Health Outcomes Of Stressful Life Events

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Does stress cause illness? Individuals are confronted with a great number of taxing situations, for instance, a noisy neighborhood, dif"culties at work, time pressure, problems with a romantic partner, or "nancial constraints. This list might seem to be an arbitrary array of situations. In fact, probably not everyone would consider these situations as being stressful or of great personal importance. However, the cumulative exposure to a number of aggravating daily hassles or situations regarded as stressful over a long time period may have detrimental health effects. In contrast, there is no doubt about the personal signi"cance of major life events and their potential impact on health. Extreme stressors can create both acute and prolonged psychological distress and bodily ailments.

Research is inconsistent when it comes to answering the question of whether the characteristics of the event itself (e.g., injury, threat, near-death experience) or the changes that occur in its aftermath (e.g., relocation, job loss) are responsible for adjustment dif"culties. How does stress cause illness? It is a general assumption that stress leads to poor health in a number of different ways. According to Selye (1956), stress operates in three phases: alarm, resistance, and exhaustion. When the organism's resistance breaks down, an ensuing long period of exhaustion can manifest itself in illness. In the 1950s, Selye did not have much evidence for his claim, but today there is a great deal of substantiation. However, a strong linear relationship cannot be expected since illness is obviously caused by many factors (stress being only one of them), contributing to pathogenesis in one way or another. Generally, correlation coef"cients from .20 to .30 are found. Cohen, Kamarck, and Mermelstein (1983), for example, reported an association of only .14 between stress scores and physiological ailments in college students.

Most individuals who experience stress do not develop illness. Stressful life changes are usually temporary, whereas other risk factors for disease can be longer lasting, for example, smoking, alcohol consumption, a high-fat, low-"ber diet, and risky lifestyle in general. When comparing a single life event with those long-term behaviors, the latter seem to be more in"uential in developing illness. Moreover, the experience of a critical life event is related to coping and social support, whereby these two factors may moderate the stress-illness connection. How can we understand the mechanisms of the stress-illness association? There are three major pathways that link stressful life events to ill health (Figure 2.2).

The main pathway places physiological changes as a mediator between origin and outcome, in particular, changes of immune parameters, and endocrine and cardiovascular reactivity. Recent research, for example, in the "eld of psy-choneuroimmunology, has documented progress in identifying bodily responses to stress that constitute precursors of disease (see Ader, 2001; Herbert & Cohen, 1993a, 1993b). Endocrine and cardiovascular reactivity, as expressed in blood pressure, heart rate, or catecholamine excretion, is considered a stress-based codeterminant of cardiovascular disease, including myocardial infarcts. The amount of reactivity is, however, not exclusively governed by the stress experience. Rather, it is moderated by genes, personality, age, and gender, as well as other factors (Weidner, 2001).

The other major pathway is represented by health-compromising behaviors. People under stress might want to relieve their tension by consuming more tobacco, illicit drugs, alcohol, and so on. They feel too absorbed by their stress to monitor their diets and to maintain other preventive behaviors. Adherence to routine self-care might suffer during a stress episode. Among smokers, stress may increase the number of cigarettes consumed as well as the intensity of smoking by deep inhaling. When under stress, women seem to be more likely to engage in unhealthy eating behaviors, whereas men tend to turn to drinking and illicit drug use (Brannon & Feist, 1997).

A third pathway pertains to all kinds of negative affect often associated with experiencing stress. Constant rumination, worrying, anxiety, pessimism, depression, and anger are health compromising in the long run. Studies have shown that optimism is related to good health, whereas depression can be a precursor of sickness (Carver, 2001). The mechanism of pathogenesis operates through physiological changes, including immune suppression and blood pressure elevations. Scheier and Bridges (1995) reviewed depression and health outcomes. Depression may be a general risk factor for premature death. The evidence for mortality effects is most compelling for cardiac disease. Studies indicate that cardiac

Figure 2.2 Mediators between stressful life events and ill health (excluding other major mediators such as personality, appraisals, coping, and social support).

Life Events Theory Health Psychology

Figure 2.2 Mediators between stressful life events and ill health (excluding other major mediators such as personality, appraisals, coping, and social support).

Negative Affect

Rumination Depressed mood Anger, anxiety Loneliness, and so on patients who were depressed while in the hospital were more likely to die of cardiac causes than those who were not depressed. However, most research in this area fails to include control variables, such as physical illness at baseline, smoking, or alcohol abuse.

Figure 2.2 gives a simpli"ed view of mediating effects. In addition, moderator effects can emerge, for example, a syn-ergistic relationship between stress, risk behaviors, and ill health. Personality, appraisals, coping, and social support were not considered in the "gure to reduce its complexity.

Efforts in contemporary life event research aim at a better understanding of the linkage between stress and the manifestation of illness. Research striving to identify single events as the cause of illness often fail. Ideally, "nding a truly causal relationship between a speci"c stressor (e.g., loss of a loved person) and a speci"c disease (e.g., breast cancer) would be a breakthrough in this "eld. The onset of speci"c diseases has been related frequently to prior stress experience. Tension headache, for example, seems to be closely connected to daily hassles, whereas a link to major life events has not been found. Infectious diseases such as the common cold can be triggered by stress. Prospective studies have shown that people develop a cold several days after the onset of negative life events. Experimental studies with the intentional administration of cold viruses have found that persons under stress are more likely to develop a cold than if they are relaxed. In a British common cold unit, Cohen, Tyrrell, and Smith (1991) administered different stress measures, including a stressful life event index based on the past year, to about 400 healthy participants. Then they exposed them to respiratory viruses to see whether they would come down with a cold. Within the experimental group, the number of respiratory infections and clinical colds was related to stress in a dose-response way: the more stressful life events experienced, the higher the likelihood of a cold.

Only a small number of studies focus explicitly on selected stressors in relation to a speci"c disease (e.g., Jacobs & Bovasso, 2000, on early loss and breast cancer; Matsunaga et al., 1999, on sexual abuse and bulimia nervosa). In most studies, either stress (often measured by a life event checklist) or health outcomes (assessed by symptom checklists) are unspeci"c. Moreover, methodological inequalities make it dif"'cult to compare research "ndings directly. Therefore, it is not surprising that research has produced con"icting results. The following example on ulcers illustrates one of the problems, namely, the differences in the time span between stress occurrence and health impairment.

In a study by Köhler, Kuhnt, and Richter (1998), participants were asked to indicate events experienced within six months prior to gastroscopy, a screening for duodenal ulcer. Contrary to the widely assumed idea that stress triggers ulcer onset, Köhler and colleagues did not "nd any relationship between perceived stress or life change scores and duodenal ulcer. Their "ndings were corroborated in a study by Gilligan, Fung, Piper, and Tennant (1987), who conclude that acute life events do not play a role in duodenal ulcer onset or relapse. They suggest that the reason could be the transient nature of the emotional as well as humoral changes caused by the event.

Kumar, Rastogi, and Nigam (1996) came to a different conclusion by analyzing the number and severity of life events in a sample of peptic ulcer patients. Compared to matched controls, ulcer patients reported a signi"cantly higher number of events and greater severity. It is important to note that the time span in this study was longer than in the former study. Here, the occurrence of the events reported was mostly four years prior to the onset of illness.

Studies that focus exclusively on physical health outcomes following an event are relatively scarce. This is due partly to methodological limitations of life event research. The repeated demand for prospective rather than retrospective studies can hardly be met. However, in some cases, settings allow for prospective designs. For example, in a study on the effects of job loss, researchers found an increase of rheumatoid arthritis during the time of unemployment (Cobb, 1976). There is some empirical evidence on the connection between stress and arthritis, but this is purely correlational. The problem here is that the main cause of rheumatoid arthritis remains unknown. For diseases whose origin has not been fully discovered, it is dif"cult to establish a causal role of stress in the pathogenesis.

It is commonly assumed that stress is detrimental to health, and different mechanisms of pathogenesis have been described earlier. But not everyone develops health problems in the face of severe stress. Other factors operate at the same time. A large body of literature is dedicated to interpersonal differences in dealing with aversive situations. In fact, it is almost impossible to examine the effects of stressful life events without considering the various ways of coping with them. As events differ in their nature and impact, so do people differ in their immediate responses to events. Since the latter belongs to the realm of coping research and is addressed elsewhere in the chapter by Manne, we will focus only on some characteristics and health effects of stressful events and the challenges they pose. In the following paragraphs, several stressful life events and their health implications are discussed.

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