Stress a nd Health

Michele M. Larzelere, PhDa,*, Glenn N. Jones, PhDb

KEYWORDS
 Stress  Stress reduction  Meditation

Stress is any situation in which environmental or perceived demands force signifi-

cant psychologic or biological change upon an organism, to preserve homeostasis
or ensure survival. Stress results from physical or psychosocial disequilibrium.
Stress responses are those behavioral, psychologic, or physiologic efforts to com-
pensate for situational demands. Stress responses sometimes lead to increased
disease risk.
It often can be useful to conceptualize an individuals reaction to stress in accor-
dance with the general adaptation syndrome, as proposed by Selye.1 Upon being pre-
sented with a physical or emotional stressor, the individual recognizes (alarm reaction)
and initially mounts a strong physiologic (or psychologic or behavioral) reaction to the
stressor (stage of resistance) until such time as the challenge is met, the stressor has
passed, or the organisms ability to mount the response is depleted (stage of exhaus-
tion). This model is understood easily by patients and allows one to draw explicit
attention to the physiologic and psychologic costs of fighting a stressor. This
paradigm easily adapts to situations in which multiple stressors, chronic stressors,
or personal or environmental factors decrease an individuals coping abilities.
Stress can be categorized in several ways, including by duration (acute/chronic),
domain (physical/psychologic), and severity (traumaticy/daily hassles). Although
physical strain often is documented and quantified, psychologic stress can be
more difficult to define. Psychologic models of stress rely on the concept of per-
ceived stress (eg, events or situations are only stressful to the degree that the indi-
vidual defines them as straining his or her ability to cope). The appraisal of the
situation as threatening brings about the physiologic and behavioral changes defined

a
Department of Family Medicine, Louisiana State University Health Sciences CenterNew
Orleans, 200 West Esplanade Avenue, Suite 412, Kenner, LA 70065, USA
b
Department of Family Medicine, Louisiana State University Health Sciences Center, Earl K.
Long Medical Center, 5825 Airline Highway, Baton Rouge, LA 70805, USA
* Corresponding author. Department of Family Medicine, Louisiana State University Health
Sciences CenterNew Orleans, 200 West Esplanade Avenue, Suite 412, Kenner, LA 70065.
E-mail address: mlarze@lsuhsc.edu (M.M. Larzelere).
y
A full description of the nature and treatment of post-traumatic stress disorder (PTSD) is be-
yond the scope of this article, so the remainder of this discussion will be devoted to the health
implications and coping challenges inherent to stress of a nontraumatic nature. Readers inter-
ested in a comprehensive treatment of PTSD are referred to Handbook of PTSD: Science and
Practice, edited by MJ Friedman, TM Keane, and PA Resick. New York: Guilford; 2007.

Prim Care Clin Office Pract 35 (2008) 839856

doi:10.1016/j.pop.2008.07.011 primarycare.theclinics.com
0095-4543/08/$ see front matter 2008 Elsevier Inc. All rights reserved.
840 Larzelere & Jones

as the stress response. The controllability of a stressor also significantly impacts its
potential for long-term psychologic detriment. Stress-causing situations do not nec-
essarily have to be negative. Selye1 chose the term adaptation, noting that both
pleasant and unpleasant events can evoke the stress response. Similarly, Holmes
and Rahe2 focused on change as a stress in their pioneering studies. Their Social
Readjustment Rating Scale asks about several life changes, some of which might
be pleasant (vacation) or positive (promotion). Across this variety of stressor types,
research has documented the possibility of resultant negative emotional and physical
impacts.

THE IMPACT OF STRESS ON PHYSICAL FUNCTIONING

The fight-or-flight response to acute stress causes rapid changes in the nervous, car-
diovascular, immune, and endocrine systems. Cortisol and catecholamines are pro-
duced to increase energy availability. Heart rate and stroke volume are increased.
The immune system is activated to prepare for the possibility of injury. Less vital ac-
tivities (eg, feeding, growth, reproduction) are suspended during the crisis. Many of
these changes have physiologic costs that are minimized by a rapid return to homeo-
static baseline following the cessation of the stressor. Acute stressors in healthy adults
are unlikely to have negative impacts on health. Stressful situations often persist be-
yond the time period when these physiologic coping strategies are adaptive, however.
Further, psychologic factors lead some individuals to turn acute stressors into chronic
stressors because of their meanings or implications. In addition, physiologic response
magnitude differs between individuals because of genetic influences and previous
stress exposures, which cause some individuals to produce a sustained hyper-re-
sponse to stress.

Stress and the Endocrine System

The corticotropin-releasing factor system is the integrator of the brains (central ner-
vous system [CNS]) response to stress and negative emotion. Under conditions of
stress, cells of the hypothalamus control the secretion of corticotropin releasing hor-
mone (CRH), which stimulates release of ACTH (adrenocorticotropic hormone). ACTH
activity leads to the secretion of glucocorticoid hormones (cortisol) from the adrenal
cortex. This constitutes the hypothalamic-pituitary-adrenal (HPA) axis. Glucocorti-
coids provide inhibitory feedback on the HPA that helps to limit the duration of the
stress response. The sympathetic adrenal medullary (SAM) axis often acts in parallel
with the HPA axis. CRH stimulation of sympathetic nervous system activity also leads
to the release of epinephrine and noradrenaline.
The interactions of adrenal system components under conditions of stress are non-
linear.3 Some of the stress-/cortisol-related changes include suppression of gonado-
tropin-releasing hormone and inhibition of thyroid-stimulating hormone (TSH) release.
Although acute stress may increase plasma concentrations of growth hormone (GH),
chronic activation of the HPA axis inhibits growth through suppression of GH secretion
and inhibition of the action of GH on target tissues. Chronic glucocorticoid elevations
may cause individuals to experience catabolic effects (visceral adiposity, decreased
lean body mass) and increased insulin resistance. This can lead to increased difficul-
ties achieving glycemic control in diabetic patients under stress.
Cortisol also plays a role in memory formation by means of its role on the amygdala
and hippocampus. Elevated cortisol levels, during conditions of stress, may aid the
formation of emotionally valenced long-term memories, promoting enhanced re-
sponse to similar future stressors. This sensitization of the amygdale to further
 Stress and Health 841

stressors (ie, cortisol-increased stress reactivity)4 would be adaptive in allowing indi-

viduals previously exposed to stressful environments to react more quickly when
faced with additional threat. Interestingly, increased cortisol levels may interfere
with working memory and information processing, which suggests that individuals
with decreased cortisol response to stress may evidence improved cognitive perfor-
mance under trying conditions.5

Stress and the Gastrointestinal System

The activities of the brain and gut are highly inter-related, which accounts for the high
prevalence of gastrointestinal (GI) symptoms reported by patients in response to
stress.6 Digestive function can be influenced by psychologic state, and GI difficulty
can impact mood, behavior, and pain responsiveness. These interrelationships are
thought to be mediated by neural, immune, and endocrine mechanisms directed by
the autonomic nervous system (ANS) and HPA axis. The limbic system, which is the
seat of emotionality, also helps to control gut function, and is thought to modulate
both visceral pain and perception.
The hypothalamus controls the release of CRH, which, when released during stress,
increases transit through the large bowel and delays gastric emptying. As noted pre-
viously, exposure to high levels of cortisol are believed to promote hyper-reactivity to
subsequent psychologically stressful conditions. These factors may help to explain
the frequently noted observation that irritable bowel syndrome (IBS) is associated
with historical psychosocial stressors. The initial studies suggesting this linkage are
bolstered by reports showing increased colonic motility in response to CRH by IBS pa-
tients when compared with individuals without IBS; suggesting hyper-responsivity to
CRH in affected populations.7 Increased cytokine production, also a result of stress,
can produce similar physiologic effects (delayed stomach emptying and increased co-
lonic motility).8 Untreated psychologic symptoms increase GI distress in patients who
have IBS, and both low-dose tricyclic antidepressants and selective serotonin reup-
take inhibitors (SSRIs) have been shown to be useful in some patients who have these
disorders.
Peptic ulcers provide another interesting domain in which to examine the impact of
stress on GI functioning. The discovery of Helicobacter pylori downgraded the long-
theorized causal link between life stress and ulcers to a clear infectious cause with
possible stress-related exacerbations. However, the presence of ulcers in H pylori-
negative patients, and the high rate of infected patients who do not develop ulcers,
argues for a more nuanced view of ulcer etiology. It has been estimated that high levels
of life stress confer an age-adjusted odds ratio of 2.8% of developing an ulcer.9
Additional data suggest that up to 40% of the excess ulcer risk attributed to stress
is mediated by stress-fueled negative health behaviors (tobacco use, skipping meals,
alcohol (ETOH) use, poor sleep patterns). Stress also promotes physiologic alterations
that may encourage ulcer development: increased acid secretion, decreased duode-
nal motility, hyperpepsinogenemia, and impaired mucosal defenses. Therefore, it has
been suggested that the alteration in the duodenal acid load secondary to stress-
related (and behavior-related) changes may promote H pylori colonization, duodenitis,
and ulcers.
Psychologic stress has been highlighted as a possible risk factor for exacerbations
in ulcerative colitis,10 although the research base supporting such a link is limited by
confounds. Pathophysiologic mechanisms for stress-related exacerbations include
the possibility of altered local intestinal and systemic immune activity and increased
gut permeability. Additional routes of stress impact include a possible decrement in
842 Larzelere & Jones

prophylactic medication adherence and other self-care behaviors by patients experi-

encing stress.11

Stress and the Immune System

Researchers have examined a range of stressors from acute, high-intensity events to
chronic, moderate-level challenges, and found a consistent pattern of immune alterations.
The acute stress response is adaptive in producing leukocytosis; however, longer-
term stress can produce dysregulation of proinflammatory cytokines.12 Changes
associated with this dysregulation suppress immunity and lead to deficits in wound
healing,13 decreased antibody response to vaccination,14 reactivation of latent vi-
ruses,15 greater vulnerability to viral infections,16 and impaired functional immune re-
sponding in women at risk for cervical cancer.17 Increased life stress also has been
associated with faster HIV to AIDS progression.18

Stress and the Cardiovascular System

Acute stress, with its catecholamine release, has numerous, well-known effects on the
cardiovascular system, including increased heart rate, cardiac output, and peripheral
vascular constriction, leading to a short-term increase in blood pressure. Chronic
stress is thought to contribute to hypertension through persistent activation of the
sympathetic nervous system and HPA axis.19 Further, the stress response can impact
the risks for cardiovascular disease through several mechanisms. It has been sug-
gested that, under conditions of prolonged stress, down-regulation in cortisol recep-
tors can lead to deficits in proinflammatory cytokine regulation.20 Proinflammatory
cytokines then would remain elevated, promoting C-reactive protein production,
and helping to account for observed worsening of pathophysiology and symptomatol-
ogy during extended periods of stress in individuals who have coronary artery disease
(CAD) or autoimmune diseases such as multiple sclerosis or rheumatoid arthritis.21,22
Animal models suggest that stressful social environments can enhance atheroscle-
rotic processes, and socially affiliative (social support) conditions can reduce athero-
genesis.23,24 Brief mental stress can cause transient endothelial dysfunction in healthy
individuals.25,26 In animal models, psychologic stress produces actual endothelial in-
jury.2729 Endothelial dysfunction and damage are potential steps toward atheroscle-
rosis. Mental stress and its sympathetic activation can lead to platelet activation and
deposition.30 Psychologic stress modifies macrophage activity,31 and emotional
arousal keeps plasma lipid levels elevated.32 Chronic cardiovascular stimulation
also can lead to vascular hypertrophy and chronically elevated blood pressure. These
changes, if sustained, can produce left ventricular hypertrophy and increased plaque
formation.33 Each of these is a potential mechanism through which stress may play
a role in atherosclerosis development.
The linkage between psychosocial factors such as stress and CAD has drawn sig-
nificant attention. In the INTERHEART study,34 a composite measure of psychosocial
stress was a strong predictor of myocardial infarction (MI), comparable to risk factors
such as smoking and hypertension. Chronically stressful situations (such as work
stress, marital stress, caregiver strain, low social support, low socioeconomic status)
have been linked to increased risk of CAD and adverse cardiac events.35,36
There is also evidence that emotional stressors can act as triggers for acute cardio-
vascular events.37 Some of the best evidence for stress as a cardiovascular event
trigger comes from studies using a case-crossover design (eg, Determinants of
Myocardial Infarction Onset Study [ONSET]38 and Stockholm Heart Epidemiology
Programme [SHEEP]),39,40 in which patients are matched to themselves to derive
a hazard and control period. The ONSET study found elevated risk associated with
 Stress and Health 843

anger and anxiety. Both studies also documented elevations in risk of acute coronary
events associated with occupational stress in the form of high-pressure deadlines. In
addition, the ONSET study found that the stress of having to fire an employee was as-
sociated with increased risk of MI.

Stress and Psychiatric Health

Stress has long been thought to precipitate mental illness, especially in vulnerable in-
dividuals (eg, stressdiathesis model).41 Stress also has been associated with in-
creased psychiatric morbidity and relapse risk in numerous psychiatric disorders.42
Stress activates the HPA axis and increases firing in the locus coeruleus, thereby dys-
regulating the noradrenergic system, which is thought to be a major cause of in-
creased psychopathology.43 Chronic stress is thought to lead to hippocampal
damage (decreased volume, dendritic atrophy in pyramidal neurons, decreased neu-
ron generation) because of overstimulation of glucocorticoid receptors. The damage,
which can impair memory and other cognitive capacities, may be enhanced by the in-
crease in proinflammatory cytokines, nitric oxide, and prostaglandins also because of
CRH activity. It has been proposed that antidepressant action may be primarily a func-
tion of returning the noradrenergic system to appropriate functioning (by limiting locus
coeruleus activity) and by reducing the neurodegenerative changes in the noradrener-
gic system caused by glucocorticoids.44 The linkage of HPA axis functioning to mental
state is bolstered by evidence that higher baseline cortisol values have been associ-
ated with anxiety, social impairment, psychotic depression, and psychosis in patients
who have post-traumatic stress disorder (PTSD).45
Cytokines released during stress can produce behaviors that are adaptive during ill-
ness, such as decreased activity, increased sleep, and decreased interest in activities.
It has not escaped notice that many of these symptoms of illness are similar to those
witnessed in depression. There is currently much speculation that prolonged proin-
flammatory cytokine production may produce depression, and several studies have
noted a correlation between depressive symptomatology and markers of inflammation
(eg, C-reactive protein).46,47 It also has been observed that depression can be an ad-
verse effect of proinflammatory cytokines (eg, interferon) given in the course of treat-
ment for other illnesses.48
Social stress also has been implicated in alterations of the serotonergic system.
It has been proposed that chronic stress, especially in early life, results in reduced
serotonergic system functioning, which negatively impacts mood and behavior.4951
Because serotonin plays an important role in both CNS and GI functioning, disruption
of the serotonergic system by stress history may help to explain the frequent sugges-
tion of a link between a history of abuse and IBS symptoms.

IMPACT OF STRESS ON HEALTH BEHAVIORS

In addition to direct physiologic effects of stress, stress impacts health through

changes in health behaviors (substance use, eating, sleep, exercise) that can both mit-
igate and enhance stress physiologic impacts. There is considerable evidence that in-
dividuals use health-impacting behaviors in an attempt to self-regulate mood (blunt
negative mood, produce positive mood), and may use some typically inhibited behav-
iors to escape paying attention to stressors or problems.52 Stress is thought to impact
diet in many ways. In general, it has been shown that stress often leads to increased
food intake, and greater consumption of high-fat, high-salt, and high-sugar foods.
Stress also may decrease motivation to adhere to prescribed diets that are felt to be
overly restrictive. Exercise has been long investigated as a possible aid to stress
844 Larzelere & Jones

coping. Research, however, has shown that stress often decreases the frequency of
exercise.53 It has been established that stress increases the frequency and amount
of substance use (ETOH, nicotine, illicit/illegal drugs) and is a predictor of relapse fol-
lowing cessation.53,54 Stress also has been implicated in promotion of sexual risk be-
haviors (although the relationship may be mediated by substance use) and decreasing
adherence to medical regimens.55,56 Given the importance of these modifiable risk fac-
tors in health promotion and maintenance, methods of reliably reducing stress are vital.

SCREENING FOR STRESS

Primary care physicians play a critical role in identifying the psychologic and health im-
pacts stress may have upon patients. Several measures of stress exist. Questions
about psychosocial stress, however, can be incorporated into the medical history/re-
view of systems by screening in three areas:
1. Chronic stressors (How are things at home? At work? Has anything been troubling
you lately?)
2. Coping strategies (When you are stressed, what do you do to cope? What do you
do for fun?)
3. Social supports (Who can you turn to in times of stress? Do you feel like you have
the help you need to cope?)
Given the prevalence of daily hassles and life stage changes, and the possibility of
traumatic stressors, it may be prudent to screen for stress regularly. After a patient is
well-known, physicians should be alert to increases in day-to-day stresses, new
chronic stressors, and major life events.
Identifying psychosocial stress and psychologic distress as part of a primary care visit
does have its challenges. Many symptoms (eg, palpitations) can be indicators of both
medical and psychologic problems. When a physician has identified symptoms that ap-
pear to be stress-linked, it may be helpful to ask the patient to record his or her physical
status and psychologic status (1 to 10 basis; 1 5 calm and relaxed; 10- 5 extreme
stress) on a daily basis for several weeks. Physical status can be recorded either by
functional ability (1 5 no impairment; 10 5 unable to participate in activities) or whatever
physical symptom is most troubling to the patient (eg, 1 5 normal bowel functioning;
10 5 hourly diarrhea). Charting these processes together may provide chronologic
clues to stress-related exacerbations of physical symptoms, or, conversely, to the psy-
chologic impact of coping with illness exacerbations. For patients who have difficulty
identifying the role stress may play in their illness, a modified stress biopsy57 may be
useful. In a stress biopsy, patients are asked to close their eyes and think about a stress-
ful situation (eg, deadline at work, aggravation by spouse, worry about the health of
a parent or child) that frequently occurs in their lives. Then, they are asked to describe
the physical sensations that would be prominent in this situation (eg, shortness of
breath, heart palpitations, muscle tension, headache, urge to defecate). This opens
a discussion of the patients stereotypic pattern of autonomic response to stress and
easily lends itself to instructing the patient to monitor both psychologic and physical
functioning to note their interrelationship. Such monitoring also can be expanded to
track the impact of medical or psychosocial interventions that are attempted.

MANAGEMENT OF STRESS

There is a growing recognition that developing skills to manage stress can be benefi-
cial to patients. Many interventions for stress exist, each with varying levels of
 Stress and Health 845

empirical support. Indeed, most stress management programs include a variety of

components, many of which can be adapted to office practice. Physicians also should
strive to develop a referral network of specialists in stress-related conditions. This net-
work is likely to include mental health practitioners, but the possible role of massage
therapists and community resources, such as meditation, yoga, and relaxation clas-
ses should not be overlooked. Follow-up is very important, as many patients never
take advantage of the referral or initially may discount the physicians investment in
stress management as a health-related goal.
For patients who seem to have difficulty with lifestyle balance, having a physician
provide them with explicit permission to take time for relaxation or self-care can be
very important. Patients (and professionals) can benefit from regularly re-evaluating
the time they spend engaged in activities versus the value they ascribe to these activ-
ities, and re-adjusting their efforts accordingly. One mnemonic that can often serve as
a starting point for exploring the domains in which individuals invest their time is the
PRAISES model (Table 1). Although patients should be assured that balance may
be sacrificed over the short term because of pressing needs, discussing a patients
long-term efforts to balance life across these areas often can illuminate changes
that would be beneficial in managing his or her stress.

Pharmacotherapy for Stress

In the aftermath of significant stressors, anxiolytics and hypnotics frequently are pre-
scribed in an understandable, humanitarian effort to do something for a patient in dis-
tress, especially one struggling with hyperarousal. The use of benzodiazepines,
especially, can often set up a false benchmark for the effectiveness of other medica-
tions in decreasing the physiologic stress response, however. Their potential for psy-
chologic and physical addiction is known, and their use decreases motivation to learn
other adaptive means to cope with chronic stress. In addition, prolonged use of ben-
zodiazepines after a traumatic stressor may predispose patients to ongoing stress
syndromes.58
A robust literature attests to the utility of selective serotonin reuptake inhibitors
(SSRIs) for treating PTSD.59 There is no scientific consensus supporting the utility of
SSRIs in stress conditions that do not meet PTSD diagnostic criteria, however. Several
preliminary investigations suggest that both short- and longer-term antidepressant
administration may decrease sympathetic nervous system (SNS) reactivity in healthy

Table 1
PRAISES model of lifestyle balance

Domain Content
Physical Time spent meeting basic physical needs and self care/health care activities
Recreational Time spent in the pursuit of fun or relaxation
Artistic Time engaging in creative pursuits, or enjoying the creativity of others
(eg, listening to music, drawing, going to movies/plays)
Intellectual Time spent expanding or engaging the mind by means of direct or indirect
learning activities
Spiritual Efforts made to connect with anything larger than the individual or family
(eg, religion, community)
Employment Time devoted to the pursuit of financial goals
Social Time spent with important others (eg, parenting)

(Data from D Glaser, personal communication, July 1997.)

846 Larzelere & Jones

subjects, which might hint toward benefit in counteracting the effects of stress.60,61
The costbenefit analysis (especially in the areas of weight gain and sexual dysfunc-
tion) of using the SSRIs becomes more problematic when they are used to treat con-
ditions of decreased severity, however.
There is some biologic plausibility to the suggestion that medications that decrease
locus coeruleus firing rate (eg, beta antagonists, alpha-2 adrenergic antagonists,
alpha-1 agonists) may aid in resilience to stress and possibly decrease risk for the
development of a mood or anxiety disorder.62,63 Few investigations, however, have
addressed this question. Determining which patients would benefit, which pharmaco-
logic agents would be most helpful, and at what point in the stress response admin-
istration would be indicated, are areas worthy of research.

Physical Activity
Exercise often is recommended as part of a stress management intervention. It has
been shown to decrease stress hormones64 and to decrease stress reactivity.65 Exer-
cise has received support as a primary or adjunctive treatment for several psychiatric
disorders,66 and improves stress and quality-of-life ratings.66,67 A written exercise pre-
scription, adapted to the patients fitness level and level of motivation, is an excellent
initial approach to managing psychologic distress. Physicians should be active in as-
sisting patients to set concrete and attainable goals that promote regular movement,
without initial focus on changing cardiovascular fitness. Being active (eg, walking) for
15 to 20 minutes three or more times a week is a reasonable place to start. Exercise
duration of at least 20 minutes may provide stress reduction after only one session in
situationally stressed individuals.68,69 Those patients who have stable tendencies to-
ward increased anxiety may take a longer duration of exercise training (10 or more
weeks) to achieve improvement.

Relaxation Training
Effective approaches to relaxation training include progressive muscle relaxation,
autogenic training, guided imagery, and diaphragmatic breathing. Relaxation training
alone is effective for treating certain anxiety disorders70 and beneficial for insomnia.71
Relaxation training techniques often are incorporated into more general stress man-
agement programs that borrow from time management and cognitivebehavioral
approaches. There is preliminary evidence that general stress management improves
immune functioning among individuals who have HIV.72 Similarly, a stress reduction
program reduced coronary events among cardiac patients.73,74 Stress management
workbooks and recorded relaxation sessions are widely available, and their use can
be prescribed for suitable patients. Intensity might be stepped up by referring the
patient to a therapist skilled in these approaches.

CognitiveBehavioral Therapy
Cognitivebehavioral therapy (CBT) is based upon the hypothesis that thoughts drive
emotions and behavior and that by changing unrealistic or irrational cognitions, behav-
ior and emotion can be altered in positive ways. As previously noted, the psychologic
component of the stress response depends on appraisals of the nature and impact of
subjective and environmental events (threatening/benign, important/irrelevant). The
link between negative thoughts and physiologic arousal long has been established.
The goal of CBT is to change the negative/distorted cognitions that might fuel a pa-
tients stress, negative mood states, and maladaptive illness behaviors. The cognitive
distortions most frequently associated with increased stress are listed in Table 2. CBT
techniques have been found to be helpful for stress reduction and are useful in treating
 Stress and Health 847

Table 2
Cognitive distortions often related to stress

Ways to Counter
Cognitive Distortion Stress Results Because this Thinking Pattern
All-or-nothing Person demands perfection or Focus on effort instead of
thinking the effort is not acceptable outcome
Overgeneralization Every negative event/occurrence Focus on counterexamples to the
predicts other negative similar statement
events
Dwelling on Person disqualifies the positive Focus on positive elements within
negatives attributes of any situation or the situation
event
Catastrophizing Person exaggerates the Realistic reappraisal of the events
importance of minor negative long-term impact
events

More information can be found in Feeling Good by Burns.106

the psychologic distress associated with change in functional status or acute or long-
term medical illness.75 Health status and quality of life in various medical conditions
have been improved through the use of cognitivebehavioral interventions, most
prominently those conditions with a substantial component of psychologic/stress
overlay.76,77 For those patients willing to follow through with a therapy referral, cogni-
tivebehavioral therapists are widely available. Many of the concepts of CBT,
however, can be incorporated into the primary care setting. Patients often have unre-
alistic expectations (both positive and negative) about the progression of their condi-
tion and their functional abilities, which can be corrected through information provision
and challenging their beliefs. Physicians also can help patients to set realistic positive
health goals that might support stress management (eg, increasing physical activity,
scheduling a pleasant activity). Finally, for those self-motivated patients without liter-
acy limitations, a prescription to purchase a cognitivebehaviorally oriented self-help
book can be efficient and cost-effective.

Social Support
It has been fairly well documented78 that social support is associated with both phys-
ical health benefit (decreased all-cause mortality) and mental health benefit. Social
support is likely to promote a sense of stability and self worth, but more importantly,
an individuals social support network may act in ways that ameliorate the impact of
stressors (eg, expressions of support, helpful advice, financial aid).79 The consistent
positive association between social support and health has garnered interest in the
health benefits of enhancing social support in patients (typically those who have
serious illnesses). Hundreds of psychosocial support interventions have been
attempted.

Professional support
For those patients without an adequate naturally occurring support network, nurse in-
terventions and educational contacts may provide similar, although reduced benefits.
Increased contacts with professional supporters can reduce distress, improve disease
coping, increase sense of control, and enhance adherence.80,81
848 Larzelere & Jones

Peer group support

Matching patients to similar peers for purposes of support has received conflicting
support in the literature.8284 Peer support groups for various conditions improve psy-
chologic well-being when established to provide frequent contacts, under conditions
designed to foster equitable exchange of social support, and when emphasis is placed
on friendship formation.80 In addition to health-related educational topics, useful com-
ponents to include in a peer group setting may be discussions of disease-related cop-
ing strategies, problem-solving skills, stress management, and methods of enhancing
support among patients natural support networks.
Support from existing network members
Intervening to enhance individuals abilities to acquire support from their existing net-
works, involve a member of the support network in treatment, or improve the support
provided by significant network members can provide positive psychosocial and
health behavior change benefits.85 Physicians can encourage social support mobiliza-
tion in their continuity relationships by exploring patients connections to others. Phy-
sicians should be mindful that negative aspects of relationships can harm well-being,
so discussion of relationship quality should precede encouragement to increase con-
tact with social supports. Additionally, physicians can encourage contacts with pro-
fessional supports or positive supports of decreased connection if the patients
primary relationships are strained. Social ties can cause a negative influence if one
is integrated into a peer group with risky health behaviors (eg, smoking, substance
abuse). Therefore, the existence of strong social ties cannot be assumed to be health
protective. Recommendations to increase social support can be tailored to the pa-
tients interests (eg, political activism, joining a church) and hobbies, and can be com-
bined with other stress management components (eg, recommending joining
a neighborhood walking group).

Positive Emotional Experience

Given the evidence that negative mood states compromise health, there has been in-
terest in examining the possible buffering effect of positive emotions. Positive emo-
tional style has been associated with resistance to illness, decreased symptom
expression, and decreased symptom complaints during experimental exposure.86
Several other measures of physical health (eg, hospital readmission rates in cardiac
patients, injury proneness, stroke rate in elderly individuals) and markers of perceived
health (eg, pain and symptom reporting) also have been demonstrated to be inversely
associated with positive emotional experience. Although conclusive intervention stud-
ies are lacking, preliminary associative studies suggest that enhancing positive mood
(in addition to decreasing negative mood states, which are somewhat independent)
may be beneficial for health.52,86 Possible means of achieving moodstate enhance-
ment include encouraging patients to engage in regularly scheduled pleasant events,
activities that provide success experiences, and prosocial activities (eg, volunteer
work). Physicians also should refrain from challenging positive illusions that might sup-
port patients optimism (eg, enhanced self-perceptions, mildly exaggerated percep-
tions of self-control) that have been linked to increased display of health-positive
behaviors and improved social relationships.87

Mindfulness Meditation
Mindfulness meditation as an adjunctive treatment for health conditions has gener-
ated significant interest because of its cost-effectiveness and applicability to a range
of conditions. Meditation strategies have been demonstrated to be helpful for several
 Stress and Health 849

psychiatric disorders in initial investigations.8891 The interest in meditation as an ad-

junctive treatment for medical illness largely was spurred by the research and writings
of Jon Kabat-Zinn, who has championed the cause of mindfulness meditation in clin-
ical and hospital settings. Mindfulness is the quality of being acutely aware of the cur-
rent moment without burdening that experience with judgments about, or emotional
reactions to, the situation (which would render it positive or negative). Mindfulness
was considered to be an ideal way to counteract the tendency of some patients to en-
gage in negative mental rumination about physical or emotional states, and to improve
the ability of patients to cope with the stress inherent in managing chronic disease.
The practice of mindfulness meditation is thought to teach patients to view their
thoughts and feelings with greater perspective (eg, thoughts are just mental events,
thoughts may not be accurate).
Although both Vipassana meditation and Zen Buddhist meditation include the con-
cept of mindfulness, the Mindfulness Based Stress Reduction (MBSR) intervention de-
veloped by Kabat-Zinn is used most frequently in research because of its manualized
techniques and disconnection from the spiritual/religious components inherent in
some meditation practices. MBSR incorporates traditional meditation practices (sit-
ting meditation, nonjudgment of thoughts, and body scan), with the teaching of
more general stress management/coping skills, assertiveness strategies, diaphrag-
matic breathing, and Hatha yoga.
MBSR typically is taught in an 8-week program of 2.5-hour weekly sessions, with
one all-day retreat during the sixth week of training. Training encourages participants
to develop seven core mindfulness attitudes:
1. Nonjudgment of their daily experiences
2. Patience
3. Beginners mind (the ability to view things as if for the first time)
4. Trust in self
5. Nonstriving (releasing of goals other than the meditative practice)
6. Acceptance of the status quo
7. Noncensoring of ones thoughts
Participants are taught to engage in a systematic focus on successive body parts
(body scan) to observe bodily sensations. Hatha yoga postures also are taught in an
attempt to enhance participants ability to increase awareness during movement. Par-
ticipants are asked to practice mindfulness skills for 30 to 45 minutes per day (initially
focused on performing body scan) during training.
Mindfulness meditation has developed a research literature suggestive of significant
benefit for enhancing coping with distress and improving indices of mental health and
quality of life.92 Further, mindfulness meditation also may be beneficial in various
chronic illnesses and conditions.92 Randomized wait list-controlled designs to exam-
ine the efficacy of MBSR have supported psychologic benefit in conditions including
fibromyalgia,93,94 pregnancy,95 and cancer.96 Pilot studies without the benefit of con-
trol also suggest a benefit of MBSR on varied parameters including subjective health
status,97 immune parameters of stress in patients who have cancer,98 and glycemic
control in patients who have diabetes.99
The practice requirements required to master mindfulness techniques may be a bar-
rier for some patients, and the need for long-term maintenance of mindfulness prac-
tice for sustained benefit has not yet been demonstrated empirically. The extant
research, however, does support mindfulness as a promising adjunctive intervention
to promote stress management and illness coping in distressed patients. For those
patients without access to a center offering MBSR training, several books and CDs
850 Larzelere & Jones

designed to teach the technique are also available.100 The benefits of individual mind-
fulness-based meditation practice, however, have not been investigated.

Emotional Expression
Emotional disclosure through writing about a trauma or stressful situation has received
much empiric attention since Pennabaker and Beall101 first obtained a significant re-
duction in illness-related physician visits among college students asked to write about
the facts and emotions surrounding a recent trauma. Writing expressively about
traumas and stressful situations generally has been found to have a beneficial but
small effect on distress, subjective well-being, anxiety, anger, and depression.102
The effects tend to be most pronounced on indices of emotional functioning (eg, re-
ducing depression) and immune parameters (eg, viral load, liver function). Interest-
ingly, perceived stress and stress-related parameters are not very amenable to
reduction through expressive writing. Taken together, these findings suggest that ex-
pressive writing may not reduce stress, but rather, the impact of stress.102,103 The sit-
uation may still be seen as stressful, but the person may be able to handle the stress in
a more productive, healthy way.
Expressive writing has much appeal as an office-based intervention. It is inexpen-
sive, readily available, and the parameters appear fairly straightforward. Typically,
a person is instructed to write expressively about an upsetting topic, including both
the facts and their emotional reactions. Optimum instructions and conditions remain
under investigation, but some guidelines can be taken from a recent meta-analysis.102
More seems better; three or more writing sessions of at least 15 minutes appeared to
be most useful. The comfort of the patient appears to improve the effectiveness, as
participants did better when they wrote at home, in private settings, and the writings
were not turned in to investigators. Instructions to write about more recent traumas or
stressful events, and about previously undisclosed events also were associated with
more benefit. The patient does not need to let anyone read the product, although if he
or she wants to disclose to a trusted, appropriate person, that also might be
beneficial.

Brief Interpersonal Counseling

Brief interpersonal counseling has a long, although largely informal, tradition of use for
stress management in primary care settings. Most successful practitioners have de-
veloped strategies to allow patients to discuss psychosocial stressors that may be im-
pacting their health status.104 A structured version of interpersonal counseling was
tested in primary care settings. A series of up to six half-hour sessions were provided
to patients who had elevated numbers of functional complaints (presumed to be
stress-related). Patients were given the opportunity to discuss recent changes and
psychosocial life stressors and were supported in their use of coping strategies to
meet these stressors. This pilot study found both psychologic and physical benefits
of the protocol.105 The widely familiar BATHE (Background, Affect, Trouble, Handling,
Empathy) technique,104 combined with an active focus on problem solving strategies,
interpersonal connections, and frequent supportive visits during stressful times would
seem to offer an efficient way to incorporate most of the components of this interven-
tion during shorter clinic visits. Interestingly, the tested intervention employed nurse
practitioners to deliver the intervention, suggesting that support staff also can play
a useful role in assisting patients with stress management needs.
 Stress and Health 851

FURTHER READINGS

Cognitivebehavioral therapy
Greenberger D, Padesky C. Mind over mood: change the way you feel by changing
the way you think. New York: Guilford; 1995.
Finding a qualified cognitivebehavioral therapist
Association for Behavioral and Cognitive Therapies. Available at: www.ABCT.org.
Academy of Cognitive Therapy. Available at: www.academyofCT.org.
Mindfulness meditation
Kabat-Zinn J. Full catastrophe living: using the wisdom of your body and mind to face
stress, pain, and illness. New York: Delta; 1990.
Kabat-Zinn J. Mindfulness for beginners (Audio CD). Louisville (CO): Sounds True;
2006.
Kabat-Zinn J. Guided mindfulness meditation (Audio CD). Louisville (CO): Sounds
True; 2005.
Jon Kabat-Zinn books for patients and audio CDs can also be obtained at: http://
www.mindfulnesstapes.com.
Relaxation skills
Davis M, Eshelman ER, McKay M. The relaxation and stress reduction workbook. 5th
edition. Oakland (CA): New Harbinger; 2000.
Catalano EM, Hardin KN. Chronic pain control workbook. Oakland (CA): New Harbin-
ger; 1996.
Weil A. Breathing. (Audio CD). Louisville (CO): Sounds True; 2006.

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