious faith, view happiness in ways
that emphasize virtuosity, reverence, and enlightened spirituality. Others see happiness as primarily
contentment—the inner peace and joy that come from deep satisfaction with one’s surroundings,
relationships with others, accomplishments, and oneself. Still others view happiness mainly as pleasurable
engagement with their personal environment—having a career and hobbies that are engaging, meaningful,
rewarding, and exciting. These differences, of course, are merely differences in emphasis. Most people
would probably agree that each of these views, in some respects, captures the essence of happiness.
Elements of Happiness
Some psychologists have suggested that happiness consists of three distinct elements: the pleasant life,
the good life, and the meaningful life, as shown in Figure 14.25 (Seligman, 2002; Seligman, Steen, Park,
& Peterson, 2005). The pleasant life is realized through the attainment of day-to-day pleasures that add
fun, joy, and excitement to our lives. For example, evening walks along the beach and a fulfilling sex
life can enhance our daily pleasure and contribute to the pleasant life. The good life is achieved through
identifying our unique skills and abilities and engaging these talents to enrich our lives; those who achieve
the good life often find themselves absorbed in their work or their recreational pursuits. The meaningful
life involves a deep sense of fulfillment that comes from using our talents in the service of the greater good:
in ways that benefit the lives of others or that make the world a better place. In general, the happiest people
tend to be those who pursue the full life—they orient their pursuits toward all three elements (Seligman et
al., 2005).
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Figure 14.25 Happiness is an enduring state of well-being involving satisfaction in the pleasant, good, and
meaningful aspects of life.
For practical purposes, a precise definition of happiness might incorporate each of these elements: an
enduring state of mind consisting of joy, contentment, and other positive emotions, plus the sense that
one’s life has meaning and value (Lyubomirsky, 2001). The definition implies that happiness is a long-
term state—what is often characterized as subjective well-being—rather than merely a transient positive
mood we all experience from time to time. It is this enduring happiness that has captured the interests of
psychologists and other social scientists.
The study of happiness has grown dramatically in the last three decades (Diener, 2013). One of the most
basic questions that happiness investigators routinely examine is this: How happy are people in general?
The average person in the world tends to be relatively happy and tends to indicate experiencing more
positive feelings than negative feelings (Diener, Ng, Harter, & Arora, 2010). When asked to evaluate their
current lives on a scale ranging from 0 to 10 (with 0 representing “worst possible life” and 10 representing
“best possible life”), people in more than 150 countries surveyed from 2010–2012 reported an average
score of 5.2. People who live in North America, Australia, and New Zealand reported the highest average
score at 7.1, whereas those living Sub-Saharan Africa reported the lowest average score at 4.6 (Helliwell,
Layard, & Sachs, 2013). Worldwide, the five happiest countries are Denmark, Norway, Switzerland, the
Netherlands, and Sweden; the United States is ranked 17th happiest (Figure 14.26) (Helliwell et al., 2013).
Figure 14.26 (a) Surveys of residents in over 150 countries indicate that Denmark has the happiest citizens in the
world. (b) Americans ranked the United States as the 17th happiest country in which to live. (credit a: modification of
work by "JamesZ_Flickr"/Flickr; credit b: modification of work by Ryan Swindell)
Chapter 14 Stress, Lifestyle, and Health 533
Several years ago, a Gallup survey of more than 1,000 U.S. adults found that 52% reported that they
were “very happy.” In addition, more than 8 in 10 indicated that they were “very satisfied” with their
lives (Carroll, 2007). However, a recent poll of 2,345 U.S. adults surprisingly revealed that only one-
third reported they are “very happy.” The poll also revealed that the happiness levels of certain groups,
including minorities, recent college graduates, and the disabled, have trended downward in recent years
(Gregoire, 2013). Although it is difficult to explain this apparent decline in happiness, it may be connected
to the challenging economic conditions the United States has endured over the last several years. Of
course, this presumption would imply that happiness is closely tied to one’s finances. But, is it? This
question brings us to the next important issue: What factors influence happiness?
Factors Connected to Happiness
What really makes people happy? What factors contribute to sustained joy and contentment? Is it money,
attractiveness, material possessions, a rewarding occupation, a satisfying relationship? Extensive research
over the years has examined this question. One finding is that age is related to happiness: Life satisfaction
usually increases the older people get, but there do not appear to be gender differences in happiness
(Diener, Suh, Lucas, & Smith, 1999). Although it is important to point out that much of this work has been
correlational, many of the key findings (some of which may surprise you) are summarized below.
Family and other social relationships appear to be key factors correlated with happiness. Studies show that
married people report being happier than those who are single, divorced, or widowed (Diener et al., 1999).
Happy individuals also report that their marriages are fulfilling (Lyubomirsky, King, & Diener, 2005).
In fact, some have suggested that satisfaction with marriage and family life is the strongest predictor of
happiness (Myers, 2000). Happy people tend to have more friends, more high-quality social relationships,
and stronger social support networks than less happy people (Lyubomirsky et al., 2005). Happy people
also have a high frequency of contact with friends (Pinquart & Sörensen, 2000).
Can money buy happiness? In general, extensive research suggests that the answer is yes, but with several
caveats. While a nation’s per capita gross domestic product (GDP) is associated with happiness levels
(Helliwell et al., 2013), changes in GDP (which is a less certain index of household income) bear little
relationship to changes in happiness (Diener, Tay, & Oishi, 2013). On the whole, residents of affluent
countries tend to be happier than residents of poor countries; within countries, wealthy individuals are
happier than poor individuals, but the association is much weaker (Diener & Biswas-Diener, 2002). To the
extent that it leads to increases in purchasing power, increases in income are associated with increases
in happiness (Diener, Oishi, & Ryan, 2013). However, income within societies appears to correlate with
happiness only up to a point. In a study of over 450,000 U.S. residents surveyed by the Gallup
Organization, Kahneman and Deaton (2010) found that well-being rises with annual income, but only
up to $75,000. The average increase in reported well-being for people with incomes greater than $75,000
was null. As implausible as these findings might seem—after all, higher incomes would enable people
to indulge in Hawaiian vacations, prime seats as sporting events, expensive automobiles, and expansive
new homes—higher incomes may impair people’s ability to savor and enjoy the small pleasures of life
(Kahneman, 2011). Indeed, researchers in one study found that participants exposed to a subliminal
reminder of wealth spent less time savoring a chocolate candy bar and exhibited less enjoyment of
this experience than did participants who were not reminded of wealth (Quoidbach, Dunn, Petrides, &
Mikolajczak, 2010).
What about education and employment? Happy people, compared to those who are less happy, are more
likely to graduate from college and secure more meaningful and engaging jobs. Once they obtain a job,
they are also more likely to succeed (Lyubomirsky et al., 2005). While education shows a positive (but
weak) correlation with happiness, intelligence is not appreciably related to happiness (Diener et al., 1999).
Does religiosity correlate with happiness? In general, the answer is yes (Hackney & Sanders, 2003).
However, the relationship between religiosity and happiness depends on societal circumstances. Nations
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and states with more difficult living conditions (e.g., widespread hunger and low life expectancy) tend to
be more highly religious than societies with more favorable living conditions. Among those who live in
nations with difficult living conditions, religiosity is associated with greater well-being; in nations with
more favorable living conditions, religious and nonreligious individuals report similar levels of well-being
(Diener, Tay, & Myers, 2011).
Clearly the living conditions of one’s nation can influence factors related to happiness. What about the
influence of one’s culture? To the extent that people possess characteristics that are highly valued by their
culture, they tend to be happier (Diener, 2012). For example, self-esteem is a stronger predictor of life
satisfaction in individualistic cultures than in collectivistic cultures (Diener, Diener, & Diener, 1995), and
extraverted people tend to be happier in extraverted cultures than in introverted cultures (Fulmer et al.,
So we’ve identified many factors that exhibit some correlation to happiness. What factors don’t show
a correlation? Researchers have studied both parenthood and physical attractiveness as potential
contributors to happiness, but no link has been identified. Although people tend to believe that
parenthood is central to a meaningful and fulfilling life, aggregate findings from a range of countries
indicate that people who do not have children are generally happier than those who do (Hansen, 2012).
And although one’s perceived level of attractiveness seems to predict happiness, a person’s objective
physical attractiveness is only weakly correlated with her happiness (Diener, Wolsic, & Fujita, 1995).
Life Events and Happiness
An important point should be considered regarding happiness. People are often poor at affective
forecasting: predicting the intensity and duration of their future emotions (Wilson & Gilbert, 2003). In one
study, nearly all newlywed spouses predicted their marital satisfaction would remain stable or improve
over the following four years; despite this high level of initial optimism, their marital satisfaction actually
declined during this period (Lavner, Karner, & Bradbury, 2013). In addition, we are often incorrect when
estimating how our long-term happiness would change for the better or worse in response to certain life
events. For example, it is easy for many of us to imagine how euphoric we would feel if we won the
lottery, were asked on a date by an attractive celebrity, or were offered our dream job. It is also easy
to understand how long-suffering fans of the Chicago Cubs baseball team, which has not won a World
Series championship since 1908, think they would feel permanently elated if their team would finally win
another World Series. Likewise, it easy to predict that we would feel permanently miserable if we suffered
a crippling accident or if a romantic relationship ended.
However, something similar to sensory adaptation often occurs when people experience emotional
reactions to life events. In much the same way our senses adapt to changes in stimulation (e.g., our eyes
adapting to bright light after walking out of the darkness of a movie theater into the bright afternoon
sun), we eventually adapt to changing emotional circumstances in our lives (Brickman & Campbell, 1971;
Helson, 1964). When an event that provokes positive or negative emotions occurs, at first we tend to
experience its emotional impact at full intensity. We feel a burst of pleasure following such things as a
marriage proposal, birth of a child, acceptance to law school, an inheritance, and the like; as you might
imagine, lottery winners experience a surge of happiness after hitting the jackpot (Lutter, 2007). Likewise,
we experience a surge of misery following widowhood, a divorce, or a layoff from work. In the long run,
however, we eventually adjust to the emotional new normal; the emotional impact of the event tends
to erode, and we eventually revert to our original baseline happiness levels. Thus, what was at first a
thrilling lottery windfall or World Series championship eventually loses its luster and becomes the status
quo (Figure 14.27). Indeed, dramatic life events have much less long-lasting impact on happiness than
might be expected (Brickman, Coats, & Janoff-Bulman, 1978).
Chapter 14 Stress, Lifestyle, and Health 535
Figure 14.27 (a) Long-suffering Chicago Cub fans would no doubt feel elated if their team won a World Series
championship, a feat that has not been accomplished by that franchise in over a century. (b) In ways that are similar,
those who play the lottery rightfully think that choosing the correct numbers and winning millions would lead to a
surge in happiness. However, the initial burst of elation following such elusive events would most likely erode with
time. (credit a: modification of work by Phil Roeder; credit b: modification of work by Robert S. Donovan)
Recently, some have raised questions concerning the extent to which important life events can
permanently alter people’s happiness set points (Diener, Lucas, & Scollon, 2006). Evidence from a number
of investigations suggests that, in some circumstances, happiness levels do not revert to their original
positions. For example, although people generally tend to adapt to marriage so that it no longer makes
them happier or unhappier than before, they often do not fully adapt to unemployment or severe
disabilities (Diener, 2012). Figure 14.28, which is based on longitudinal data from a sample of over 3,000
German respondents, shows life satisfaction scores several years before, during, and after various life
events, and it illustrates how people adapt (or fail to adapt) to these events. German respondents did not
get lasting emotional boosts from marriage; instead, they reported brief increases in happiness, followed
by quick adaptation. In contrast, widows and those who had been laid off experienced sizeable decreases
in happiness that appeared to result in long-term changes in life satisfaction (Diener et al., 2006). Further,
longitudinal data from the same sample showed that happiness levels changed significantly over time for
nearly a quarter of respondents, with 9% showing major changes (Fujita & Diener, 2005). Thus, long-term
happiness levels can and do change for some people.
Figure 14.28 This graphs shows life satisfaction scores several years before and after three significant life events (0
represents the year the event happened) (Diener et al., 2006).
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Increasing Happiness
Some recent findings about happiness provide an optimistic picture, suggesting that real changes in
happiness are possible. For example, thoughtfully developed well-being interventions designed to
augment people’s baseline levels of happiness may increase happiness in ways that are permanent and
long-lasting, not just temporary. These changes in happiness may be targeted at individual, organizational,
and societal levels (Diener et al., 2006). Researchers in one study found that a series of happiness
interventions involving such exercises as writing down three good things that occurred each day led to
increases in happiness that lasted over six months (Seligman et al., 2005).
Measuring happiness and well-being at the societal level over time may assist policy makers in
determining if people are generally happy or miserable, as well as when and why they might feel the
way they do. Studies show that average national happiness scores (over time and across countries) relate
strongly to six key variables: per capita gross domestic product (GDP, which reflects a nation’s economic
standard of living), social support, freedom to make important life choices, healthy life expectancy,
freedom from perceived corruption in government and business, and generosity (Helliwell et al., 2013).
Investigating why people are happy or unhappy might help policymakers develop programs that increase
happiness and well-being within a society (Diener et al., 2006). Resolutions about contemporary political
and social issues that are frequent topics of debate—such as poverty, taxation, affordable health care and
housing, clean air and water, and income inequality—might be best considered with people’s happiness in
In 1998, Seligman (the same person who conducted the learned helplessness experiments mentioned
earlier), who was then president of the American Psychological Association, urged psychologists to focus
more on understanding how to build human strength and psychological well-being. In deliberately setting
out to create a new direction and new orientation for psychology, Seligman helped establish a growing
movement and field of research called positive psychology (Compton, 2005). In a very general sense,
positive psychology can be thought of as the science of happiness; it is an area of study that seeks to
identify and promote those qualities that lead to greater fulfillment in our lives. This field looks at people’s
strengths and what helps individuals to lead happy, contented lives, and it moves away from focusing
on people’s pathology, faults, and problems. According to Seligman and Csikszentmihalyi (2000), positive
at the subjective level is about valued subjective experiences: well-being, contentment, and
satisfaction (in the past); hope and optimism (for the future); and… happiness (in the present).
At the individual level, it is about positive individual traits: the capacity for love and vocation,
courage, interpersonal skill, aesthetic sensibility, perseverance, forgiveness, originality, future
mindedness, spirituality, high talent, and wisdom. (p. 5)
Some of the topics studied by positive psychologists include altruism and empathy, creativity, forgiveness
and compassion, the importance of positive emotions, enhancement of immune system functioning,
savoring the fleeting moments of life, and strengthening virtues as a way to increase authentic happiness
(Compton, 2005). Recent efforts in the field of positive psychology have focused on extending its principles
toward peace and well-being at the level of the global community. In a war-torn world in which conflict,
hatred, and distrust are common, such an extended “positive peace psychology” could have important
implications for understanding how to overcome oppression and work toward global peace (Cohrs,
Christie, White, & Das, 2013).
Chapter 14 Stress, Lifestyle, and Health 537
The Center for Investigating Healthy Minds
On the campus of the University of Wisconsin–Madison, the Center for Investigating Healthy Minds at the
Waisman Center conducts rigorous scientific research on healthy aspects of the mind, such as kindness,
forgiveness, compassion, and mindfulness. Established in 2008 and led by renowned neuroscientist Dr.
Richard J. Davidson, the Center examines a wide range of ideas, including such things as a kindness
curriculum in schools, neural correlates of prosocial behavior, psychological effects of Tai Chi training, digital
games to foster prosocial behavior in children, and the effectiveness of yoga and breathing exercises in
reducing symptoms of post-traumatic stress disorder.
According to its website, the Center was founded after Dr. Davidson was challenged by His Holiness, the 14th
Dalai Lama, “to apply the rigors of science to study positive qualities of mind” (Center for Investigating Health
Minds, 2013). The Center continues to conduct scientific research with the aim of developing mental health
training approaches that help people to live happier, healthier lives).
Positive Affect and Optimism
Taking a cue from positive psychology, extensive research over the last 10-15 years has examined the
importance of positive psychological attributes in physical well-being. Qualities that help promote
psychological well-being (e.g., having meaning and purpose in life, a sense of autonomy, positive
emotions, and satisfaction with life) are linked with a range of favorable health outcomes (especially
improved cardiovascular health) mainly through their relationships with biological functions and health
behaviors (such as diet, physical activity, and sleep quality) (Boehm & Kubzansky, 2012). The quality that
has received attention is positive affect, which refers to pleasurable engagement with the environment,
such as happiness, joy, enthusiasm, alertness, and excitement (Watson, Clark, & Tellegen, 1988). The
characteristics of positive affect, as with negative affect (discussed earlier), can be brief, long-lasting, or
trait-like (Pressman & Cohen, 2005). Independent of age, gender, and income, positive affect is associated
with greater social connectedness, emotional and practical support, adaptive coping efforts, and lower
depression; it is also associated with longevity and favorable physiological functioning (Steptoe,
O’Donnell, Marmot, & Wardle, 2008).
Positive affect also serves as a protective factor against heart disease. In a 10-year study of Nova Scotians,
the rate of heart disease was 22% lower for each one-point increase on the measure of positive affect, from
1 (no positive affect expressed) to 5 (extreme positive affect) (Davidson, Mostofsky, & Whang, 2010). In
terms of our health, the expression, “don’t worry, be happy” is helpful advice indeed. There has also been
much work suggesting that optimism—the general tendency to look on the bright side of things—is also a
significant predictor of positive health outcomes.
Although positive affect and optimism are related in some ways, they are not the same (Pressman &
Cohen, 2005). Whereas positive affect is mostly concerned with positive feeling states, optimism has been
regarded as a generalized tendency to expect that good things will happen (Chang, 2001). It has also
been conceptualized as a tendency to view life’s stressors and difficulties as temporary and external to
oneself (Peterson & Steen, 2002). Numerous studies over the years have consistently shown that optimism
is linked to longevity, healthier behaviors, fewer postsurgical complications, better immune functioning
among men with prostate cancer, and better treatment adherence (Rasmussen & Wallio, 2008). Further,
optimistic people report fewer physical symptoms, less pain, better physical functioning, and are less
likely to be rehospitalized following heart surgery (Rasmussen, Scheier, & Greenhouse, 2009).
Another factor that seems to be important in fostering a deep sense of well-being is the ability to derive
flow from the things we do in life. Flow is described as a particular experience that is so engaging and
engrossing that it becomes worth doing for its own sake (Csikszentmihalyi, 1997). It is usually related to
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creative endeavors and leisure activities, but it can also be experienced by workers who like their jobs or
students who love studying (Csikszentmihalyi, 1999). Many of us instantly recognize the notion of flow.
In fact, the term derived from respondents’ spontaneous use of the term when asked to describe how it felt
when what they were doing was going well. When people experience flow, they become involved in an
activity to the point where they feel they lose themselves in the activity. They effortlessly maintain their
concentration and focus, they feel as though they have complete control of their actions, and time seems to
pass more quickly than usual (Csikszentmihalyi, 1997). Flow is considered a pleasurable experience, and
it typically occurs when people are engaged in challenging activities that require skills and knowledge
they know they possess. For example, people would be more likely report flow experiences in relation
to their work or hobbies than in relation to eating. When asked the question, “Do you ever get involved
in something so deeply that nothing else seems to matter, and you lose track of time?” about 20% of
Americans and Europeans report having these flow-like experiences regularly (Csikszentmihalyi, 1997).
Although wealth and material possessions are nice to have, the notion of flow suggests that neither are
prerequisites for a happy and fulfilling life. Finding an activity that you are truly enthusiastic about,
something so absorbing that doing it is reward itself (whether it be playing tennis, studying Arabic, writing
children’s novels, or cooking lavish meals) is perhaps the real key. According to Csikszentmihalyi (1999),
creating conditions that make flow experiences possible should be a top social and political priority. How
might this goal be achieved? How might flow be promoted in school systems? In the workplace? What
potential benefits might be accrued from such efforts?
In an ideal world, scientific research endeavors should inform us on how to bring about a better world for
all people. The field of positive psychology promises to be instrumental in helping us understand what
truly builds hope, optimism, happiness, healthy relationships, flow, and genuine personal fulfillment.
Chapter 14 Stress, Lifestyle, and Health 539
alarm reaction
cardiovascular disorders
daily hassles
fight-or-flight response
general adaptation syndrome
health psychology
heart disease
hypothalamic-pituitary-adrenal (HPA) axis
Key Terms
first stage of the general adaptation syndrome; characterized as the body’s immediate
physiological reaction to a threatening situation or some other emergency; analogous to the fight-or-flight
psychophysiological disorder in which the airways of the respiratory system become obstructed,
leading to great difficulty expelling air from the lungs
stress-reduction technique using electronic equipment to measure a person’s involuntary
(neuromuscular and autonomic) activity and provide feedback to help the person gain a level of
voluntary control over these processes
disorders that involve the heart and blood circulation system
mental or behavioral efforts used to manage problems relating to stress, including its cause and
the unpleasant feelings and emotions it produces
stress hormone released by the adrenal glands when encountering a stressor; helps to provide a
boost of energy, thereby preparing the individual to take action
minor irritations and annoyances that are part of our everyday lives and are capable of
producing stress
bad form of stress; usually high in intensity; often leads to exhaustion, fatigue, feeling burned
out; associated with erosions in performance and health
good form of stress; low to moderate in intensity; associated with positive feelings, as well as
optimal health and performance
set of physiological reactions (increases in blood pressure, heart rate, respiration
rate, and sweat) that occur when an individual encounters a perceived threat; these reactions are
produced by activation of the sympathetic nervous system and the endocrine system
state involving intense engagement in an activity; usually is experienced when participating in
creative, work, and leisure endeavors
Hans Selye’s three-stage model of the body’s physiological reactions to
stress and the process of stress adaptation: alarm reaction, stage of resistance, and stage of exhaustion
enduring state of mind consisting of joy, contentment, and other positive emotions; the sense
that one’s life has meaning and value
subfield of psychology devoted to studying psychological influences on health,
illness, and how people respond when they become ill
several types of adverse heart conditions, including those that involve the heart’s arteries
or valves or those involving the inability of the heart to pump enough blood to meet the body’s needs;
can include heart attack and stroke
high blood pressure
set of structures found in both the limbic system
(hypothalamus) and the endocrine system (pituitary gland and adrenal glands) that regulate many of the
body’s physiological reactions to stress through the release of hormones
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immune system
job burnout
job strain
negative affectivity
perceived control
positive affect
positive psychology
primary appraisal
psychophysiological disorders
relaxation response technique
secondary appraisal
Social Readjustment Rating Scale (SRRS)
social support
stage of exhaustion
stage of resistance
various structures, cells, and mechanisms that protect the body from foreign substances
that can damage the body’s tissues and organs
decreased effectiveness of the immune system
general sense of emotional exhaustion and cynicism in relation to one’s job; consists of three
dimensions: exhaustion, depersonalization, and sense of diminished personal accomplishment
work situation involving the combination of excessive job demands and workload with little
decision making latitude or job control
white blood cells that circulate in the body’s fluids and are especially important in the
body’s immune response
tendency to experience distressed emotional states involving anger, contempt,
disgust, guilt, fear, and nervousness
tendency toward a positive outlook and positive expectations
peoples’ beliefs concerning their capacity to influence and shape outcomes in their
state or a trait that involves pleasurable engagement with the environment, the
dimensions of which include happiness, joy, enthusiasm, alertness, and excitement
scientific area of study seeking to identify and promote those qualities that lead to
happy, fulfilled, and contented lives
judgment about the degree of potential harm or threat to well-being that a stressor
might entail
field that studies how psychological factors (such as stress) influence the
immune system and immune functioning
physical disorders or diseases in which symptoms are brought about or
worsened by stress and emotional factors
stress reduction technique combining elements of relaxation and
judgment of options available to cope with a stressor and their potential
popular scale designed to measure stress; consists of 43
potentially stressful events, each of which has a numerical value quantifying how much readjustment is
associated with the event
soothing and often beneficial support of others; can take different forms, such as advice,
guidance, encouragement, acceptance, emotional comfort, and tangible assistance
third stage of the general adaptation syndrome; the body’s ability to resist stress
becomes depleted; illness, disease, and even death may occur
second stage of the general adaptation syndrome; the body adapts to a stressor for a
period of time
Chapter 14 Stress, Lifestyle, and Health 541
Type A
Type B
process whereby an individual perceives and responds to events that one appraises as
overwhelming or threatening to one’s well-being
environmental events that may be judged as threatening or demanding; stimuli that initiate the
stress process
psychological and behavior pattern exhibited by individuals who tend to be extremely
competitive, impatient, rushed, and hostile toward others
psychological and behavior pattern exhibited by a person who is relaxed and laid back
14.1 What Is Stress?
Stress is a process whereby an individual perceives and responds to events appraised as overwhelming
or threatening to one’s well-being. The scientific study of how stress and emotional factors impact health
and well-being is called health psychology, a field devoted to studying the general impact of psychological
factors on health. The body’s primary physiological response during stress, the fight-or-flight response,
was first identified in the early 20th century by Walter Cannon. The fight-or-flight response involves
the coordinated activity of both the sympathetic nervous system and the hypothalamic-pituitary-adrenal
(HPA) axis. Hans Selye, a noted endocrinologist, referred to these physiological reactions to stress as part
of general adaptation syndrome, which occurs in three stages: alarm reaction (fight-or-flight reactions
begin), resistance (the body begins to adapt to continuing stress), and exhaustion (adaptive energy is
depleted, and stress begins to take a physical toll).
14.2 Stressors
Stressors can be chronic (long term) or acute (short term), and can include traumatic events, significant
life changes, daily hassles, and situations in which people are frequently exposed to challenging and
unpleasant events. Many potential stressors include events or situations that require us to make changes
in our lives, such as a divorce or moving to a new residence. Thomas Holmes and Richard Rahe developed
the Social Readjustment Rating Scale (SRRS) to measure stress by assigning a number of life change units
to life events that typically require some adjustment, including positive events. Although the SRRS has
been criticized on a number of grounds, extensive research has shown that the accumulation of many
LCUs is associated with increased risk of illness. Many potential stressors also include daily hassles, which
are minor irritations and annoyances that can build up over time. In addition, jobs that are especially
demanding, offer little control over one’s working environment, or involve unfavorable working
conditions can lead to job strain, thereby setting the stage for job burnout.
14.3 Stress and Illness
Psychophysiological disorders are physical diseases that are either brought about or worsened by stress
and other emotional factors. One of the mechanisms through which stress and emotional factors can
influence the development of these diseases is by adversely affecting the body’s immune system. A
number of studies have demonstrated that stress weakens the functioning of the immune system.
Cardiovascular disorders are serious medical conditions that have been consistently shown to be
influenced by stress and negative emotions, such as anger, negative affectivity, and depression. Other
psychophysiological disorders that are known to be influenced by stress and emotional factors include
asthma and tension headaches.
14.4 Regulation of Stress
When faced with stress, people must attempt to manage or cope with it. In general, there are two basic
forms of coping: problem-focused coping and emotion-focused coping. Those who use problem-focused
coping strategies tend to cope better with stress because these strategies address the source of stress rather
than the resulting symptoms. To a large extent, perceived control greatly impacts reaction to stressors
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and is associated with greater physical and mental well-being. Social support has been demonstrated to
be a highly effective buffer against the adverse effects of stress. Extensive research has shown that social
support has beneficial physiological effects for people, and it seems to influence immune functioning.
However, the beneficial effects of social support may be related to its influence on promoting healthy
14.5 The Pursuit of Happiness
Happiness is conceptualized as an enduring state of mind that consists of the capacity to experience
pleasure in daily life, as well as the ability to engage one’s skills and talents to enrich one’s life and the lives
of others. Although people around the world generally report that they are happy, there are differences
in average happiness levels across nations. Although people have a tendency to overestimate the extent to
which their happiness set points would change for the better or for the worse following certain life events,
researchers have identified a number of factors that are consistently related to happiness. In recent years,
positive psychology has emerged as an area of study seeking to identify and promote qualities that lead
to greater happiness and fulfillment in our lives. These components include positive affect, optimism, and
Review Questions
1. Negative effects of stress are most likely to be
experienced when an event is perceived as
a. negative, but it is likely to affect one’s
friends rather than oneself
b. challenging
c. confusing
d. threatening, and no clear options for
dealing with it are apparent
2. Between 2006 and 2009, the greatest increases
in stress levels were found to occur among
a. Blacks
b. those aged 45–64
c. the unemployed
d. those without college degrees
3. At which stage of Selye’s general adaptation
syndrome is a person especially vulnerable to
a. exhaustion
b. alarm reaction
c. fight-or-flight
d. resistance
4. During an encounter judged as stressful,
cortisol is released by the ________.
a. sympathetic nervous system
b. hypothalamus
c. pituitary gland
d. adrenal glands
5. According to the Holmes and Rahe scale,
which life event requires the greatest amount of
a. marriage
b. personal illness
c. divorce
d. death of spouse
6. While waiting to pay for his weekly groceries
at the supermarket, Paul had to wait about 20
minutes in a long line at the checkout because only
one cashier was on duty. When he was finally
ready to pay, his debit card was declined because
he did not have enough money left in his checking
account. Because he had left his credit cards at
home, he had to place the groceries back into the
cart and head home to retrieve a credit card. While
driving back to his home, traffic was backed up
two miles due to an accident. These events that
Paul had to endure are best characterized as
a. chronic stressors
b. acute stressors
c. daily hassles
d. readjustment occurrences
7. What is one of the major criticisms of the Social
Readjustment Rating Scale?
a. It has too few items.
b. It was developed using only people from
the New England region of the United
Chapter 14 Stress, Lifestyle, and Health 543
c. It does not take into consideration how a
person appraises an event.
d. None of the items included are positive.
8. Which of the following is not a dimension of
job burnout?
a. depersonalization
b. hostility
c. exhaustion
d. diminished personal accomplishment
9. The white blood cells that attack foreign
invaders to the body are called ________.
a. antibodies
b. telomeres
c. lymphocytes
d. immune cells
10. The risk of heart disease is especially high
among individuals with ________.
a. depression
b. asthma
c. telomeres
d. lymphocytes
11. The most lethal dimension of Type A
behavior pattern seems to be ________.
a. hostility
b. impatience
c. time urgency
d. competitive drive
12. Which of the following statements pertaining
to asthma is false?
a. Parental and interpersonal conflicts have
been tied to the development of asthma.
b. Asthma sufferers can experience asthma-
like symptoms simply by believing that an
inert substance they breathe will lead to
airway obstruction.
c. Asthma has been shown to be linked to
d. Rates of asthma have decreased
considerably since 2000.
13. Emotion-focused coping would likely be a
better method than problem-focused coping for
dealing with which of the following stressors?
a. terminal cancer
b. poor grades in school
c. unemployment
d. divorce
14. Studies of British civil servants have found
that those in the lowest status jobs are much more
likely to develop heart disease than those who
have high status jobs. These findings attest to the
importance of ________ in dealing with stress.
a. biofeedback
b. social support
c. perceived control
d. emotion-focused coping
15. Relative to those with low levels of social
support, individuals with high levels of social
support ________.
a. are more likely to develop asthma
b. tend to have less perceived control
c. are more likely to develop cardiovascular
d. tend to tolerate stress well
16. The concept of learned helplessness was
formulated by Seligman to explain the ________.
a. inability of dogs to attempt to escape
avoidable shocks after having received
inescapable shocks
b. failure of dogs to learn to from prior
c. ability of dogs to learn to help other dogs
escape situations in which they are
receiving uncontrollable shocks
d. inability of dogs to learn to help other dogs
escape situations in which they are
receiving uncontrollable electric shocks
17. Which of the following is not one of the
presumed components of happiness?
a. using our talents to help improve the lives
of others
b. learning new skills
c. regular pleasurable experiences
d. identifying and using our talents to enrich
our lives
18. Researchers have identified a number of
factors that are related to happiness. Which of the
following is not one of them?
a. age
b. annual income up to $75,000
c. physical attractiveness
d. marriage
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19. How does positive affect differ from
a. Optimism is more scientific than positive
b. Positive affect is more scientific than
c. Positive affect involves feeling states,
whereas optimism involves expectations.
d. Optimism involves feeling states, whereas
positive affect involves expectations.
20. Carson enjoys writing mystery novels, and
has even managed to publish some of his work.
When he’s writing, Carson becomes extremely
focused on his work; in fact, he becomes so
absorbed that that he often loses track of time,
often staying up well past 3 a.m. Carson’s
experience best illustrates the concept of ________.
a. happiness set point
b. adaptation
c. positive affect
d. flow
Critical Thinking Questions
21. Provide an example (other than the one described earlier) of a situation or event that could be
appraised as either threatening or challenging.
22. Provide an example of a stressful situation that may cause a person to become seriously ill. How
would Selye’s general adaptation syndrome explain this occurrence?
23. Review the items on the Social Readjustment Rating Scale. Select one of the items and discuss how it
might bring about distress and eustress.
24. Job burnout tends to be high in people who work in human service jobs. Considering the three
dimensions of job burnout, explain how various job aspects unique to being a police officer might lead to
job burnout in that line of work.
25. Discuss the concept of Type A behavior pattern, its history, and what we now know concerning its
role in heart disease.
26. Consider the study in which volunteers were given nasal drops containing the cold virus to examine
the relationship between stress and immune function (Cohen et al., 1998). How might this finding explain
how people seem to become sick during stressful times in their lives (e.g., final exam week)?
27. Although problem-focused coping seems to be a more effective strategy when dealing with stressors,
do you think there are any kinds of stressful situations in which emotion-focused coping might be a better
28. Describe how social support can affect health both directly and indirectly.
29. In considering the three dimensions of happiness discussed in this section (the pleasant life, the good
life, and the meaningful life), what are some steps you could take to improve your personal level of
30. The day before the drawing of a $300 million Powerball lottery, you notice that a line of people waiting
to buy their Powerball tickets is stretched outside the door of a nearby convenience store. Based on what
you’ve learned, provide some perspective on why these people are doing this, and what would likely
happen if one of these individuals happened to pick the right numbers.
Chapter 14 Stress, Lifestyle, and Health 545
Personal Application Questions
31. Think of a time in which you and others you know (family members, friends, and classmates)
experienced an event that some viewed as threatening and others viewed as challenging. What were some
of the differences in the reactions of those who experienced the event as threatening compared to those
who viewed the event as challenging? Why do you think there were differences in how these individuals
judged the same event?
32. Suppose you want to design a study to examine the relationship between stress and illness, but you
cannot use the Social Readjustment Rating Scale. How would you go about measuring stress? How would
you measure illness? What would you need to do in order to tell if there is a cause-effect relationship
between stress and illness?
33. If a family member or friend of yours has asthma, talk to that person (if he or she is willing) about their
symptom triggers. Does this person mention stress or emotional states? If so, are there any commonalities
in these asthma triggers?
34. Try to think of an example in which you coped with a particular stressor by using problem-focused
coping. What was the stressor? What did your problem-focused efforts involve? Were they effective?
35. Think of an activity you participate in that you find engaging and absorbing. For example, this might
be something like playing video games, reading, or a hobby. What are your experiences typically like while
engaging in this activity? Do your experiences conform to the notion of flow? If so, how? Do you think
these experiences have enriched your life? Why or why not?
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