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Stress, Coping and Health
Stress, Coping and Health Kate Faasse and Keith J Petrie, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand Ó 2015 Elsevier Ltd. All rights reserved. This article is a revision of the previous edition article by H.W. Krohne, volume 22, pp. 15163–15170, Ó 2001, Elsevier Ltd.
Abstract Stress has been consistently associated with negative health outcomes, including increased rates of heart disease, slower wound healing, and compromised immune function. Interventions designed to improve peoples’ ability to cope with stress can improve health outcomes. Such interventions include relaxation training, emotional expression, benefit finding, and cognitive-behavioral stress management and mindfulness-based stress reduction programs. Coping interventions have the potential to improve health outcomes for patients undergoing a stressful illness experience.
Introduction There is a large body of literature surrounding the impact of stress on health, and more recently on how coping effectively with stress might influence this relationship. Most people are able to identify a stressful event or experience when it is happening to them. However, attempting to provide a definition of ‘stress’ that accurately encompasses the vast range of experiences that people might report as stressful elucidates stress as a broad and subjective concept. Within the social and behavioral sciences, much of the literature on stress stems from the work of Lazarus and Folkman (1984). Their model views stress as occurring when an individual is faced with a situation that places demands on them, but for which the individual does not have the necessary resources to manage these demands. Importantly, this situation must be appraised as personally relevant to the individual, making stress a transactional process between the person and their environment. Segerstrom and O’Connor (2012) highlight that ‘stress’ can originate from a variety of sources, including from the environment, personal appraisal, and response to a situation. Stress and coping are difficult to disentangle, and it is hard to imagine the need to attempt to cope without being first faced with a stressor of some sort. Indeed, coping is often viewed as an attempt to deal with a demanding situation in a way that removes the threat or at least minimizes its impact on the individual (Carver, 2006). These attempts may involve the use of cognitive and behavioral strategies in order to manage the stressful situation (Folkman and Moskowitz, 2004). Lazarus and Folkman (1984) proposed different broad types of coping. Problem-focused coping is aimed at the source of the stress, and involves attempts to remove or avoid the threat itself. For example, a person who feels that they are at high risk of developing cancer may engage in problem-focused coping by quitting smoking, changing their diet, or taking part in an exercise program. Emotion-focused coping is aimed at managing the emotions associated with stressful experiences. In the example above, the same person may engage in emotionfocused coping by adjusting their personal perception of risk, or reframing the threat; ‘we all have to die of something.’ Importantly, while coping is typically thought of as a positive process, this is not necessarily the case. Likewise, it cannot be
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assumed that coping strategies that are adopted will necessarily be appropriate or effective in helping an individual avoid or reduce the impact of a stressor (Carver, 2006). The focus of this article is on the relationship between stress, coping, and physical health. Health in this context is seen as the presence or absence of disease states, physiological markers of underlying disease processes, rates of healing from physical injury, and the functioning of the immune system.
Stress and Health There is evidence spanning many fields of scientific enquiry that links stress and health. While the mechanisms may not be fully understood at this stage, it is clear that experiencing an event or situation that is perceived as stressful can have negative consequences for physical health. While the majority of evidence points to the negative impact of stress on health outcomes, it is worth noting that in some cases stress can have a beneficial impact; for example, in encouraging people to more rapidly seek assessment of worrying physical symptoms (Meechan et al., 2003).
Disease Outcomes Perhaps one of the largest literature linking stress to disease outcomes involves cardiovascular disease. The experience of a relatively brief stressor has been associated with increased risk of experiencing a cardiac event. For example, the death of a loved one substantially increases the risk of a cardiac event in the month following the loss (Kaprio et al., 1987). Other acute stressors, including natural disasters, missile attacks, or even watching a tense sports contest have also been associated with increased mortality from heart attacks (Leor et al., 1996; Meisel et al., 1991; Wilbert-Lampen et al., 2008). Chronic or ongoing stress has also been reliably associated with increased cardiac morbidity. Greater exposure to chronic work stress has been linked to higher blood pressure (Schnall et al., 1998) and a greater risk of coronary heart disease (Steptoe and Kivimaki, 2013). Actual and remembered hostile marital interactions can increase blood pressure (Carels et al., 1998; Ewart et al., 1991), and women with coronary heart disease who experience chronic marital stress are almost three
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times more likely to experience recurrent cardiac events (OrthGomér et al., 2000). The chronic stress of social isolation also confers an increased risk of coronary heart disease (Steptoe and Kivimaki, 2013). A recent review of the role of stress in cardiovascular disease highlights the impact that stress can have across decades; stressors experienced during childhood, including abuse and socioeconomic adversity, are associated with higher rates of later cardiovascular disease in adulthood (Steptoe and Kivimaki, 2013). There is also evidence for the role of stress in other disease processes. Reported physical illness increased 18% in the 3 years following the terror attacks of 9/11 in the United States (Holman and Silver, 2011). In a group of men undergoing prostate-specific antigen level testing, higher levels of distress at initial testing was associated with a 23% increased risk of receiving a prostate cancer diagnosis (Turner et al., 2009). Psychological distress has also been associated with more rapid HIV disease progression and associated CD4þ T cell decline (Yoichi and Vedhara, 2009).
Wound Healing Another body of work focuses on the relationship between the experience of stress and the rate with which wounds heal over time. A recent review and meta-analysis demonstrated a robust relationship between stress and wound healing, with higher levels of stress being associated with slower healing rates or other physiological markers of impaired healing (Walburn et al., 2009). These findings were seen in naturally occurring and experimental wounds, acute and chronic wounds, using different definitions and assessments of stress. Much early work in this area has focused on standardized wounds created for the purposes of research. When comparing wound healing rates in women who were caregivers for a family member with Alzheimer’s disease to matched controls, Kiecolt-Glaser and colleagues found that the experimentally inflicted wounds took a significantly longer time to heal in caregivers compared to the control participants (Kiecolt-Glaser et al., 1995). Similar findings were seen when comparing students across examination and vacation time periods; punch biopsy wounds took approximately 40% longer to heal during the stressful examination period (Marucha et al., 1998). The impact of stress on wound healing is also seen in wounds created through surgical intervention. In patients undergoing hernia surgery, those with greater reported preoperative stress levels demonstrated an impaired immune response following surgery, as well as experiencing a more painful and slower recovery (Broadbent et al., 2003).
Immune Function Wound healing appears to be mediated by a more adaptive immune response following tissue injury. Immune activity and the impact of stress can also be assessed using other measures of immune function, including susceptibility to viral infection and immune response to vaccination. When exposing healthy participants to the common cold virus, those with higher reported stress levels were more susceptible to infection than their less stressed counterparts (Cohen
et al., 1991). Similarly, when comparing elderly participants who were caring for a spouse with dementia to control participants, caregivers produced fewer antibodies in response to a pneumococcal bacterial vaccination both 3 and 6 months after immunization (Glaser et al., 2000). However, when looking at a younger sample of spousal caregivers, similar declines in immune function have not been seen (Vedhara et al., 2002). The effects of stress on infection appear to be seen predominantly in response to chronic stressors, which are associated with an increased risk of infection with a cold virus; however, more acute stress lasting less than 1 month was not (Cohen et al., 1998). Indeed, there is some evidence that acute stress can result in an enhanced immune response, as evidenced by higher antibody titers following vaccination (Edwards et al., 2006). A recent meta-analysis supports this and indicates that brief or acute stress may result in increased activity of natural immunity including natural killer cells and large granular lymphocytes, although acute stress does not appear to be beneficial in all instances or across all immune parameters (Segerstrom and Miller, 2004).
Coping and Health A large body of work has sought to understand what coping strategies are associated with better health outcomes. Additionally, recent research has focused on developing coping interventions with the aim of improving patient outcomes. Peoples’ coping reactions to a stressful event can vary markedly. Carver and colleagues investigated the effects of different coping strategies in a group of women undergoing treatment for early stage breast cancer (Carver et al., 1993). Lower levels of distress both before and after surgery were seen in women who reported using the coping strategies of acceptance, positive reframing, and humor. Denial and behavioral disengagement were associated with greater distress. All the women in the study were experiencing a similar stressor, yet their coping strategies and resultant distress levels varied widely. A review of the coping literature notes that coping is associated with regulating emotions; while our focus tends to be on negative emotions and distress, positive emotions also occur alongside negative emotions, which can lead to health benefits (Folkman and Moskowitz, 2004). Importantly, the authors also note that coping skills can be taught. It is this process, and the utility of coping interventions in improving health outcomes, that will be the focus of this section. A recent review by Broadbent and Koschwanez (2012) highlights recent advances in wound healing and psychological interventions in clinical populations.
Relaxation Training Relaxation training aims to reduce stress by lowering levels of physiological arousal, and it is included in many stress management interventions (Taylor, 2012). The effectiveness of relaxation training has been investigated as a possible intervention for improving markers of wound healing following surgery (Broadbent et al., 2012). Patients undergoing
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laparoscopic cholecystectomy were randomly assigned to receive a guided imagery and relaxation intervention or standard care. Participants who received the intervention reported reduced perceived stress and increased hydroxyproline deposition, a marker of collagen deposition and healing, in the surgical wound. However, the mechanism of action remains unclear, as changes in perceived stress were not associated with rates of wound healing.
Emotional Expression Another coping strategy that has been examined as an intervention in the context of health is that of emotional expression. It is thought that inhibiting negative emotions takes physiological effort, thus greater inhibition must be facilitated by increased physiological activity (Pennebaker, 1997). The physiological effort necessary for such inhibition may result in fewer resources being available to support other important bodily processes. Being asked to suppress thoughts, whether they are related to trauma or more mundane events, can result in a reduction in circulating immune cells, including T lymphocytes (Petrie et al., 1998). The ability to express or disclose negative emotions may reduce the need for such inhibition, reducing physiological demand (Stanton, 2010). Written emotional disclosure has the ability to increase reported physical health as well as physiological functioning in healthy participants (Smyth, 1998). Emotional expression does not appear to be beneficial for all people or across all stressors (Stanton and Low, 2012). Expressing emotions appears to be of greatest utility for helping people adjust in situations in which they have low levels of control, where emotion-focused coping strategies tend to be of greatest benefit. Additionally, emotional expression seems to be of most benefit to people who already have a tendency toward emotional expression before encountering a stressor, and who experience intense emotions. Finally, the benefit of disclosure depends on the reactions of those to whom people choose to express their emotions. Written disclosure of a secret while imagining an accepting response from another person results in fewer reported illnesses following the experiment compared to a group imaging a nonaccepting response (Rodriguez and Kelly, 2006). Stanton and colleagues investigated the coping strategies of women with stage I or II breast cancer, and found that women who expressed their emotions about cancer had better psychological and physical outcomes following medical treatment, including less distress, fewer cancer-related medical appointments, and enhanced physical health (Stanton et al., 2000). Early experimental work in this area found that writing about traumatic events once a day for 4 days resulted in higher blood pressure and more negative mood immediately after writing. However, the students who were randomly assigned to write about a trauma visited the student health center fewer times during the 6 months following the writing task than those who wrote about trivial events (Pennebaker and Beall, 1986). Similarly, medical students who were randomly assigned to write about traumatic events had higher antibody levels following a Hepatitis B vaccination compared to control participants (Petrie et al., 1995). Wound healing is also
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enhanced in older adults engaging in expressive writing compared to control participants (Koschwanez et al., 2013). Expressive writing also appears to confer some benefits to patient populations, and such interventions appear to have a high degree of acceptability. In HIV patients, writing about emotional topics was associated with increased CD4þ lymphocyte counts following the intervention compared to participants writing about control topics (Petrie et al., 2004). Breast and prostate cancer patients have been shown to experience a reduction in physical symptoms and less medical care utilization following writing interventions; however, the mechanism is unclear, as levels of emotional distress do not appear to be affected by the expressive writing tasks (Corter and Petrie, 2011).
Mindfulness-Based Stress Reduction Mindfulness-based stress reduction (MBSR) involves using meditation training to help people develop skills to enable them to regulate their emotional reaction to stress (Brown and Ryan, 2003). MBSR does appear to be an effective intervention in improving coping and health across a wide range of conditions, including various cancers, coronary artery disease, and fibromyalgia (Grossman et al., 2004). In women who were recently diagnosed with early stage breast cancer, an MBSR intervention resulted in increased natural killer cell activity and cytokine production, as well as increased coping effectiveness compared to the control group (Witek-Janusek et al., 2008). A recent trial found that patients with irritable bowel syndrome who received MBSR training experienced significant improvement in symptom severity compared to a wait-list control group (Zernicke et al., 2013). However, MBSR training was not found to be effective in reducing ambulatory blood pressure in patients with hypertension when compared to wait-list controls (Blom et al., 2014).
Cognitive-Behavioral Stress Management Cognitive-behavioral stress management (CBSM) interventions are composed of training in techniques including relaxation, cognitive restructuring, social skills, and recognizing environmental stressors (Lichstein, 1988). Following a CBSM intervention, elderly spouses caring for dementia patients demonstrated an improved immune response to an influenza vaccination when compared to both nonintervention caregivers and noncaregiver control participants (Vedhara et al., 2003). Improvements in immune function, including increased cytokine production and reduced cortisol, have also been found in postsurgical breast cancer patients who have undergone a CBSM intervention when compared to control patients (Antoni et al., 2008). In a recent study, Antoni et al. (2012) found that a CBSM program for women with breast cancer reversed leukocyte gene expression, downregulating proinflammatory and metastasisrelated genes. This suggests that stress management interventions may impact directly on immune activity by influencing proinflammatory processes at the level of gene expression. There also is some evidence to suggest that the effectiveness of CBSM may be mediated by increased benefit finding (Cruess et al., 2000).
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Benefit Finding Benefit finding is a commonly utilized emotion-focused coping strategy; many patients identify positive effects that follow a serious illness. In a group of heart attack and breast cancer patients, almost two-thirds reported some positive changes following their illness; myocardial infarction patients most often reported a healthy lifestyle change, while a closer relationship with others was the most common theme reported by breast cancer patients (Petrie et al., 1999). An experimental written emotional disclosure study with breast cancer patients found that participants who were encouraged to write about positive aspects of their breast cancer experience required fewer cancer-related medical appointments in the 3 months following the intervention compared to control participants (Stanton et al., 2002).
Conclusions Stress is a transactional process involving an individual and their environment. Situations that place demands on a person that they do not see themselves as having the resources to meet are typically experienced as stressful. However, there is much variation regarding what situations will generate such a response between individuals and even within the same person on different occasions. Research into the impact of stress on health involves both specific experiences that are likely to be stressful, as well as more general personal perceptions of stress. Acute stressors discussed in this article include the death of a loved one, environmental disasters, and examination stress. Chronic stressors that have been investigated include marital discord, being a caregiver for an ill spouse, and workplace stress. Importantly, the experience of a serious illness is also often perceived as a highly stressful event. Across a broad range of stressors, it is clear that stress can have negative consequences for physical health. Such consequences include increased rates of cardiovascular disease, slower healing of both experimental and surgical wounds, and dysregulation of immune function. While stress can be detrimental to health, it is worth noting that, under some circumstances, the experience of stress can also prove to be beneficial. The stress process involves the experience of both negative and positive emotions, and these positive emotions can result in health benefits. There is also some evidence that certain acute stressors can enhance the functioning of some aspects of the immune system. Finally, the experience of distress following the discovery of physical symptoms is associated with more rapid health care seeking, enabling prompt access to treatment should it be needed. While the experience of stress tends to be associated with negative health outcomes, coping provides a potential pathway by which to mitigate this damage. Coping refers to attempts to remove or reduce the threat that a stressful situation presents. Such attempts may involve cognitive or behavioral strategies, directed at the problem itself, or at managing negative emotions associated with the stressful experience. However, the coping strategies that people engage in may not necessarily be helpful or successful in reducing stress or eliminating a threat. This highlights the importance of interventions that are aimed at teaching adaptive coping strategies
that can improve health outcomes. Research has investigated a number of coping interventions, including relaxation training, emotional expression, benefit finding, and MBSR and CBSM programs. All of these have been associated with improved health outcomes. It is likely that these interventions will have the most benefit when they are appropriately matched to both the individual and the situation. Participants with a natural tendency for emotional expression are likely to benefit more from such interventions, and emotion-focused techniques appear to be more useful in situations where participants have low levels of control over the stressful situation. The mechanisms by which such interventions work require more investigation. Some studies report better health outcomes in the intervention group, but do not demonstrate a reduction in perceived stress, although it is possible that physiological changes may precede psychological adaptation. Regardless, the strong evidence linking high levels of stress to worse health outcomes and the promising results from a number of coping studies, suggest that with appropriate interventions health outcomes for many patients could be improved.
See also: Behavioral Medicine; Cardiac Disease, Coping with; Caregiver Burden; Chronic Illness, Psychosocial Coping with; Coping with Job Stress; Coronary Heart Disease: Psychosocial Aspects; Environmental Stress and Health; Health: Definitions; Mindfulness; Psychoneuroimmunology; Social Support and Recovery from Disease and Medical Procedures; Socioeconomic Status and Health.
Bibliography Antoni, M.H., Lechner, S., Diaz, A., Vargas, S., Holley, H., Phillips, K., Blomberg, B., 2008. Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer. Brain, Behavior, and Immunity 23, 580–591. Antoni, M.H., Lutgenforf, S.K., Blomberg, B., Carver, C.S., Lechner, S., Diaz, A., Cole, S.W., 2012. Cognitive-behavioral stress management reverses anxietyrelated leukocyte transcriptional dynamics. Biological Psychiatry 15, 366–372. Blom, K., Baker, B., How, M., Dai, M., Irvine, J., Abbey, S., Tobe, S.W., 2014. Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from the harmony randomized controlled trial. American Journal of Hypertension 27, 122–129. Broadbent, E., Kahokehr, A., Booth, R.J., Thomas, J., Windsor, J.A., Buchanan, C.M., Hill, A.G., 2012. A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial. Brain, Behavior, and Immunity 26, 212–217. Broadbent, E., Koschwanez, H.E., 2012. The psychology of wound healing. Current Opinion in Psychiatry 25, 135–140. Broadbent, E., Petrie, K.J., Alley, P.G., Booth, R.J., 2003. Psychological stress impairs early wound repair following surgery. Psychosomatic Medicine 65, 865–869. Brown, K.W., Ryan, R.M., 2003. The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology 84, 822–848. Carels, R.A., Sherwood, A., Blumenthal, J.A., 1998. Psychosocial influences on blood pressure during daily life. International Journal of Psychophysiology 28, 117–129. Carver, C.S., 2006. Stress, coping, and health. In: Friedman, H.S., Cohen Silver, R. (Eds.), Foundations of Health Psychology. Oxford University Press, Cary, NC, USA, pp. 117–144. Carver, C.S., Pozo, C., Harris, S.D., Noriega, V., Scheier, M.F., Robinson, D.S., Clark, K.C., 1993. How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer. Journal of Personality and Social Psychology 65, 375–390.
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Cohen, S., Frank, E., Doyle, W.J., Skoner, D.P., Rabin, B.S., Gwaltney Jr., J.M., 1998. Types of stressors that increase susceptibility to the common cold in healthy adults. Health Psychology 17, 214–223. Cohen, S., Tyrrell, D.A., Smith, A.P., 1991. Psychological stress and susceptibility to the common cold. New England Journal of Medicine 325, 606–612. Corter, A., Petrie, K.J., 2011. Expressive writing in patients diagnosed with cancer. In: Nyklicek, I., Vingerhoets, A., Zeelenberg, M. (Eds.), Emotion Regulation and Wellbeing. Springer Science and Business Media, New York, pp. 297–306. Cruess, D.G., Antoni, M.H., McGregor, B.A., Kilbourn, K.M., Boyers, A.E., Alferi, S.M., Kumar, M., 2000. Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer. Psychosomatic Medicine 62, 304–308. Edwards, K.M., Burns, V.E., Reynolds, T., Carroll, D., Drayson, M., Ring, C., 2006. Acute stress exposure prior to influenza vaccination enhances antibody response in women. Brain, Behavior, and Immunity 20, 159–168. Ewart, C.K., Taylor, C.B., Kraemer, H.C., Agras, W.S., 1991. High blood pressure and marital discord: not being nasty matters more than being nice. Health Psychology 10, 155–163. Folkman, S., Moskowitz, J.T., 2004. Coping: pitfalls and promise. Annual Review of Psychology 55, 745–774. Glaser, R., Sheridan, J., Malarkey, W.B., MacCallum, R.C., Kiecolt-Glaser, J.K., 2000. Chronic stress modulates the immune response to a pneumococcal pneumonia vaccine. Psychosomatic Medicine 62, 804–807. Grossman, P., Niemann, L., Schmidt, S., Walach, H., 2004. Mindfulness-based stress reduction and health benefits: a meta-analysis. Journal of Psychosomatic Research 57, 35–43. Holman, E.A., Silver, R.C., 2011. Health status and health care utilization following collective trauma: a 3-year national study of the 9/11 terrorist attacks in the United States. Social Science and Medicine 73, 483–490. Kaprio, J., Koskenvuo, M., Rita, H., 1987. Mortality after bereavement: a prospective study of 95 647 persons. American Journal of Public Health 77, 283–287. Kiecolt-Glaser, J.K., Marucha, P.T., Malarkey, W.B., Mercado, A.M., Glaser, R., 1995. Slowing of wound healing by psychological stress. Lancet 346, 1194–1196. Koschwanez, H.E., Kerse, N., Darragh, M., Jarrett, P., Booth, R.J., Broadbent, E., 2013. Expressive writing and wound healing in older adults: a randomized controlled trial. Psychosomatic Medicine 75, 581–590. Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer Publishing, New York. Leor, J., Poole, W.K., Kloner, R.A., 1996. Sudden cardiac death triggered by an earthquake. New England Journal of Medicine 334, 413–419. Lichstein, K., 1988. Clinical Relaxation Strategies. Wiley, New York. Marucha, P.T., Kiecolt-Glaser, J.K., Favagehi, M., 1998. Mucosal wound healing is impaired by examination stress. Psychosomatic Medicine 60, 362–365. Meechan, G., Collins, J., Petrie, K.J., 2003. The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms. Preventive Medicine 36, 374–378. Meisel, S.R., Kutz, I., Dayan, K.I., Pauzner, H., Chetboun, I., Arbel, Y., David, D., 1991. Effects of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet 338, 660–661. Orth-Gomér, K., Wamala, S.P., Horsten, M., Schenck-Gustafsson, K., Schneiderman, N., Mittleman, M.A., 2000. Marital stress worsens prognosis in women with coronary heart disease: the Stockholm female coronary risk study. Journal of the American Medical Association 284, 3008–3014. Pennebaker, J.W., 1997. Writing about emotional experiences as a therapeutic process. Psychological Science 8, 162–166. Pennebaker, J.W., Beall, S.K., 1986. Confronting a traumatic event: toward an understanding of inhibition and disease. Journal of Abnormal Psychology 95, 274–281. Petrie, K.J., Booth, R.J., Pennebaker, J.W., 1998. The immunological effects of thought suppression. Journal of Personality and Social Psychology 75, 1264–1272. Petrie, K.J., Booth, R.J., Pennebaker, J.W., Davison, K.P., Thomas, M.G., 1995. Disclosure of trauma and immune response to a hepatitis B vaccination program. Journal of Consulting and Clinical Psychology 63, 787–792.
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Petrie, K.J., Buick, D.L., Weinman, J., Booth, R.J., 1999. Positive effects of illness reported by myocardial infarction and breast cancer patients. Journal of Psychosomatic Research 47, 537–543. Petrie, K.J., Fontanilla, I., Thomas, M.G., Booth, R.J., Pennebaker, J.W., 2004. Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: a randomized trial. Psychosomatic Medicine 66, 272–275. Rodriguez, R.R., Kelly, A.E., 2006. Health effects of disclosing secrets to imagined accepting versus nonaccepting confidants. Journal of Social and Clinical Psychology 25, 1023–1047. Schnall, P.L., Schwartz, J.E., Landsbergis, P.A., Warren, K., Pickering, T.G., 1998. A longitudinal study of job strain and ambulatory blood pressure: results from a threeyear follow-up. Psychosomatic Medicine 60, 697–706. Segerstrom, S.C., Miller, G.E., 2004. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychological Bulletin 130, 601–630. Segerstrom, S.C., O’Connor, D.B., 2012. Stress, health and illness: four challenges for the future. Psychology & Health 27, 128–140. Smyth, J.M., 1998. Written emotional expression: effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology 66, 174–184. Stanton, A.L., 2010. Regulating emotions during stressful experiences: the adaptive utility of coping through emotional approach. In: Folkman, S. (Ed.), Oxford Handbook of Stress, Health and Coping. Oxford University Press, New York. Stanton, A.L., Danoff-Burg, S., Cameron, C.L., Bishop, M., Collins, C.A., Kirk, S.B., Twillman, R., 2000. Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. Journal of Consulting and Clinical Psychology 68, 875–882. Stanton, A.L., Danoff-Burg, S., Sworowski, L.A., Collins, C.A., Branstetter, A.D., Rodriguez-Hanley, A., Austenfeld, J.L., 2002. Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients. Journal of Clinical Oncology 20, 4160–4168. Stanton, A.L., Low, C.A., 2012. Expressing emotions in stressful contexts: benefits, moderators, and mechanisms. Current Directions in Psychological Science 21, 124–128. Steptoe, A., Kivimaki, M., 2013. Stress and cardiovascular disease: an update on current knowledge. Annual Review of Public Health 34, 337–354. Taylor, S.E., 2012. Health Psychology, eighth ed. McGraw-Hill, New York. Turner, E.L., Lane, J.A., Metcalfe, C., Down, L., Donovan, J.L., Hamdy, R., Vedhara, K., 2009. Psychological distress and prostate specific antigen levels in men with and without prostate cancer. Brain, Behavior, and Immunity 23, 1073–1078. Vedhara, K., Bennett, P.D., Clark, S., Lightman, S.L., Shaw, S., Perks, P., Shanks, N.M., 2003. Enhancement of antibody responses to influenza vaccination in the elderly following a cognitive-behavioural stress management intervention. Psychotherapy and Psychosomatics 72, 245–252. Vedhara, K., McDermott, M.P., Evans, T.G., Treanor, J.J., Plummer, S., Tallon, D., Schiffitto, G., 2002. Chronic stress in nonelderly caregivers: psychological, endocrine and immune implications. Journal of Psychosomatic Research 53, 1153–1161. Walburn, J., Vedhara, K., Hankins, M., Rixon, L., Weinman, J., 2009. Psychological stress and wound healing in humans: a systematic review and meta-analysis. Journal of Psychosomatic Research 67, 253–271. Wilbert-Lampen, U., Leistner, D., Greven, S., Pohl, T., Sper, S., Volker, C., Guthlin, D., Plasse, A., Knez, A., Kuchenhoff, H., Steinbeck, G., 2008. Cardiovascular events during World Cup soccer. New England Journal of Medicine 358, 475–483. Witek-Janusek, L., Albuquerque, K., Rambo Chroniak, K., Chroniak, C., DurazoArvizu, R., Mathews, H.L., 2008. Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain, Behavior, and Immunity 22, 969–981. Yoichi, C., Vedhara, K., 2009. Adverse psychosocial factors predict poorer prognosis in HIV disease: a meta-analytic review of prospective investigations. Brain, Behavior, and Immunity 23, 434–445. Zernicke, K.A., Campbell, T.S., Blustein, P.K., Fung, T.S., Johnson, J.A., Bacon, S.L., Carlson, L.E., 2013. Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized wait-list controlled trial. International Journal of Behavioral Medicine 20, 385–396.
Abstract Stress has been consistently associated with negative health outcomes, including increased rates of heart disease, slower wound healing, and compromised immune function. Interventions designed to improve peoples’ ability to cope with stress can improve health outcomes. Such interventions include relaxation training, emotional expression, benefit finding, and cognitive-behavioral stress management and mindfulness-based stress reduction programs. Coping interventions have the potential to improve health outcomes for patients undergoing a stressful illness experience.
Introduction There is a large body of literature surrounding the impact of stress on health, and more recently on how coping effectively with stress might influence this relationship. Most people are able to identify a stressful event or experience when it is happening to them. However, attempting to provide a definition of ‘stress’ that accurately encompasses the vast range of experiences that people might report as stressful elucidates stress as a broad and subjective concept. Within the social and behavioral sciences, much of the literature on stress stems from the work of Lazarus and Folkman (1984). Their model views stress as occurring when an individual is faced with a situation that places demands on them, but for which the individual does not have the necessary resources to manage these demands. Importantly, this situation must be appraised as personally relevant to the individual, making stress a transactional process between the person and their environment. Segerstrom and O’Connor (2012) highlight that ‘stress’ can originate from a variety of sources, including from the environment, personal appraisal, and response to a situation. Stress and coping are difficult to disentangle, and it is hard to imagine the need to attempt to cope without being first faced with a stressor of some sort. Indeed, coping is often viewed as an attempt to deal with a demanding situation in a way that removes the threat or at least minimizes its impact on the individual (Carver, 2006). These attempts may involve the use of cognitive and behavioral strategies in order to manage the stressful situation (Folkman and Moskowitz, 2004). Lazarus and Folkman (1984) proposed different broad types of coping. Problem-focused coping is aimed at the source of the stress, and involves attempts to remove or avoid the threat itself. For example, a person who feels that they are at high risk of developing cancer may engage in problem-focused coping by quitting smoking, changing their diet, or taking part in an exercise program. Emotion-focused coping is aimed at managing the emotions associated with stressful experiences. In the example above, the same person may engage in emotionfocused coping by adjusting their personal perception of risk, or reframing the threat; ‘we all have to die of something.’ Importantly, while coping is typically thought of as a positive process, this is not necessarily the case. Likewise, it cannot be
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assumed that coping strategies that are adopted will necessarily be appropriate or effective in helping an individual avoid or reduce the impact of a stressor (Carver, 2006). The focus of this article is on the relationship between stress, coping, and physical health. Health in this context is seen as the presence or absence of disease states, physiological markers of underlying disease processes, rates of healing from physical injury, and the functioning of the immune system.
Stress and Health There is evidence spanning many fields of scientific enquiry that links stress and health. While the mechanisms may not be fully understood at this stage, it is clear that experiencing an event or situation that is perceived as stressful can have negative consequences for physical health. While the majority of evidence points to the negative impact of stress on health outcomes, it is worth noting that in some cases stress can have a beneficial impact; for example, in encouraging people to more rapidly seek assessment of worrying physical symptoms (Meechan et al., 2003).
Disease Outcomes Perhaps one of the largest literature linking stress to disease outcomes involves cardiovascular disease. The experience of a relatively brief stressor has been associated with increased risk of experiencing a cardiac event. For example, the death of a loved one substantially increases the risk of a cardiac event in the month following the loss (Kaprio et al., 1987). Other acute stressors, including natural disasters, missile attacks, or even watching a tense sports contest have also been associated with increased mortality from heart attacks (Leor et al., 1996; Meisel et al., 1991; Wilbert-Lampen et al., 2008). Chronic or ongoing stress has also been reliably associated with increased cardiac morbidity. Greater exposure to chronic work stress has been linked to higher blood pressure (Schnall et al., 1998) and a greater risk of coronary heart disease (Steptoe and Kivimaki, 2013). Actual and remembered hostile marital interactions can increase blood pressure (Carels et al., 1998; Ewart et al., 1991), and women with coronary heart disease who experience chronic marital stress are almost three
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times more likely to experience recurrent cardiac events (OrthGomér et al., 2000). The chronic stress of social isolation also confers an increased risk of coronary heart disease (Steptoe and Kivimaki, 2013). A recent review of the role of stress in cardiovascular disease highlights the impact that stress can have across decades; stressors experienced during childhood, including abuse and socioeconomic adversity, are associated with higher rates of later cardiovascular disease in adulthood (Steptoe and Kivimaki, 2013). There is also evidence for the role of stress in other disease processes. Reported physical illness increased 18% in the 3 years following the terror attacks of 9/11 in the United States (Holman and Silver, 2011). In a group of men undergoing prostate-specific antigen level testing, higher levels of distress at initial testing was associated with a 23% increased risk of receiving a prostate cancer diagnosis (Turner et al., 2009). Psychological distress has also been associated with more rapid HIV disease progression and associated CD4þ T cell decline (Yoichi and Vedhara, 2009).
Wound Healing Another body of work focuses on the relationship between the experience of stress and the rate with which wounds heal over time. A recent review and meta-analysis demonstrated a robust relationship between stress and wound healing, with higher levels of stress being associated with slower healing rates or other physiological markers of impaired healing (Walburn et al., 2009). These findings were seen in naturally occurring and experimental wounds, acute and chronic wounds, using different definitions and assessments of stress. Much early work in this area has focused on standardized wounds created for the purposes of research. When comparing wound healing rates in women who were caregivers for a family member with Alzheimer’s disease to matched controls, Kiecolt-Glaser and colleagues found that the experimentally inflicted wounds took a significantly longer time to heal in caregivers compared to the control participants (Kiecolt-Glaser et al., 1995). Similar findings were seen when comparing students across examination and vacation time periods; punch biopsy wounds took approximately 40% longer to heal during the stressful examination period (Marucha et al., 1998). The impact of stress on wound healing is also seen in wounds created through surgical intervention. In patients undergoing hernia surgery, those with greater reported preoperative stress levels demonstrated an impaired immune response following surgery, as well as experiencing a more painful and slower recovery (Broadbent et al., 2003).
Immune Function Wound healing appears to be mediated by a more adaptive immune response following tissue injury. Immune activity and the impact of stress can also be assessed using other measures of immune function, including susceptibility to viral infection and immune response to vaccination. When exposing healthy participants to the common cold virus, those with higher reported stress levels were more susceptible to infection than their less stressed counterparts (Cohen
et al., 1991). Similarly, when comparing elderly participants who were caring for a spouse with dementia to control participants, caregivers produced fewer antibodies in response to a pneumococcal bacterial vaccination both 3 and 6 months after immunization (Glaser et al., 2000). However, when looking at a younger sample of spousal caregivers, similar declines in immune function have not been seen (Vedhara et al., 2002). The effects of stress on infection appear to be seen predominantly in response to chronic stressors, which are associated with an increased risk of infection with a cold virus; however, more acute stress lasting less than 1 month was not (Cohen et al., 1998). Indeed, there is some evidence that acute stress can result in an enhanced immune response, as evidenced by higher antibody titers following vaccination (Edwards et al., 2006). A recent meta-analysis supports this and indicates that brief or acute stress may result in increased activity of natural immunity including natural killer cells and large granular lymphocytes, although acute stress does not appear to be beneficial in all instances or across all immune parameters (Segerstrom and Miller, 2004).
Coping and Health A large body of work has sought to understand what coping strategies are associated with better health outcomes. Additionally, recent research has focused on developing coping interventions with the aim of improving patient outcomes. Peoples’ coping reactions to a stressful event can vary markedly. Carver and colleagues investigated the effects of different coping strategies in a group of women undergoing treatment for early stage breast cancer (Carver et al., 1993). Lower levels of distress both before and after surgery were seen in women who reported using the coping strategies of acceptance, positive reframing, and humor. Denial and behavioral disengagement were associated with greater distress. All the women in the study were experiencing a similar stressor, yet their coping strategies and resultant distress levels varied widely. A review of the coping literature notes that coping is associated with regulating emotions; while our focus tends to be on negative emotions and distress, positive emotions also occur alongside negative emotions, which can lead to health benefits (Folkman and Moskowitz, 2004). Importantly, the authors also note that coping skills can be taught. It is this process, and the utility of coping interventions in improving health outcomes, that will be the focus of this section. A recent review by Broadbent and Koschwanez (2012) highlights recent advances in wound healing and psychological interventions in clinical populations.
Relaxation Training Relaxation training aims to reduce stress by lowering levels of physiological arousal, and it is included in many stress management interventions (Taylor, 2012). The effectiveness of relaxation training has been investigated as a possible intervention for improving markers of wound healing following surgery (Broadbent et al., 2012). Patients undergoing
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laparoscopic cholecystectomy were randomly assigned to receive a guided imagery and relaxation intervention or standard care. Participants who received the intervention reported reduced perceived stress and increased hydroxyproline deposition, a marker of collagen deposition and healing, in the surgical wound. However, the mechanism of action remains unclear, as changes in perceived stress were not associated with rates of wound healing.
Emotional Expression Another coping strategy that has been examined as an intervention in the context of health is that of emotional expression. It is thought that inhibiting negative emotions takes physiological effort, thus greater inhibition must be facilitated by increased physiological activity (Pennebaker, 1997). The physiological effort necessary for such inhibition may result in fewer resources being available to support other important bodily processes. Being asked to suppress thoughts, whether they are related to trauma or more mundane events, can result in a reduction in circulating immune cells, including T lymphocytes (Petrie et al., 1998). The ability to express or disclose negative emotions may reduce the need for such inhibition, reducing physiological demand (Stanton, 2010). Written emotional disclosure has the ability to increase reported physical health as well as physiological functioning in healthy participants (Smyth, 1998). Emotional expression does not appear to be beneficial for all people or across all stressors (Stanton and Low, 2012). Expressing emotions appears to be of greatest utility for helping people adjust in situations in which they have low levels of control, where emotion-focused coping strategies tend to be of greatest benefit. Additionally, emotional expression seems to be of most benefit to people who already have a tendency toward emotional expression before encountering a stressor, and who experience intense emotions. Finally, the benefit of disclosure depends on the reactions of those to whom people choose to express their emotions. Written disclosure of a secret while imagining an accepting response from another person results in fewer reported illnesses following the experiment compared to a group imaging a nonaccepting response (Rodriguez and Kelly, 2006). Stanton and colleagues investigated the coping strategies of women with stage I or II breast cancer, and found that women who expressed their emotions about cancer had better psychological and physical outcomes following medical treatment, including less distress, fewer cancer-related medical appointments, and enhanced physical health (Stanton et al., 2000). Early experimental work in this area found that writing about traumatic events once a day for 4 days resulted in higher blood pressure and more negative mood immediately after writing. However, the students who were randomly assigned to write about a trauma visited the student health center fewer times during the 6 months following the writing task than those who wrote about trivial events (Pennebaker and Beall, 1986). Similarly, medical students who were randomly assigned to write about traumatic events had higher antibody levels following a Hepatitis B vaccination compared to control participants (Petrie et al., 1995). Wound healing is also
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enhanced in older adults engaging in expressive writing compared to control participants (Koschwanez et al., 2013). Expressive writing also appears to confer some benefits to patient populations, and such interventions appear to have a high degree of acceptability. In HIV patients, writing about emotional topics was associated with increased CD4þ lymphocyte counts following the intervention compared to participants writing about control topics (Petrie et al., 2004). Breast and prostate cancer patients have been shown to experience a reduction in physical symptoms and less medical care utilization following writing interventions; however, the mechanism is unclear, as levels of emotional distress do not appear to be affected by the expressive writing tasks (Corter and Petrie, 2011).
Mindfulness-Based Stress Reduction Mindfulness-based stress reduction (MBSR) involves using meditation training to help people develop skills to enable them to regulate their emotional reaction to stress (Brown and Ryan, 2003). MBSR does appear to be an effective intervention in improving coping and health across a wide range of conditions, including various cancers, coronary artery disease, and fibromyalgia (Grossman et al., 2004). In women who were recently diagnosed with early stage breast cancer, an MBSR intervention resulted in increased natural killer cell activity and cytokine production, as well as increased coping effectiveness compared to the control group (Witek-Janusek et al., 2008). A recent trial found that patients with irritable bowel syndrome who received MBSR training experienced significant improvement in symptom severity compared to a wait-list control group (Zernicke et al., 2013). However, MBSR training was not found to be effective in reducing ambulatory blood pressure in patients with hypertension when compared to wait-list controls (Blom et al., 2014).
Cognitive-Behavioral Stress Management Cognitive-behavioral stress management (CBSM) interventions are composed of training in techniques including relaxation, cognitive restructuring, social skills, and recognizing environmental stressors (Lichstein, 1988). Following a CBSM intervention, elderly spouses caring for dementia patients demonstrated an improved immune response to an influenza vaccination when compared to both nonintervention caregivers and noncaregiver control participants (Vedhara et al., 2003). Improvements in immune function, including increased cytokine production and reduced cortisol, have also been found in postsurgical breast cancer patients who have undergone a CBSM intervention when compared to control patients (Antoni et al., 2008). In a recent study, Antoni et al. (2012) found that a CBSM program for women with breast cancer reversed leukocyte gene expression, downregulating proinflammatory and metastasisrelated genes. This suggests that stress management interventions may impact directly on immune activity by influencing proinflammatory processes at the level of gene expression. There also is some evidence to suggest that the effectiveness of CBSM may be mediated by increased benefit finding (Cruess et al., 2000).
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Benefit Finding Benefit finding is a commonly utilized emotion-focused coping strategy; many patients identify positive effects that follow a serious illness. In a group of heart attack and breast cancer patients, almost two-thirds reported some positive changes following their illness; myocardial infarction patients most often reported a healthy lifestyle change, while a closer relationship with others was the most common theme reported by breast cancer patients (Petrie et al., 1999). An experimental written emotional disclosure study with breast cancer patients found that participants who were encouraged to write about positive aspects of their breast cancer experience required fewer cancer-related medical appointments in the 3 months following the intervention compared to control participants (Stanton et al., 2002).
Conclusions Stress is a transactional process involving an individual and their environment. Situations that place demands on a person that they do not see themselves as having the resources to meet are typically experienced as stressful. However, there is much variation regarding what situations will generate such a response between individuals and even within the same person on different occasions. Research into the impact of stress on health involves both specific experiences that are likely to be stressful, as well as more general personal perceptions of stress. Acute stressors discussed in this article include the death of a loved one, environmental disasters, and examination stress. Chronic stressors that have been investigated include marital discord, being a caregiver for an ill spouse, and workplace stress. Importantly, the experience of a serious illness is also often perceived as a highly stressful event. Across a broad range of stressors, it is clear that stress can have negative consequences for physical health. Such consequences include increased rates of cardiovascular disease, slower healing of both experimental and surgical wounds, and dysregulation of immune function. While stress can be detrimental to health, it is worth noting that, under some circumstances, the experience of stress can also prove to be beneficial. The stress process involves the experience of both negative and positive emotions, and these positive emotions can result in health benefits. There is also some evidence that certain acute stressors can enhance the functioning of some aspects of the immune system. Finally, the experience of distress following the discovery of physical symptoms is associated with more rapid health care seeking, enabling prompt access to treatment should it be needed. While the experience of stress tends to be associated with negative health outcomes, coping provides a potential pathway by which to mitigate this damage. Coping refers to attempts to remove or reduce the threat that a stressful situation presents. Such attempts may involve cognitive or behavioral strategies, directed at the problem itself, or at managing negative emotions associated with the stressful experience. However, the coping strategies that people engage in may not necessarily be helpful or successful in reducing stress or eliminating a threat. This highlights the importance of interventions that are aimed at teaching adaptive coping strategies
that can improve health outcomes. Research has investigated a number of coping interventions, including relaxation training, emotional expression, benefit finding, and MBSR and CBSM programs. All of these have been associated with improved health outcomes. It is likely that these interventions will have the most benefit when they are appropriately matched to both the individual and the situation. Participants with a natural tendency for emotional expression are likely to benefit more from such interventions, and emotion-focused techniques appear to be more useful in situations where participants have low levels of control over the stressful situation. The mechanisms by which such interventions work require more investigation. Some studies report better health outcomes in the intervention group, but do not demonstrate a reduction in perceived stress, although it is possible that physiological changes may precede psychological adaptation. Regardless, the strong evidence linking high levels of stress to worse health outcomes and the promising results from a number of coping studies, suggest that with appropriate interventions health outcomes for many patients could be improved.
See also: Behavioral Medicine; Cardiac Disease, Coping with; Caregiver Burden; Chronic Illness, Psychosocial Coping with; Coping with Job Stress; Coronary Heart Disease: Psychosocial Aspects; Environmental Stress and Health; Health: Definitions; Mindfulness; Psychoneuroimmunology; Social Support and Recovery from Disease and Medical Procedures; Socioeconomic Status and Health.
Bibliography Antoni, M.H., Lechner, S., Diaz, A., Vargas, S., Holley, H., Phillips, K., Blomberg, B., 2008. Cognitive behavioral stress management effects on psychosocial and physiological adaptation in women undergoing treatment for breast cancer. Brain, Behavior, and Immunity 23, 580–591. Antoni, M.H., Lutgenforf, S.K., Blomberg, B., Carver, C.S., Lechner, S., Diaz, A., Cole, S.W., 2012. Cognitive-behavioral stress management reverses anxietyrelated leukocyte transcriptional dynamics. Biological Psychiatry 15, 366–372. Blom, K., Baker, B., How, M., Dai, M., Irvine, J., Abbey, S., Tobe, S.W., 2014. Hypertension analysis of stress reduction using mindfulness meditation and yoga: results from the harmony randomized controlled trial. American Journal of Hypertension 27, 122–129. Broadbent, E., Kahokehr, A., Booth, R.J., Thomas, J., Windsor, J.A., Buchanan, C.M., Hill, A.G., 2012. A brief relaxation intervention reduces stress and improves surgical wound healing response: a randomised trial. Brain, Behavior, and Immunity 26, 212–217. Broadbent, E., Koschwanez, H.E., 2012. The psychology of wound healing. Current Opinion in Psychiatry 25, 135–140. Broadbent, E., Petrie, K.J., Alley, P.G., Booth, R.J., 2003. Psychological stress impairs early wound repair following surgery. Psychosomatic Medicine 65, 865–869. Brown, K.W., Ryan, R.M., 2003. The benefits of being present: mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology 84, 822–848. Carels, R.A., Sherwood, A., Blumenthal, J.A., 1998. Psychosocial influences on blood pressure during daily life. International Journal of Psychophysiology 28, 117–129. Carver, C.S., 2006. Stress, coping, and health. In: Friedman, H.S., Cohen Silver, R. (Eds.), Foundations of Health Psychology. Oxford University Press, Cary, NC, USA, pp. 117–144. Carver, C.S., Pozo, C., Harris, S.D., Noriega, V., Scheier, M.F., Robinson, D.S., Clark, K.C., 1993. How coping mediates the effect of optimism on distress: a study of women with early stage breast cancer. Journal of Personality and Social Psychology 65, 375–390.
Stress, Coping and Health
Cohen, S., Frank, E., Doyle, W.J., Skoner, D.P., Rabin, B.S., Gwaltney Jr., J.M., 1998. Types of stressors that increase susceptibility to the common cold in healthy adults. Health Psychology 17, 214–223. Cohen, S., Tyrrell, D.A., Smith, A.P., 1991. Psychological stress and susceptibility to the common cold. New England Journal of Medicine 325, 606–612. Corter, A., Petrie, K.J., 2011. Expressive writing in patients diagnosed with cancer. In: Nyklicek, I., Vingerhoets, A., Zeelenberg, M. (Eds.), Emotion Regulation and Wellbeing. Springer Science and Business Media, New York, pp. 297–306. Cruess, D.G., Antoni, M.H., McGregor, B.A., Kilbourn, K.M., Boyers, A.E., Alferi, S.M., Kumar, M., 2000. Cognitive-behavioral stress management reduces serum cortisol by enhancing benefit finding among women being treated for early stage breast cancer. Psychosomatic Medicine 62, 304–308. Edwards, K.M., Burns, V.E., Reynolds, T., Carroll, D., Drayson, M., Ring, C., 2006. Acute stress exposure prior to influenza vaccination enhances antibody response in women. Brain, Behavior, and Immunity 20, 159–168. Ewart, C.K., Taylor, C.B., Kraemer, H.C., Agras, W.S., 1991. High blood pressure and marital discord: not being nasty matters more than being nice. Health Psychology 10, 155–163. Folkman, S., Moskowitz, J.T., 2004. Coping: pitfalls and promise. Annual Review of Psychology 55, 745–774. Glaser, R., Sheridan, J., Malarkey, W.B., MacCallum, R.C., Kiecolt-Glaser, J.K., 2000. Chronic stress modulates the immune response to a pneumococcal pneumonia vaccine. Psychosomatic Medicine 62, 804–807. Grossman, P., Niemann, L., Schmidt, S., Walach, H., 2004. Mindfulness-based stress reduction and health benefits: a meta-analysis. Journal of Psychosomatic Research 57, 35–43. Holman, E.A., Silver, R.C., 2011. Health status and health care utilization following collective trauma: a 3-year national study of the 9/11 terrorist attacks in the United States. Social Science and Medicine 73, 483–490. Kaprio, J., Koskenvuo, M., Rita, H., 1987. Mortality after bereavement: a prospective study of 95 647 persons. American Journal of Public Health 77, 283–287. Kiecolt-Glaser, J.K., Marucha, P.T., Malarkey, W.B., Mercado, A.M., Glaser, R., 1995. Slowing of wound healing by psychological stress. Lancet 346, 1194–1196. Koschwanez, H.E., Kerse, N., Darragh, M., Jarrett, P., Booth, R.J., Broadbent, E., 2013. Expressive writing and wound healing in older adults: a randomized controlled trial. Psychosomatic Medicine 75, 581–590. Lazarus, R.S., Folkman, S., 1984. Stress, Appraisal, and Coping. Springer Publishing, New York. Leor, J., Poole, W.K., Kloner, R.A., 1996. Sudden cardiac death triggered by an earthquake. New England Journal of Medicine 334, 413–419. Lichstein, K., 1988. Clinical Relaxation Strategies. Wiley, New York. Marucha, P.T., Kiecolt-Glaser, J.K., Favagehi, M., 1998. Mucosal wound healing is impaired by examination stress. Psychosomatic Medicine 60, 362–365. Meechan, G., Collins, J., Petrie, K.J., 2003. The relationship of symptoms and psychological factors to delay in seeking medical care for breast symptoms. Preventive Medicine 36, 374–378. Meisel, S.R., Kutz, I., Dayan, K.I., Pauzner, H., Chetboun, I., Arbel, Y., David, D., 1991. Effects of Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians. Lancet 338, 660–661. Orth-Gomér, K., Wamala, S.P., Horsten, M., Schenck-Gustafsson, K., Schneiderman, N., Mittleman, M.A., 2000. Marital stress worsens prognosis in women with coronary heart disease: the Stockholm female coronary risk study. Journal of the American Medical Association 284, 3008–3014. Pennebaker, J.W., 1997. Writing about emotional experiences as a therapeutic process. Psychological Science 8, 162–166. Pennebaker, J.W., Beall, S.K., 1986. Confronting a traumatic event: toward an understanding of inhibition and disease. Journal of Abnormal Psychology 95, 274–281. Petrie, K.J., Booth, R.J., Pennebaker, J.W., 1998. The immunological effects of thought suppression. Journal of Personality and Social Psychology 75, 1264–1272. Petrie, K.J., Booth, R.J., Pennebaker, J.W., Davison, K.P., Thomas, M.G., 1995. Disclosure of trauma and immune response to a hepatitis B vaccination program. Journal of Consulting and Clinical Psychology 63, 787–792.
555
Petrie, K.J., Buick, D.L., Weinman, J., Booth, R.J., 1999. Positive effects of illness reported by myocardial infarction and breast cancer patients. Journal of Psychosomatic Research 47, 537–543. Petrie, K.J., Fontanilla, I., Thomas, M.G., Booth, R.J., Pennebaker, J.W., 2004. Effect of written emotional expression on immune function in patients with human immunodeficiency virus infection: a randomized trial. Psychosomatic Medicine 66, 272–275. Rodriguez, R.R., Kelly, A.E., 2006. Health effects of disclosing secrets to imagined accepting versus nonaccepting confidants. Journal of Social and Clinical Psychology 25, 1023–1047. Schnall, P.L., Schwartz, J.E., Landsbergis, P.A., Warren, K., Pickering, T.G., 1998. A longitudinal study of job strain and ambulatory blood pressure: results from a threeyear follow-up. Psychosomatic Medicine 60, 697–706. Segerstrom, S.C., Miller, G.E., 2004. Psychological stress and the human immune system: a meta-analytic study of 30 years of inquiry. Psychological Bulletin 130, 601–630. Segerstrom, S.C., O’Connor, D.B., 2012. Stress, health and illness: four challenges for the future. Psychology & Health 27, 128–140. Smyth, J.M., 1998. Written emotional expression: effect sizes, outcome types, and moderating variables. Journal of Consulting and Clinical Psychology 66, 174–184. Stanton, A.L., 2010. Regulating emotions during stressful experiences: the adaptive utility of coping through emotional approach. In: Folkman, S. (Ed.), Oxford Handbook of Stress, Health and Coping. Oxford University Press, New York. Stanton, A.L., Danoff-Burg, S., Cameron, C.L., Bishop, M., Collins, C.A., Kirk, S.B., Twillman, R., 2000. Emotionally expressive coping predicts psychological and physical adjustment to breast cancer. Journal of Consulting and Clinical Psychology 68, 875–882. Stanton, A.L., Danoff-Burg, S., Sworowski, L.A., Collins, C.A., Branstetter, A.D., Rodriguez-Hanley, A., Austenfeld, J.L., 2002. Randomized, controlled trial of written emotional expression and benefit finding in breast cancer patients. Journal of Clinical Oncology 20, 4160–4168. Stanton, A.L., Low, C.A., 2012. Expressing emotions in stressful contexts: benefits, moderators, and mechanisms. Current Directions in Psychological Science 21, 124–128. Steptoe, A., Kivimaki, M., 2013. Stress and cardiovascular disease: an update on current knowledge. Annual Review of Public Health 34, 337–354. Taylor, S.E., 2012. Health Psychology, eighth ed. McGraw-Hill, New York. Turner, E.L., Lane, J.A., Metcalfe, C., Down, L., Donovan, J.L., Hamdy, R., Vedhara, K., 2009. Psychological distress and prostate specific antigen levels in men with and without prostate cancer. Brain, Behavior, and Immunity 23, 1073–1078. Vedhara, K., Bennett, P.D., Clark, S., Lightman, S.L., Shaw, S., Perks, P., Shanks, N.M., 2003. Enhancement of antibody responses to influenza vaccination in the elderly following a cognitive-behavioural stress management intervention. Psychotherapy and Psychosomatics 72, 245–252. Vedhara, K., McDermott, M.P., Evans, T.G., Treanor, J.J., Plummer, S., Tallon, D., Schiffitto, G., 2002. Chronic stress in nonelderly caregivers: psychological, endocrine and immune implications. Journal of Psychosomatic Research 53, 1153–1161. Walburn, J., Vedhara, K., Hankins, M., Rixon, L., Weinman, J., 2009. Psychological stress and wound healing in humans: a systematic review and meta-analysis. Journal of Psychosomatic Research 67, 253–271. Wilbert-Lampen, U., Leistner, D., Greven, S., Pohl, T., Sper, S., Volker, C., Guthlin, D., Plasse, A., Knez, A., Kuchenhoff, H., Steinbeck, G., 2008. Cardiovascular events during World Cup soccer. New England Journal of Medicine 358, 475–483. Witek-Janusek, L., Albuquerque, K., Rambo Chroniak, K., Chroniak, C., DurazoArvizu, R., Mathews, H.L., 2008. Effect of mindfulness based stress reduction on immune function, quality of life and coping in women newly diagnosed with early stage breast cancer. Brain, Behavior, and Immunity 22, 969–981. Yoichi, C., Vedhara, K., 2009. Adverse psychosocial factors predict poorer prognosis in HIV disease: a meta-analytic review of prospective investigations. Brain, Behavior, and Immunity 23, 434–445. Zernicke, K.A., Campbell, T.S., Blustein, P.K., Fung, T.S., Johnson, J.A., Bacon, S.L., Carlson, L.E., 2013. Mindfulness-based stress reduction for the treatment of irritable bowel syndrome symptoms: a randomized wait-list controlled trial. International Journal of Behavioral Medicine 20, 385–396.