Discuss the key pathways that have been proposed to linking stress to physical illness and critically evaluate evidence in support of these links.

It commonly accepted that stress can lead to illness, both psychological and physical, and there are numerous studies into the causative links between the two situations. Psychologists continue to attempt to establish exactly what makes humans succumb to stress, along with how this relates to illness and what preventative measures, coping methods and other treatments can be employed to relieve the negative effects of such situations.

Stress can be considered one of many emotional responses to external stimuli or experiences. Since early psychology the various realms of emotional experience have been identified, defined and built upon. Wunt (1896) and Schlosberg (1941), among others, identified the states of pleasantness and unpleasantness (along with various activating factors) as key dimensions in emotional state. Ekman and Friesen (1975) compounded these theories and identified surprise, fear, disgust, happiness, anger and sadness as the six primary emotions (distinct from ‘complex emotions’) which were likely to be innate in humans as they crossed boundaries of culture, ethnicity and geographical location. Whilst Averill (1994) agrees with Ekman (1994) regarding the evolutionary approach, he asserted that basic emotions, rather than biological, were psychologically intrinsic and differ over time within cultures or between cultures.

It should be considered that each distinct emotional state can be broken down into distinct components; the subjective experience (which could include happiness, anger, etc.), a physiological change (often combined with a change of behaviour) and a cognitive assessment of the situation or stimuli that has caused or is causing the situation (Gross 1996).

The nature of physiological change and the manner in which it occurs has been the subject of contentious debate in psychological academia. Research conducted by Levenson, et al. (1990), in an extension of the principles laid out previously in the James-Lange theory, showed that there was a corresponding Autonomic Nervous System response (ANS) when they experimented in directed action facial method and the relived emotional methods. Whilst differences were established between the negative emotions and positive emotions, specificity was difficult. These experiments implied that physiological arousal was sufficient for emotional response. This was refuted by Cannon who contested that ‘…the same visceral changes occur in very different emotional states and in non-emotional states’ (Cannon, 1929). Related studies conducted by Maranon (1924) and Hohmann (1966) supported Canon’s theory although Schachter’s cognitive labelling theory (1964) asserted that the emotional experience is dependent both on physiological changes and their interpretation, in contrast to Canon’s claims that these two factors were independent. This theory was compounded in the ‘adrenaline experiment’ conducted by Schachter and Siner (1962) and concluded that the focus of emphasis should be on the cognitive label given to arousal as opposed to the nature of that arousal, although a failure to replicate the results of this experiment suggests Schachter’s claims may have certain shortfalls. Namely that emotional experience is less acquiescent than the declaration made by Schachter and also that arousal which is unexplained or cannot be explained is likely to receive negative interpretation.

There are numerous attributional theories that have emerged from this work, including Wiener’s theory (1992) and Abramson and Martin’s theory of depression (1981). Another such theory (influenced heavily by the work of Schachter) is the cognitive appraisal theory (Lazerus, 1982), which suggests that there is some minimal cognitive appraisal of a situation or stimuli which always comes before the emotional experience, be it consciously or automatically occurring.

Now that the basis of emotional theory is acknowledged the links between emotion and stress should be illustrated, and the manner by which this can lead to harmful effects. Cox ...

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Now that the basis of emotional theory is acknowledged the links between emotion and stress should be illustrated, and the manner by which this can lead to harmful effects. Cox (1978) asserted that emotions such as shame, anxiety, guilt, grief, jealousy, fear and anger, which Lazerus (1976) termed the ‘stress emotions’, are all emotions that are associated with the experience of stress. Pain is also an important factor within these studies as whilst it is not an emotion it shares an association with emotions such as depression and anxiety, it follows the components of subjective experience, emotional response and cognitive appraisal and is often treated with the same methodology which is employed to help people suffering from stress. Pain is also often related to psychophysiological (i.e. stress-related) disorders and contingency management, biofeedback and self-management/cognitive behaviour treatment are all behavioural treatments used to treat pain and stress (Gross, 1996). Although pain is essentially a biological occurrence, it also has social, cultural and psychological significance, the latter including explanations and attributions of pain, such as whether it is controllable or not, and this significance carries over into the phenomenon of stress.

Stress can be defined as one of three categorisations; as a stimulus, a response or as an interaction between an organism and its environment (Goetsch & Fuller, 1995). Goetsch & Fuller’s classification also corresponds very closely to the stress models identified by Cox (1978). According to Lazurus (1966), stress cannot be defined objectively. What counts as a potential cause of stress or ‘stressor’ depends on the individual’s perception of an excessive demand being made on his or her capacities. Other stressors could include frustrations and conflicts. The three main kinds of conflict are approach-avoidance, avoidance-avoidance, approach-approach (Coon, 1983). Extreme physical demands can also be causes of stress. The disruption of circadian rhythms, or the ‘biological clock’, which involves the internal desynchronisation of the body’s functions, can be very stressful. This can occur when shift workers change their shift pattern and when people cross time zones (causing jet lag). These negative effects are increased when the biological clock is brought forward (a phase advance), as when shifts start earlier or when time zones are crossed in a West-East direction (Pinel, 1993).

These changes in human lives are often most stressful when they are uncontrollable. Holmes and Rahe’s Social Readjustment Rating Scale (SRRS) (1967) is a self-administered way of measuring stress, which it does in terms of life change units. The scale was intended to predict the onset of illness on the premise of the greater the amount of life change, the greater the likelihood of future illness. Studies which claim to have found support for this prediction are correlational and retrospective and the SRRS assumes that all change is inherently stressful. The distinction should be made here as to the change that is predictable or controllable and that which is not. Some people are more susceptible to stress and therefore place themselves more prone to the harmful effects of such. People rated high on external locus of control (Rotter, 1966) are more vulnerable to the harmful effects of change and learned helplessness (Seligman, 1975) is seen as a major feature of clinical depression. The Assessment of Daily Experience (Stone, et al., 1987) is another alternative to the SRRS and has been used in prospective studies to predict the onset of respiratory illness whilst the hassles scale (Kanner, 1981) is designed to measure everyday stressors, which seems to be a better predictor of ill health than the life events of the SRRS, probably due to the prolonged residual effect that even the smallest, seemingly trivial, events or occurrences can maintain. Many occupations, including the health care professions, seem to be inherently stressful according to these scales, as in the case of nurses having to deal continuously with illness, death, distress and suffering whilst surviving disaster or turmoil of various kinds, such as the attacks on the twin towers of 9/11 or the Gulf war, can result in ill health in the form of post-traumatic stress disorder.

In order to determine what the effects of stress were, Seyle (1956) devised the General Adaptation syndrome (GAS) which refers to the body’s response to any stressor. It comprises the alarm reaction, resistance and exhaustion. Seyle defined stress as:

‘...the individual’s psychophysiological response, mediated largely by the autonomic nervous system and the endocrine system, to any demands made on the individual’ (Seyle, 1956).

Two main bodily systems are involved in Seyle’s description of the stress process: the sympathetic branch of the ANS which stimulates the adrenal medulla to produce adrenaline and noradrenaline (the catecholamenes), and the anterior pituitary-adrenal cortex system, which involves the release of corticosteroids (Seyle 1956).

While most stressors do not present us with physical danger in contemporary society, our nervous and endocrine systems have evolved in such a way that we typically react to stressors as if they did, since society has evolved much quicker than our physical bodies can adapt. These once-adaptive responses are maladaptive in current society and resultantly there are a number of ways in which stress can result in physical illness, including its influence on the immune system. Studies have found stressful situations to be associated with decreased lymphocyte activity, decreased levels of antibodies found within immunoglobulin and increased incidence of infection and immunological abnormalities due to increased output of endorphins/enkephalins. Personality, gender and ethnic background all act as modifiers/mediators of the response to stress. Perhaps the most researched is the Type A personality (Rosenman et al, 1975), who is especially vulnerable to high blood pressure and coronary heart disease resulting from stress whilst Type C personality (Temoshok, 1987) has difficulty expressing emotion and is thought to be more cancer prone than other personality types. Day to day occurrences as they relate to a person’s social situation or the manner in which society operates have a great effect on the stress a subject is exposed to. The greater incidence of high blood pressure among African Americans has been attributed to the direct and indirect effects of racism, one facer of which is accumulative stress (Anderson, 1991).

Women seem to be relatively unresponsive to stress-producing situations, which may help explain their longer average life expectancy. Women are also less likely than men to be Type A personalities, although the gap in death rates between men and women is closing, due perhaps to an alteration of lifestyle choices. An example could be the increase in drinking and smoking among females in more recent history (Davidson and Neale, 1994).

The effects of stress as they relate to physical illness are compelling. Whilst basic physiological responses to a stressor may be common across humans, different factors can mediate the effects of a perceived source of stress. There are important issues raised by these correlations in terms of what coping methods are in place to accommodate such perceived threats. The term ‘coping mechanism’ is sometimes contrasted with ‘defence mechanism’, referring to conscious or constructive and unconscious or distorting solutions respectively. Secondary appraisal involves a search for coping responses that will reduce or remove the stressor (Lazerus, 1966). Five categories of coping response were highlighted; information seeking, inhibition of action, intrapsychic/palliative coping and turning to others (Cohen & Lazerus, 1979). This notion also overlaps with problem-focused and emotion-focused coping (Lazerus & Folkman, 1984). Concepts of stress management are crucial in slowing the tide of stress related illness which increases in contemporary society and can refer to a range of psychological techniques used deliberately to help reduce stress, including biofeedback, progressive muscle relaxation, meditation, hypnosis and cognitive restructuring.

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