The purpose of this page is to examine whether stress plays an important part in the aetiology of illness. In the first instance, however, it is important to define the term ‘illness’. Illness can take on many forms. For the purposes of this report, the author will treat the word ‘illness’ as something that is inextricably interconnected with physiological, emotional, cognitive and behavioural processes. It is beyond the remit of the paper to challenge or debate present-day classifications of ‘mental illness’ and some maladaptive behaviours—for instance, gambling or excessive drinking—but, the author will attempt to explain possible causes of physiological illness, some ‘mental illnesses’ as well as non-adaptive cognitive and behavioural patterns in society. Causation in medicine and psychology is generally accepted when there is a definable, tangible event which can be linked to an illness: for example, bacteria causes infection, alcoholism can lead to liver disease, smoking can cause lung cancer or coronary heart disease (Pope et al, 2002), and so forth. But, how can stress cause illness?
Holmes and Rahe (1967) measured stress by adding up scores allocated to stressful events in individuals’ lives: they ranked the death of a spouse as being the most stressful situation, and also included other events such as divorce, death of a family member, personal injury, marriage, losing one’s job and retirement. Although this theory helped psychologists to understand the additive nature of stress, it failed to take into consideration individual differences in the perception of stress and varying degrees of coping strategies that people use in every day life. In addition, the theory does not take into account the fact that some individuals are able to resolve these life events after a period of transition.
Nevertheless, it has been shown that prolonged periods of stress can prolong illness or reduce the ability to recover from infection. Marucha, Kiecolt-Glaser & Favagehi (1998) for example, found that students who had been given an experimentally-created punch biopsy took 40% longer to recover prior to taking an important examination compared to when they were on a summer break, while Walburn, Vedhara, Hankins, Rixon & Weinman 2009), in a meta-analysis of 22 studies, showed there to be a significant relationship between stress and the healing of wounds. Leserman et al (2000) in a longitudinal study of 9 years duration, tracked the progress of 82 HIV positive—but asymptomatic—men, and found that stress, cumulative symptoms of depression and lack of social support contributed to a faster progression of the virus; further, they reported that men with higher cortisol levels were more likely to develop AIDS.
But, from a biological perspective, how can stress be responsible for causing, or helping to maintain, illness? During periods of stress, the corticotropin-releasing hormone (CRH) acts on the pituitary gland, releasing adrenocorticotrophic hormone (ACTH), which causes the adrenal gland to release cortisol. There are a number of physiological responses that occur during this time. When adrenaline is released, the blood vessels constrict and the heart rate increases. Further, when cortisol is released, it increases the level of glucose in the blood; but this is meant to be a temporary event, and prolonged periods of this stress may cause hypertension initially, but may lead to cardiac problems later in life (Zimmerman & Frohlich, 1990). Other problems include visceral tension or gastric dysfunction, And, after prolonged periods of stress, the body may react to associated situations in a similar way; for example, events during the day—for example, seeing a dentist—may lead to hypertension, hyperhidrosis and/or tachycardia as a result of the physiological changes in endocrine and immune system functioning. Indeed, any reduction in the activity of natural killer cells may lead to respiratory infections (Cohen, Doyle & Skoner, 1999), elevated cholesterol (Friedman, Rosenman, Carroll & Tat, 1958; Muldoon, Bachen, Manuck, Waldstein, Bricker & Bennett, 1992) and atherosclerosis (Bruunsgaard, Pederson, Schroll, Shinhøj & Pederson, 2001), while negative cognitions can cause many problems including sleep disorders (Espie, 2002), psychosexual dysfunction (Watson, 1997), depression (Pietromonaco & Markus, 1985), panic attacks (Salkovskis & Clark, 1991) and irritable bowel syndrome (IBS) (Chen, Blankstein, Diamant & Davis, 2011).
This mechanism, or dynamic interaction, underlines the basic tenet of a fast-evolving, multi-disciplinary approach to therapy known as psychoneuroimmunology (Ader, Cohen & Felten, 1995; Glaser, 2005): indeed, many theorists (for example, Vitetta, Anton, Cortizo & Sali, 2005; Calvert, 2011) believe that the mind and body communicate in a bidirectional flow of hormones, neurotransmitters and cytokines. For example, the use of mindfulness (Reibel, Greeson, Brainard & Rosenzweig, 2001) and hypnosis (Capafons, 1998) are extremely helpful in reducing stress and tension: the effects of these interventions reduce sympathetic activity while increasing parasympathetic activity. Indeed, the parasympathetic nervous system is an extremely important mechanism in the body for growth and repair (Greeson, 2009). During these altered states of awareness, the hypothalamic pituitary adrenal axis becomes less active so that less cortisol is produced: as a result, the individual is able to experience an enhanced sense of well being and control in the moment, but also can emulate this experience outside the consulting room. Thus, not only can negative thoughts have a deleterious effect on the body, but also positive and adaptive thoughts can help to reduce or eliminate illness, and aid recovery.
So, if the brain and immune system represents an interactive defense system, and our cognitions, beliefs and emotions have a direct neurochemical consequence right down to the cellular level, how do we account for individuals who thrive on stress? Indeed, some forms of stress can be very helpful for individuals, and it has been found that some employees in the work place thrive on working in potentially stressful situations—a concept known as ‘eustress’ (Nelson & Cooper, 2005). In fact, the body is able to adapt, defend and resist stress: for instance, Nelson and Cooper (2005) found that some individuals gain positive benefits from this form of stimulation. Some positive psychologists suggest that stress only has a deleterious effect on the body if it causes distress and that it is possible to gain benefits from ‘stressful’ situations at work (Le Fevre, Matheny & Kolt, 2003). Indeed, Quick, Cooper, Nelson, Quick and Gavin (2003) pointed out that ‘positive stress’ is essential for personal growth and development, self mastery and achieving high levels of performance. Interestingly, Berk, Felton, Tan, Bittman & Westengard (2001), in a multivariate repeated measures design on 52 healthy men, concluded that humour-associated eustress of laughter caused a modulation of neurotransmitter activity which may provide benefits as an adjunctive tool to multi-modal or integrative approaches to therapy.
However, it is not clear how negative responses are measured or even identified. Possible positive responses might include thoughts such as, ‘I have enjoyed the challenge of today’s work’ or a sigh of relief at the end of the day; however, individuals who ruminate negatively about their feelings often do so in private and, often, the negative effects of perceived stress works on an unconscious level, causing psychosomatic pain, illness, loss of appetite and/or depression. And, in addition, in the same way that managers have used attribution theory in order to maximize productivity in the workplace (see, for example, Martinko, 1995), perhaps this is another form of propaganda within ‘managerial psychology’ (Leavitt & Bahrami, 1988) to capitalize on profitability.
It is clear that social factors play an important role in causing stress, and also illness. And, in addition, some individuals have a propensity to be ill compared to others. A significant ‘life event’—particularly one which involves death of a loved one that causes dramatic, life-changing situation—can often lead to depression (Paykel, Emms, Fletcher & Rassaby, 1980). The situation becomes worse if the individual has no-one with whom (s)he can confide or if (s)he doesn’t feel safe at home (Brown, 1993): importantly, social support has been found to be highly effective in helping people with a number of stress-related problems (Cobb, 1976). However, it is often one’s perception of the situation, self esteem and coping ability that affect one’s ability to function and take control of the situation, and this varies from person to person (Herbert. 1997). Other anxiety disorders can be also caused by real or perceived danger: this can lead to a number of disorders including phobic anxiety, post traumatic stress disorder, panic disorder with or without agoraphobia, sleeping disturbances and psychosomatic pain.
There is no doubt that unhealthy behaviours—for example, smoking, over-eating, prolonged periods of lethargy and substance abuse—have a serious effect on illness. Certainly, some individuals may have personality traits which might pre-dispose them to engaging in various unhealthy behaviours (Bogg & Roberts, 2004). It is also extremely helpful for individuals to practise health protecting behaviors such as regular check-ups, screening and healthy eating (Bermúdez, 1999). Further, some individuals might have a genetic predisposition to certain illnesses and diseases. However, it is clear that stress plays an important role in functioning, and the way that individuals process the various forms of stress will have a significant effect on well being (Lazarus & Folkman, 1984). In society today it is perhaps impossible to eliminate stress. However, positive thinking, solution-focussed strategies (Iverson, 2002) and adaptive functioning may help individuals in several ways. First, fewer negative thoughts will reduce one’s stress response and will create a more receptive state for a more adaptive and positive belief system. And, second, this will have a direct impact on the brain and the rest of the body right down to the cellular level. This ‘learned optimism’ (Seligman, 2011) is something that needs to be encouraged by psychologists trained in CBT or other integrative therapists; further, with all that researchers have discovered with regard to the positive and negative effects of suggestion, encouraging comments should be used carefully within all settings in health care.
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