Chapter 12: Stress, Coping, and Health




What is Stress?

            Stress as Stimulus or Response

                        Stress as a Stimulus

                        Relationship Between Person and Situation

            The Physiology of Stress

            The General Adaptation Syndrome (GAS)

            How We Adapt to Stress

                        Stress and the Brain


Coping Strategies

                        Problem-Focused Coping

                        Emotion-Focused Coping

                        Social Support

            The Positive Psychology of Coping

                        Positive Traits, Positive Emotions

                        Finding Meaning

Psychology in the Real World: Effects of Chronic Stress On Aging

How Stress and Coping Affect Health

Breaking New Ground: Psychological Processes and the Immune System

            Stress and Immune Function

                        Overview of the Immune System

                        Research on Stress, Immune Function, and Health

            Psychological Risk Factors for Heart Disease

                        Type A and Anger


Research on Health-Relevant Behavior


                        Drinking Alcohol

                        Diet and Eating

                                    Eating and Stress

                                    Eating Disorders


                        Meditation for Stress Reduction

Making Connections in Stress and Health: The Health Psychology of HIV and AIDS

Chapter Review




·         Stress occurs when an emotionally evocative situation overwhelms a person’s perceived ability to meet the demands of that situation.

·         As with emotions, we continually evaluate our experiences of stressful situations and attempt to cope with the challenges they pose.


Stress as Stimulus or Response

·         The stimulus view of stress focuses on situations that cause stress (e.g., situations that push us to the limit or threaten our safety or well-being or a relentless onslaught of difficulties). 

o       We call these events that push us to the limit or exceed our ability to manage the situation at hand stressors.

·         The response view of stress focuses on the physiological changes that occur when someone encounters an excessively challenging situation.

·         The relational view of stress focuses on the relationship between the people and the situations in which they find themselves.

Stress as a Stimulus

o       Stressors are events that push us to the limit or exceed our ability to manage the situation at hand (e.g., divorce, financial troubles, illness, weddings, or the birth of a child).

o       Psychologists measure stress as a stimulus by quantifying the number of stressors a person experiences during a given period. Two major categories of stressors are major life events and daily hassles.

o       Holmes and Rahe developed the “Social Readjustment Rating Scale” (SRRS) to quantify stress in terms of major life changes.

§         One of the drawbacks of this measure is that it ignores the fact that people view similar events differently. 

§         Also, by measuring stress in terms of life events, the SRRS fails to consider differences in people’s emotional responses to stressors.

o       The “Hassles and Uplifts Scale” measures the frequency and intensity of minor irritations (hassles) and positive events of daily life that may counteract their damaging effects.

§         A number of studies report positive correlations between the frequency of daily hassles and self-reported health symptoms.

§         Some data indicate that hassles are more strongly related to health outcomes than are major life events.

o       A major limitation to both the major life event approach and the hassles approach is that not all people view situations in the same way.  Because people do not view similar situations in the same way, it is misleading to examine stress solely in terms of the situations that may call it forth.

§         CONNECTION: Like stress, emotions are generated by our appraisals of events in life. (See Chapter 11.)

Relationship Between Person and Situation

o       When we first encounter a situation in our environment, we quickly appraise what it means for us.

o       Two kinds of appraisal:

§         Primary appraisal is an assessment of what a situation means to us. The outcome of this appraisal determines whether an emotional response might occur.

·         If we view the event as not personally relevant, we feel no emotion.

·         If we consider it personally relevant, we appraise its significance as either contrary to or consistent with our goals or welfare.

·         If we appraise it as contrary to our well-being, we feel a negative emotion, which might cause stress.

·         If we appraise it as consistent with our well-being, we feel a positive emotion.

·         Stress emerges from negative emotional responses to events that we cannot get under control.

§         We assess the resources available to cope with stress in a process called secondary appraisal.


The Physiology of Stress

o       When stressful situations lead to negative emotions, physiological changes occur in the autonomic nervous system (ANS), the endocrine system, and the brain.

§         CONNECTION: The sympathetic branch of the ANS activates the body; the parasympathetic branch calms the body. Both branches play a role in stress and emotion. (See Chapter 3.)

o       The second major system involved in stress is the endocrine system, which consists of the major hormone-releasing glands.

o       The term neuroendocrine system refers to the hormonal systems involved in emotions and stress.

§         The key structures involved in the neuroendocrine regulation of stress responses include the hypothalamus, the pituitary gland, and the adrenal glands.

·         The hypothalamus serves as a major link between the nervous system and the endocrine systems relevant to emotions: It releases chemicals that stimulate the release of hormones from the pituitary gland, which sits just beneath it, and it is connected to brain stem structures that control the ANS.

·         The pituitary releases hormones that play a key role in the stress response.

·         The adrenal glands sit atop the kidneys, and they release several stress-related hormones:

o       the catecholamines, which control ANS activation, and

o       the glucocorticoids, which are responsible for maintaining the activation of physiological systems during emergencies.

§         When activated by an emotional event, the hypothalamus initiates a series of endocrine events that have a profound effect on the body.

·         First, the adrenal-medullary system is activated. Here, the hypothalamus sends instructions to the brain stem to activate sympathetic neurons.

·         Then, sympathetic neurons tell the adrenal gland to release the important catecholamine norepinephrine.

·         Norepinephrine activates the sympathetic response, increasing heart rate, rate of respiration, and blood pressure in order to support rapid action by the body.

§         The sympathetic response evolved because rapid mobilization of the body’s resources in emergency situations had clear survival and reproductive benefits. In cases of stress, however, we cannot regulate this emergency response.

§         If we continually live with stress-inducing situations, our body remains in “emergency mode” for long periods. This can lead to health problems such as increased blood pressure and heart rate.

§         The other major neuroendocrine pathway that is relevant to the stress response is the hypothalamic-pituitary-adrenal (HPA) axis.

·         During emotional arousal and stress, the hypothalamus releases a substance called corticotropin releasing factor (CRF), which stimulates the pituitary to release adreno-corticotropic hormone (ACTH).

·         ACTH then stimulates the cortex of the adrenal gland to release cortisol, the major glucocorticoid produced in humans, which is commonly known as the “stress hormone.”

·         When the level of cortisol in the blood adequately meets the body’s metabolic needs, the hypothalamus stops releasing CRF, thereby reducing the release of cortisol.

§         Cortisol plays a role in the breakdown of complex molecules into simpler ones to release energy, and in this way it plays an important role in the process by which more glucose is made available for fuel in the bloodstream.

§         Cortisol also has a regulatory effect on the immune system. Researchers once thought that cortisol always acted to suppress immune function.  

The General Adaptation Syndrome (GAS)

o       Selye (1946) proposed a three-stage model to explain the changes in physiology that occur during exposure to severe stressors.

§         He believed that attempts to adapt to overwhelming stressors cause the body to wear down and eventually get sick. 

§         He used homeostasis as his starting point, and he viewed the changes that the body goes through when confronted with extreme situational demands as manifestations of adaptation to stress.

§         He exposed animals to a range of stressors, such as extreme temperature change, severe electrical shock, radiation, or extreme exercise (Selye, 1976).

§         CONNECTION: Do you think an ethics review board would allow Selye to conduct his research on extreme stressors in animals today? (See Chapter 2.)

o       General adaptation syndrome (GAS): Although an infinite range of circumstances can elicit stress, all stress causes a generalized, nonspecific set of changes in the body.

o       The GAS consists of three stages: alarm, resistance, and exhaustion.

§         Upon exposure to a stressor, an animal enters into a state of physiological shock, called the alarm stage, which is the body’s emergency response to an environmental threat.

·         The alarm stage mobilizes the body’s resources to act.

·         It involves the effects of adrenal-medullary activation of the sympathetic nervous system.

·         During this stage the HPA axis is active, and the sustained release of cortisol from the adrenal glands may move from being helpful to being harmful in the long run.

·         With continued exposure to the stressor, animals eventually either die or find other ways of coping with the enduring threat.

§         When they develop other ways to cope, they enter the second stage of adaptation, the resistance stage. Here, the organism maintains its efforts to fight off or manage the threat.

·         This extended effort takes its toll diverting resources from maintenance of normal body functions.

·         Resistance cannot be maintained indefinitely.

§         With repeated or continuous exposure to a stressor, animals enter the exhaustion stage. Here, resources for fighting off threats have been depleted, and illness becomes much more likely.

o       The GAS model does not apply to all stress responses.

§         Selye studied extreme physical stressors and subjected animals to these stressors for prolonged periods. Questions arose as to whether the body changes that occurred in response to such severe demands provided a good model for enduring the stress of, say, divorce or financial troubles.

§         Some researchers question the idea of a syndrome of body responses to stress occurring regardless of the type of stressor.

·         Mason (1971, 1975) showed that an animal’s response to a stressor differed depending on its psychological state. For example, if the animal could anticipate a stressor, it showed a less severe physiological response than an animal that could not anticipate a stressor.

How We Adapt to Stress

o       Most accounts of the physiology of stress think of stress as a deviation from balance. Recovery from stress occurs when all systems return to normal.

§         This view is based on the notion of homeostasis – the idea that unless we are being provoked by something, we are operating at a state of balance, humming along at an even-keeled baseline state.

§         CONNECTION: The concept of homeostasis is key to drive theories of motivation. (See Chapter 11.)

o       Our normal state is one of actively responding to the world around us. This more dynamic, responsive “resting” state is an alternative explanation of how the body usually is operating, known as allostasis, which means that the body achieves stability through change.

§         The concept of allostasis makes clear that our bodies can adaptively respond to challenge for only a short period of time. If we are pushed too long, and the kinds of active attempts the body makes to adapt are sustained, we are taxed, and the body starts to wear down. This is how stress causes illness.

Stress and the Brain

o       We tend to think of stress as being caused by processes within the brain, for it is our interpretations of the events in the world around us that trigger emotions.

o       In another example of the bidirectional relationship between nature and nurture, the physiological activation triggered by stress also affects the brain.

§         Cortisol has a profound effect on the hippocampus, a brain structure that plays a pivotal role in memory. The hippocampus also plays a role in terminating the activation of the HPA axis via a negative feedback mechanism.

§         CONNECTION: The hippocampus, located deep inside the brain, is critical for memory formation. (See Chapter 3 and Chapter 7.)

·         Stress-related cortisol release can cause dendrites to whither and shrink, and this can interfere with several types of memory.

·         Stress reduces neurogenesis in the hippocampus, and it may inhibit the synaptic plasticity in the hippocampus and neocortex, impacting learning and memory formation.



·         Coping refers to anything people do to deal with or manage stress or emotions.


Coping Strategies

·         Lazarus and Folkman (1984) differentiated between these two types of coping strategies:

Problem-focused coping

o       Problem-focused coping involves strategies that aim to change the situation that is creating stress.

§         This involves devising a plan to solve the problem, seeking social support as a way to gather information, and taking assertive action.

§         Problem-focused coping tends to focus attention on the stress-provoking situation.

§         We are most likely to use it when we feel that we can do something to change the situation.

Emotion-focused coping

o       Emotion-focused coping involves strategies aimed at regulating the experience of distress. This includes:

§         reappraisal: the emotional regulation strategy of reevaluation of a situation in light of new information or additional thought

§         distancing: attempting  to separate oneself from an emotional experience

§         escape-avoidance: wishful thinking or doing something to get one’s mind off the situation

§         seeking social support: talking with friends for purposes of emotional support

§         self-control: trying to  regulate one’s feelings or actions regarding the problem

§         accepting responsibility: acknowledging one’s role in the stress-eliciting situation

o       Emotion-focused coping may be beneficial when a situation is beyond one’s control.

o       Certain types of emotion-focused coping—especially reappraisal—can be helpful in regulating the emotional aspects of stress.

o       Some types of emotion-focused coping are problematic.

§         Willful suppression of upsetting emotions, which is a form of self-control, can lead to chronic physiological arousal and is associated with poor psychological adjustment.

§         Some strategies that we use to reduce the experience of distress, such as drinking, smoking, and other forms of drug use, may be maladaptive.

§         CONNECTION: Emotion regulation is another term for the strategies we use to alter our emotional state and is similar to emotion-focused coping. (See Chapter 11.)

Traumatic Disclosure

o       Emotional disclosure is the discussion of stressful concerns to relieve oneself of the emotional burden.

o       James Pennebaker developed and tested a technique that enables people to unburden.

§         In a typical emotional disclosure task, people are instructed to write for about 15 minutes about a recent emotional experience.  Participants in the control condition write for a similar amount of time about non-emotional events.

§         Emotional disclosure consistently improves a number of health outcomes, including health variables related to HIV/AIDS, immune function, and cancer.

o       People in both Western and non-Western cultures believe that confession is beneficial.

o       It is also thought that not working through difficult emotions taxes the body, as research on the association between emotional suppression and ANS arousal suggests.

§         When confession or disclosure occurs, then, one should observe a decrease in sympathetic nervous system activation, or a return to a more relaxed state. 

Social Support

o       A coping strategy that combines problem- and emotion-focused coping is seeking social support.

o       Social support is one of the most frequently used ways of coping and can benefit physical health.

o       The direct effects hypothesis states that social support is beneficial to mental and physical health whether or not the person is under stress.

§         Being part of a social network guarantees the availability of certain resources.

§         Our social network may offer guidelines for health-related behaviors, help us regulate our emotions, and give us a sense of identity.

§         Examples of social connectedness include being married, belonging to social groups such as churches or clubs, and having many friends.

o       The buffering hypothesis states that social support works as a buffer only under certain conditions, such as a highly stressful life.

o       One factor that influences whether social resources are beneficial to health is the extent to which the person is integrated into a social network – a cluster of related people.

§         When people are well integrated into a social network, social support can buffer the effects of stress by providing interpersonal resources for emotional support and problem solving.

o       The health benefits of social connectedness include longer life and reduced susceptibility to colds.

o       Social networks may be harmful to health as well.

§         The risk of obesity spread among people who were socially connected.

§         Individuals of the same gender in a social network influenced same-sexed individuals more than opposite-sexed individuals.


The Positive Psychology of Coping

Positive Traits, Positive Emotions

o       Optimists tend to emphasize the positive, see the glass as “half full” rather than “half empty,” and believe that things will turn out well.

o        Pessimists, by contrast, emphasize the negative; for them, the glass is always half empty and the future uncertain.

o       Optimists are less likely to feel helpless or depressed, adjust better to negative life events than do pessimists, and show better general mental health than pessimists.

o       Optimists may appraise events in such a way that negative emotions are less likely and positive emotions more likely.

o       Believing that you have some control over situations in life, especially traumatic situations, can improve your psychological health.

§         People who believe they have some control over their illness—in spite of medical evidence to the contrary—are happier and less stressed than less optimistic people with the same diseases.

o       Positive emotions may facilitate recovery from the physiological effects of negative emotions. They seem to help the body return to a state of calmness.

o       Resilient people (those who are more flexible and able to bounce back from difficult situations) experience quicker recovery from stress-induced cardiovascular arousal.

Finding Meaning

o       Perhaps the key to psychological health is to be open enough to notice the other things going on in life, even in the midst of tragedy.

o       Positive psychological traits and states play a big role in whether people are able to find meaning in stressful and tragic events.


Psychology in the Real World: Effects of Chronic Stress On Aging

Nature-Nurture Pointer: Stress makes your cells age faster.

·         Selye believed that the physiological effect of long-term stress is a wearing out or wearing down of the body, which makes the person more vulnerable to illness (which is the exhaustion stage).

·         Elissa Epel and her colleagues examined indicators of cellular aging in healthy women who were biological mothers of either normal or chronically ill children. The mothers reported on the amount of stress they perceived in their daily lives, using a standard questionnaire.

·         The researchers derived indicators of cellular aging from tests on blood samples collected from each woman.

o       In particular, they examined the telomeres (the parts of the chromosome involved in replication during cell division) in the DNA of certain white blood cells.

o       With age, telomeres shorten; moreover, the activity of telomerase, an enzyme that protects telomeres, decreases with age. Both of these phenomena are good measures of aging.

·         Researchers measured stress in terms of the duration of stress and the perceived severity of stress experienced by the women.

·         They found that the more stress a woman perceived in her life, the shorter the telomeres and the lower the level of telomerase activity in her blood, conditions that imply older cells.

·         They also found a positive relationship between measures of cellular aging and the stress-relevant hormones norepinephrine and cortisol (Epel et al., 2006).



·         Psychosomatic theory deals with how emotional factors can increase the likelihood of certain disorders occurring or worsening.

·         Health psychology is the study of psychological factors related to health and illness. It includes disease onset, prevention, treatment, and rehabilitation, and involves clinical practice as well as research.

·         There are two major ways of explaining the relationship between stress and illness (note: they are not mutually exclusive):

o       The physiological reactivity model examines how sustained physiological activation associated with the stress response can affect body systems in such a way as to increase the likelihood that illness or disease occurs.

o       The health behavior approach focuses on the behaviors in which people engage, such as diet, exercise, or substance abuse, which may make them more susceptible to illness or may enhance health.

·         What is sustained physiological arousal?

o       The sympathetic branch of the ANS activates organ systems to enable an animal to respond to emergency situations. From an evolutionarily perspective, these physiological effects were advantageous because of their ability to enable a quick and efficient response.

o       The same type of emotional responses occur in daily life, in most cases without an outlet for action so the activation persists for hours or days, or is elicited repeatedly in similar situations over many years.  Under such conditions, you can become ill as a result of the recurring arousal produced by stress-related body changes.

·         One physiological manifestation of sustained arousal concerns the cardiovascular system (the heart and all the blood vessels of the body).

o       During activation of the sympathetic nervous system, heart rate and blood pressure increase.

o       In sustained physiological activation, heart rate and blood pressure remain elevated or are activated repeatedly over extended periods. Frequent blood pressure elevations can damage arteries by reducing their elasticity and increasing the likelihood of fatty buildup. These processes set the stage for heart disease.

·         Another way in which sustained stress might increase susceptibility to disease is via the effects of sustained stress on immune function. This model hinges on the fact that sustained activation of the HPA axis leads to sustained release of cortisol, which inhibits the production of certain immune cells.

o       In the short term, suppression of immune cell production makes sense, as in an emergency these immune cells might not be immediately necessary.

o       In the long term, however, immune suppression may make the person more susceptible to certain diseases.

§         Psychoneuroimmunology (PNI) is the science of how immune suppression might make the person more susceptible to certain diseases. 

Nature-Nurture Pointer: Stress hormones can change the function of the immune system, which in turn can affect areas of the brain that regulate mood.


Stress and Immune Function

·         PNI examines the relationships among the brain, thought, feeling, endocrine changes, and immune system functioning. As a discipline, it is concerned with any kind of connection between psychological processes and the immune system.

·         Connections between the CNS and immune system are bi-directional – just as stress can change immune function, certain immune changes (such as the release of chemicals called cytokines which regulate immune response) also can feedback and influence brain areas involved in mood regulation.

Overview of the Immune System

o       The human immune system defends the body against invasion by disease-causing agents (pathogens), inspects the body for cells that may take on dangerous mutations, and performs basic housekeeping functions such as cleaning up cellular debris after an injury.

o       There are two basic lines of defense:

§         Natural immunity consists of a number of inborn processes that help remove foreign substances from the body.

·         These responses typically are very quick, and they provide the first line of defense upon exposure to antigens – foreign substances that trigger an immune response.).

·         Two forms of natural immunity include phagocytosis and inflammation.

o       Phagocytosis is a process in which a white blood cell engulfs a substance and digests it or moves it to a place where it will be destroyed.

o       Inflammation is a process in which tissues are restored following injury.

§         Acquired immunity involves a number of endocrine and cellular processes that recognize specific antigens and then reproduce specialized cells or circulating proteins to fight that antigen.

·         This involves experience – an effective immune response occurs only after prior exposure to a particular antigen.

·         Acquired immune responses take longer to initiate than natural immune responses because the former involve recognition processes and duplication of cells. On subsequent exposure to a specific antigen, however, acquired immune responses can be rapid and efficient.

o       This forms the basis for how vaccination protects against disease.

·         Acquired immunity involves two classes of lymphocytes (white blood cells which control acquired immunity).

o       In response to specific antigens, B lymphocytes release antibodies into the bloodstream. Antibodies destroy antigens directly.

o       The T lymphocytes, or “T cells,” fight antigens by means of a variety of cellular processes, which is why immune processes connected with T cells are collectively known as cellular immunity.

Research on Stress, Immune Function, and Health

o       The physiological reactivity model predicts that the physiological effects of stress, when sustained over time, will eventually weaken the immune system.

o       Immunosuppression increases susceptibility to disease by reducing the body’s ability to fight invading bacteria or viruses or its ability to fight off potentially cancerous cells, or both.

o       Many studies have shown linkages between stress and numerous immune system measures, but very few have shown that these reductions actually affect susceptibility to disease.

o       Results from animal research show that a variety of stressors can weaken responses to antigens, reduce the numbers of certain immune cells, and impair immune cell functions such as responses to vaccines.

o       A few studies have manipulated stress in humans by randomly assigning people to participate in a stressful task, such as public speaking, or an emotion-evoking task, such as writing about a traumatic event.

o       The more common approach in human research relies on both acute (short-term) and chronic (long-term) naturally occurring stressors. In these studies, different measures of immunity are dependent variables (e.g., the numbers of certain lymphocytes; the toxicity of tumor-fighting cells called natural killer cells; and the quantities of chemicals that regulate lymphocytes).

o       The major finding in studies of humans is that stressors are associated with changes in various kinds of immune function but it is often difficult to know whether the observed immune changes have meaningful effects on health.

o       It appears as if it is not the situation as much as how the individual evaluates that situation that drives the stress and its effects.

Nature-Nurture Pointer:  Having plenty of quality social relationships can protect you from the common cold.


Psychological Risk Factors for Heart Disease 

·         Heart disease is the number one killer of both men and women in the United States.

·         Research on the neuroendocrine and ANS linkages between stress and the heart has identified a number of psychological risk factors for heart disease.

Type A and Anger

o       Type A Behavior Pattern (TABP) is a way of responding to challenge or stress, characterized by hostility, impatience, competitiveness, and time-urgency. This pattern of behavior has been predictive of heart disease incidence and mortality.

o       Friedman and Rosenman hypothesized that people who exhibit the TABP under provocation are at greater risk for heart disease than those who do not.

§         They developed an interview to measure Type A behavior and distinguish it from Type B behavior (a more relaxed, laid-back style).

§         Then they designed a study in which healthy people were assessed on psychological and health-related variables at some initial baseline point, and then assessed periodically over a period that spanned over 20 years.

§         They found that Type A behavior predicted the incidence of coronary heart disease, over and above such traditional risk factors as blood pressure, cholesterol, and age.

o       Twenty-two years later these participants were evaluated again. Surprisingly, Type A did not predict death from heart disease in this group.

o       Matthews et al. (1977) took a closer look at the follow-up interviews of Friedman and Rosenman’s original sample to see how each component of the Type A pattern (hostility, time urgency, competitiveness, and impatience) related to coronary outcomes. She found that hostility was the only component that predicted death from heart disease at a 22-year follow-up.

o       Williams and his colleagues (1980) measured Type A behavior, hostility, and other psychological variables in 400 patients who were about to undergo angiography. Measures of hostility positively correlated with the degree of arterial blockage in those patients, much more so than Type A behavior did. Hostility also correlates with a number of other cardiovascular conditions that are relevant to coronary health, such as blood pressure reactivity to situations that provoke anger and increases in fats in the bloodstream.

o       Hostility is an affective trait which sets a threshold for the likelihood of particular emotional responses. By this logic, hostile people would have a lower threshold for the elicitation of anger.

§         In the cardiovascular reactivity (CVR) model, hostility can increase the likelihood of heart disease through at least two different causal routes.

·         Hostility makes the elicitation of anger more likely and more frequent. Frequent episodes of anger lead to frequent cardiovascular reactivity. Over time, repeated cardiovascular reactivity sets the stage for the development of coronary artery disease.

·         It is also possible that hostility has a direct connection to how much cardiovascular reactivity certain people experience, without the need for anger elicitation.

o       Research indicates that anger affects health-relevant cardiovascular outcomes. Anger can lead to heightened and prolonged blood pressure reactivity.

§         A study of coronary patients undergoing the Type A Structured Interview found that episodes of insufficient blood supply to the muscle of the heart were more likely to occur when those patients displayed facial expressions of anger.


o       Depression, a mood disorder associated with sadness and lethargy, is associated with an increased severity of symptoms and increased risk of death from coronary heart disease.

o       A large-scale meta-analysis reported that for people with diagnosed coronary heart disease, being clinically depressed more than doubles the risk of death from the disease.

o       Chemicals involved in inflammation that present a risk for coronary heart disease are present at higher levels in people who are depressed than in others.


Research on Health-Relevant Behavior

·         People engage in behaviors that increase risk for disease or help to prevent disease. Some health behaviors are conscious lifestyle choices, such as how and what to eat or whether or not to exercise. Others may begin as conscious choices but over time become habits that have serious health implications.

·         Sometimes, when under stress, people drink, eat, smoke, or take drugs to change their mood. This is emotion-focused coping. Long-term use of some of these substances can create health problems, in some cases increasing the likelihood of major, sometimes fatal, illnesses.


o       Many smokers say that, even though nicotine is a stimulant, they have a cigarette when they are stressed because it calms them down.

§         Nicotine relaxes the skeletal muscles, however, which is probably why some people find it calming. This calming effect is one reason that smokers tend to have a cigarette when stressed – they use nicotine for emotion regulation.

o       Cigarette smoking reduces life expectancy by an average of 10 years, increases one’s risk for lung cancer more than tenfold, and triples the risk of death from heart disease in both men and women. Smoking is also a risk factor for many other cancers, stroke, lung disease, emphysema, and male impotence (USDHHS, 2004).

Drinking Alcohol

o       People often drink alcohol (a depressant) to calm down or loosen up.

o       Alcohol slows down CNS functions.

o       Drinking can cause liver damage, and severe alcoholism can lead to a serious liver condition known as cirrhosis. Heavy alcohol consumption also increases the likelihood of liver cancer and cancers of the digestive tract, not to mention an increased risk for accidents due to alcohol’s effect on motor and cognitive performance.

o       Considerable data indicate that regular but moderate alcohol consumption (one to two drinks), especially with food, may reduce the risk of coronary heart disease.

o       CONNECTION: Binge drinking can lead to sudden death. (See Chapter 6.)

Diet and Eating

o       Eating well promotes health. Eating saturated fats, such as those found in meats and dairy products, increase risk for heart disease, while other essential fats, such as those found in certain kinds of fish and nuts, may have protective effects.

o       Obesity increases a person’s risk for heart disease, high blood pressure, adult-onset diabetes, and certain cancers (McTiernan, 2005).

o       Eating and Stress

§         Stress increases eating and, in turn, eating reduces stress reactivity in the HPA axis.

§         When people eat in response to stress (especially sugary foods), reward pathways in the brain are stimulated. These areas release endorphins that make people feel better. So people eat under stress because they get a “good feeling” reward—like a drug high—from the brain.  This makes it likely they will continue to do such eating.

§         Stress-induced eating is risky, as it increases fat in the abdominal area (compared to other places), which is a predictor of heart disease in men and women.

o       Eating Disorders

§         People diagnosed with anorexia nervosa cannot maintain 85% of their ideal body weight for their height, and have an intense fear of eating and a distorted body image. Moreover, they do not recognize that they are unusually thin or that they have an eating disorder.

§         A person suffering from bulimia nervosa is prone to binge eating and feeling a lack of control during the eating session. Binge eating involves eating much more food in one seating than the average person would.  The person regularly engages in purging behaviors (e.g., self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise) in order to prevent weight gain.

§         Women who develop eating disorders show higher physiological reactivity to stress, may have a genetic predisposition to the disease, have demonstrated a proneness to anxiety, depression, and low self-esteem, are highly conscientious, introverted, and less open to new and novel situations.


o       Besides not smoking, one of the best things you can do for your health is exercise regularly. It can reduce the risk of heart disease, stroke, and certain types of cancer.

o       Exercise helps keep diabetes under control and also slows the rate of bone loss in older women.

o       Moderate exercise, even as little as walking 20-25 minutes a day 3 or 4 times per week, can extend life by 3 to 4 years.

o       Exercise offers a healthy way to regulate mood (it reduces anxiety and depression).

Nature-Nurture Pointer: Physical exercise causes new neurons to grow in brain areas devoted to learning and memory.

§         Exercise seems to grow new neurons (neurogenesis) in the hippocampus, the area of the brain most involved in learning and memory.

Meditation for Stress Reduction

o       CONNECTION: Mindfulness meditation can improve well-being, cognition, and brain function. (See Chapter 6.)

§         Mindfulness meditation involves both paying attention to the present moment and being aware that everything that may arise in one’s mind, be it a thought, an emotion, or a sensation, will eventually fade away.

§         The meditator is trained to note experiences as they occur, without clinging to or ascribing value to them. These skills allow one to keep thoughts and emotions in perspective and help prevent an unhealthy obsession with negative emotions.

o       Research by Kabat-Zinn and his colleagues has examined the effectiveness of a program called Mindfulness-Based Stress Reduction (MBSR) for treating a variety of physical and psychological conditions.

§          MBSR training reduces self-reported pain and pain-related behaviors in people suffering from chronic pain.

§         MBSR training also significantly reduces anxiety, depression, and fear in people who have various types of anxiety disorders.

o       Mindfulness training also improves the rate of skin healing in people with psoriasis.


Breaking New Ground: Psychological Processes and the Immune System

·         See separate “Breaking New Ground” section for detailed explanation.


Making Connections in Stress and Health: The Health Psychology of HIV and AIDS

  • See separate “Making Connections” section for detailed explanation.





acquired immunity: endocrine and cellular processes that recognize specific antigens and then reproduce specialized cells or circulating proteins to fight that antigen.

adrenal-medullary system: one of the major neuroendocrine pathways stimulated when we experience a stressful event; the hypothalamus sends instructions to the brain stem to activate sympathetic neurons.

alarm stage: the part of the general adaptation syndrome that is the body’s emergency response to a threat, when all of the body’s resources respond.

allostasis: explanation for the body’s dynamic way of responding to the world in which the body achieves stability through change.

anorexia nervosa: an eating disorder in which people cannot maintain 85% of their ideal body weight for their height, and have an intense fear of eating and a distorted body image.

bulimia nervosa: an eating disorder characterized by binge eating and feeling a lack of control during the eating session.

cardiovascular system: bodily system that consists of the heart and all the blood vessels of the body.

cardiovascular reactivity (CVR) model: hypothesis that hostility can increase the likelihood of heart disease through at least two different causal routes.

catecholamines: hormones that control ANS activation.

cellular immunity: the immune response that occurs when the T-lymphocytes (T cells) fight antigens by means of a variety of cellular processes instead of by releasing antibodies.

coping: act of dealing with or managing stress or emotions, consciously or unconsciously.

cortisol: the stress hormone; the primary glucocorticoid produced by the body; it ensures that the body gets enough fuel.

emotional disclosure: way of coping with stress that involves unburdening, through writing or talking about the situation.

emotion-focused coping: way of dealing with stress that aims to regulate the experience of distress.

exhaustion stage: the part of the general adaptation syndrome when all resources for fighting the threat have been depleted and illness is more likely.

general adaptation syndrome (GAS): as defined by Hans Selye, a generalized, nonspecific set of changes in the body, composed of three stages: alarm, resistance, and exhaustion.

glucocorticoids: hormones responsible for maintaining the activation of physiological systems during emergencies.

health psychology: the study of psychological factors related to health and illness.

health behavior approach: explanation for illness or health that focuses on the behaviors people engage in, such as diet, exercise, or substance abuse.

hypothalamic-pituitary-adrenal (HPA) axis: a major neuroendocrine pathway relevant to the stress response and consisting of the hypothalamus, pituitary gland, and the adrenal cortex.

immunosuppression: condition in which susceptibility to disease is increased because the body’s ability to fight invading pathogens or its ability to kill potentially cancerous cells, or both, is reduced.

inflammation: a process in which tissues are restored following injury.

natural immunity: form of immunity that is the first response to antigens and includes phagocytosis and inflammation.

neuroendocrine system: the hormonal systems involved in emotions and stress.

norepinephrine: a neurotransmitter that activates the sympathetic response to stress, increasing heart rate, rate of respiration, and blood pressure in support of rapid action.

primary appraisal: assessment made upon first encountering a situation in the environment; an appraisal made—often very quickly—in terms of what the situation means for the individual.

problem-focused coping: way of dealing with stress that aims to change the situation that is creating stress.

psychological reactivity model: explanation for how the stress response leads to an increased likelihood of illness or disease.

Psychoneuroimmunology (PNI): the science of how psychological factors lead to immune suppression that might make a person more susceptible to certain diseases. 

psychosomatic theory: the idea that emotional factors can lead to the occurrence or worsening of illness.

resistance stage: the part of the general adaptation syndrome that is an extended effort by the body to deal with a threat.

secondary appraisal: assessment of the resources available to cope with stress.

stress: condition that occurs when a situation that elicits a strong emotional response overwhelms a person’s perceived ability to meet the demands of that situation.

stressors: events related to the experience of stress that push people to their limits of control and capability.

Type A Behavior Pattern: a way of responding to challenge or stress, characterized by hostility, impatience, competitiveness, and time-urgency; predictive of heart disease and mortality.





What is Stress?

CONNECTION: Like stress, emotions are generated by our appraisals of events in life. (See Chapter 11.)

  • Discussion: Ask students how they would feel if their new roommate declared that they were going to throw a party.  For some students, this is cause for excitement!  They love parties; they always have fun and meet new and interesting people.  They can’t wait to co-host.  For others, this brings a feeling of dread.  They are always awkward at parties and they don’t want to take financial responsibility to help. They don’t want people going through their stuff.  The amount of stress they feel as a result of this announcement is also different.  Some feel stress at the task at hand.  Others would say “your party, your problem.”  Some students may feel stress at the social implications, while others are at ease.  In all these examples we see the interplay between interpretation of the situation and experience.  Ask students for other examples where they may see these differences.

CONNECTION: The sympathetic branch of the ANS activates the body; the parasympathetic branch calms the body. Both branches play a role in stress and emotion. (See Chapter 3.)

  • Example: Ask students how they feel when they are driving and someone cuts them off in traffic and they almost crash. Their heart pounds, their palms sweat, and it takes a few minutes for their body to return to a calm state.  The sympathetic is responsible for the panicked sensation and the parasympathetic is responsible for the return of the body to a resting state. A mnemonic device you can provide here is the sympathetic nervous system reacts because it has “sympathy” for you being in a bad situation, while the parasympathetic acts like a parachute to slow the body back down.
  • Suggested Activity: Students were just reminded of this issue in Chapter 11 as well so it shouldn’t take much to jog their memory.  Show them the following Brinks Home Security Commercial:  Ask them to interpret the commercial from both the homeowner’s and burglar’s perspective.  When is sympathetic nervous system active?  When is the parasympathetic nervous system active?

CONNECTION: Do you think an ethics review board would allow Style to conduct his research on extreme stressors in animals today? (See Chapter 2.)

  • Discussion: Remind students that IRBs today have strict policies for animal participants.  Ask them if they feel this research meets those criteria.  If not, how would they suggest Style’s theories be tested ethically?

CONNECTION: The concept of homeostasis is key to drive theories of motivation. (See Chapter 11.)

  • Suggested Website: This Heart Helps – Stress and Health (offers some examples of the interplay between stress and homeostasis):

CONNECTION: The hippocampus, located deep inside the brain, is critical for memory formation. (See Chapter 3 and Chapter 7.)



CONNECTION: Emotion regulation is another term for the strategies we use to alter our emotional state and is similar to emotion-focused coping. (See Chapter 11.)

  • Discussion: Ask students which emotion-focused coping strategies they use most often and which are most effective. Ask them how these strategies are altered in emotional regulation (the cognitive and behavioral efforts people use to modify their emotions) discussed in Chapter 11.


Breaking New Ground: Psychological Processes and the Immune System

CONNECTION:  Conditioned taste aversion is a type of learning similar to what happened when Pavlov’s dogs learned to salivate to the sound of a bell (classical conditioning). (See  Chapter 8.)

  • Discussion: Unlike other types of classical conditioning, taste aversion generally only requires one trial before we see the conditioned response.  Ask students why, evolutionarily, this would be true.  Relate their answers to Ader’s research.

For fun, you can also ask students what foods they have developed taste aversion toward.


How Stress and Coping Affect Health

CONNECTION: Binge drinking can lead to sudden death. (See Chapter 6.)

  • Suggested Website: U.S. Department of Human Services - Binge drinking in Adolescents and College Students:  This site offers some interesting statistics about college students and their drinking habits.  It might be a good jumping-off point for discussion.

CONNECTION: Mindfulness meditation can improve well-being, cognition, and brain function. (See Chapter 6.)

  • Suggested Website: The following site has some student-friendly information on meditation in general, how to meditate, its effects on the body, its effect on stress, and how using meditation as a coping tool compares to other stress-coping strategies:



  • HIV enters the bloodstream and latches onto T lymphocytes, inserts its own genetic information into that cell, and then turns the lymphocyte into a HIV replication factory. If untreated, it wipes out the infected person’s cellular immunity, making him or her vulnerable to many kinds of infections.
  • AIDS is the disease that results from living with such an extremely deficient immune system. A host of irritating infections may characterize it; ultimately, the victim may die of rare forms of pneumonia or cancer.
  • New drug treatments for HIV, however, have transformed it from a death sentence into a chronic, manageable disease for many people.
    • Living with the human immunodeficiency virus (HIV) is a serious challenge, though, involving enormous stressors such as managing the symptoms of a chronic illness, dealing with the threat of death, and carrying out a complex treatment regimen.
    • Those who care for people suffering from AIDS also endure the extreme stress of caring for loved ones who are dying.
  • In the early to mid-1990s, Folkman and her colleagues (1997) interviewed caregivers of men dying with AIDS. Many of the caregivers were themselves infected with HIV.
    • Some of the caregivers managed to find beauty or meaning in the details of daily life in spite of the stress of caring for a partner who was dying of AIDS.  That is, they managed to find a source of positive emotion.
      • This is a coping strategy that may provide mental and physical health benefits, as we know that positive emotions can alleviate negative emotional arousal.
  • Choosing to use a particular coping strategy in times of stress is also an indicator of coping ability.
    • Reappraisal, especially reframing a situation in a positive light, is an adaptive coping strategy in chronic stress situations.
    • Research shows that those coping with the loss of a partner to AIDS found that engaging in reappraisal correlated with increases in positive mood.
  • The physiological reactivity model would predict that people with HIV who experienced greater distress might be more vulnerable to disease progression than people who experienced less distress.
    • Research has reported that relatively happy men infected with HIV show slower disease progression.
    • Research has also found that depression appears to alter the functioning of certain T cells in both men and women infected with HIV.
    • Chronic depression increases the risk of mortality in men infected with HIV.
  • One longitudinal study found that psychological factors in men and women infected with HIV (e.g., baseline self-reports of stress, depression, hopelessness, and avoidant coping) predicted significant reductions in the kinds of T-lymphocytes that are most dramatically targeted by HIV.
    • More stressful life events, more depressive symptoms, and less social support all correlated with a faster progression to AIDS in gay men infected with HIV.
  • Faster disease progression is also associated with denial as a form of coping and with less satisfactory social support.




Psychology in the Real World: Effects of Chronic Stress On Aging

Nature-Nurture Pointer: Stress makes your cells age faster.

  • Discussion:  Ask students what physical changes in their appearance they notice about themselves when they are under stress.  Ask how they recognize stress in their friends and loved ones.


How Stress and Coping Affect Health

Nature-Nurture Pointer: Stress hormones can change the function of the immune system, which in turn can affect areas of the brain that regulate mood.

  • Discussion: You may want to point out to your students that one example of this can be found in victims of PTSD, particularly those who have been the victims of long-term abuse (e.g., battered women, prisoners of war). The thinking goes that due to extended periods of high levels of cortisol, the individual’s level of cortisol becomes so heightened that the parasympathetic nervous system can no longer do its job. See for more information.
  • Discussion: Research has shown that high cortisol levels for extended periods of time suppress the immune system. Why? Cortisol gets the body ready for “fight or flight” and thus, everything else moves to the back burner. See: for a review of some of the literature.      

Nature-Nurture Pointer:  Having plenty of quality social relationships can protect you from the common cold.

  • Discussion:  Have students think about the last time they got a cold.  What was going on in their lives?  Was there stress from school, work, their romantic relationships, and their friendships?  Was it when the first went away to college? Often these events are tied together. 

Nature-Nurture Pointer: Physical exercise causes new neurons to grow in brain areas devoted to learning and memory.

  • Discussion: This is a good time to bring up the concept of epigenisis we discussed back in Chapter 3. For example, you go to the gym and exercise, and your body releases proteins in response to the activity. These, in turn, change the way your brain operates so the next time you go to work out, your brain is actually different than the time before. Another example is that after your lecture on a given day, students’ brains are actually different.
  • Suggested Sites: A good article on how exercise impacts neural growth:  

Breaking New Ground: Psychological Processes and the Immune System

  • For centuries, it was believed that nerves and the brain worked as a general structure, with little to no specific brain region performing specific tasks.
  • With the general adaptation syndrome, Hans Selye provided a framework for thinking about how stress might make the body vulnerable to disease, and he suggested that this vulnerability might be due to the effects of stress on the immune system.

 Immune System as an Autonomous Defense System

·         The job of the immune system is to defend the body against foreign substances.

·         Before the 1970s, the prevailing view was that the immune system operated independently of the central nervous system (i.e., the immune system was invulnerable to thoughts, feelings, and stress).

·         Even though most physicians believed that stress can make people sick, or at least sicker, they did not consider it physiologically possible for psychological conditions to have any effect on the immune system.

Connecting the Brain and the Immune System

·         Robert Ader paired a chemical that induces nausea with saccharine water to create taste aversion to the saccharine water. He noticed that the rats exposed to a lot of saccharine water after having learned to associate it with nausea were dying.

·         Ader remembered that the toxin he was using to induce nausea also happened to be an immunosuppressant (something that suppresses immune system function). He reasoned, in addition to learning to avoid saccharine water, the rats were acquiring conditioned immunosuppression from the repeated pairing of the saccharine solution with the immunosuppressant.

o       CONNECTION:  Conditioned taste aversion is a type of learning similar to what happened when Pavlov’s dogs learned to salivate to the sound of a bell (classical conditioning). (See Chapter 8.)

·         Ader and Cohen went on to classically condition nausea or “illness-induced” taste aversion in an experimental group by pairing saccharine water with injections of the immunosuppressant.

o       They created two control groups: a group that was injected with a placebo around the time they drank saccharine water (which served as a control for the stress-inducing effects of injection in the absence of conditioning) and a group that received the immunosuppressant and plain water (a nonconditioning control group).

o       They reintroduced the conditioned stimulus (saccharine) and then introduced an antigen (substance foreign to the body, in this case sheep blood cells) into the bloodstreams of all the rats.

§         In healthy animals, exposure to a foreign substance like this should create certain immune cells to release chemicals called antibodies.

§         If immune suppression had been conditioned to the taste of saccharine water, the taste of saccharine water should impair the antibody response to the antigen.

o       They found that the rats that had been conditioned to avoid saccharine via the immunosuppressant showed a much weaker antibody response to the sheep blood cells than did rats that had been injected with the placebo.

The Birth of Psychoneuroimmunology

·         By demonstrating that one could classically condition the suppression of an antibody response to an antigen, Ader and Cohen had shown that there must be connections between the CNS and the immune system.

·         In the late 1970s and early 1980s, scientists discovered that the ANS is linked to immune system structures such as the thymus gland, and that immune cells have receptors for and can produce certain stress.

·         This work provided behavioral and biological evidence for the notion that psychological processes and immune processes interact.




Additional Discussion Topics

1.      Ask students to imagine the most stressful event in their lives over the past 6 months.  What was it?  How did it feel (i.e., what did the stress feel like)?  How did they get through it (i.e., how did they cope)?

  1. Ask students to describe the physical sensation of stress.  Then ask them to focus on the emotional feelings that accompany stress.  Finally, ask them about the interaction between the two.  The text discusses final exam week – there is cognitive and emotional stress here that can lead to physical ailments.  Some other examples you can use are roommate stress, romantic relationship stress, moving stress, and the stress they felt when applying for college.
  2. Is stress adaptive? You may want to discuss with students if they think there is an adaptive values to stress. What does it do that’s good and helpful? For example, on the next exam, should they have some stress? What if they had none? Would they even study? 
  3. Students sometimes find it difficult to understand how nicotine (which calms people down) is a stimulant, while alcohol (which seems to liven people up) is a depressant.  Explain how the drugs work on the body.  With alcohol, for example, the CNS is depressed so that their normal social inhibitions are relaxed, leading to more outgoing behaviors.  Nicotine activates the sympathetic nervous system, increasing heart rate and blood pressure, but it also relaxes the skeletal muscles. You might also poll the smokers in the room and ask them when they smoke – it is either to calm them down or wake them up.  This shows the interaction between the person and their situation (the drug).  You can take that opportunity to discuss the risks of that habit with your class.

Finally, you can discuss the irony that trying to quit smoking can lead to stress that can lead to the desire to keep smoking (see for more information).

  1. Ask students how their eating habits change with stress (e.g., if there is a hurricane, a problem with a family member or their relationship partner, or if it’s finals week).  Do they hit the fridge or do they go on a diet?  If they hit the fridge, what foods do they go after?  Vegetables and meats or chips, sweets, and carbs?  Explain why some foods are “comfort foods” and the risks involved with these eating patterns.
  2. This is a good time to discuss incurable chronic health conditions and their effect on stress levels, not only for the person with the disease but also family, friends, and caregivers. The book talks about HIV in particular, but clearly the same issues can be applied easily to any long-term incurable condition (e.g., cancer, diabetes, herpes, etc.). Keep in mind that many folks have difficulty adjusting to a diagnosis, as may their loved ones. This may actually even have greater impact on family, friends, and caregivers, as they may feel that “they have to be strong” for their loved one.



  1. Have students complete Holmes and Rahe’s Social Readjustment Rating Scale (SRRS)
    at  You can use the CPS clickers and have them enter their score for polling purposes.  You can also use this as a paper by having students then evaluate the values assigned to each major life event.  Ask them if they think the values accurately represent different stressors.  Why or why not?  You can also ask them if they think that the value of each stressor should reflect things like gender, age, sexual orientation, etc.
  2. Have students keep a journal starting up to a week before you cover this unit or as you cover this unit.  Each night they should write down their daily stresses/hassles.  They should monitor their stress levels throughout the day and the week.  They should discuss how they coped with each stress and link that coping strategy to one of Lazarus and Folkman’s (1984) categories.
  3. Have your university’s student health department come in and give a presentation on safe sex and the myriad sexual diseases that are incurable. You may also want to contact your university’s mental health or counseling department and have them come by and talk with students about stress.
  4. Have students watch Born on the 4th of July (1989) (an R rating) or Steel Magnolias (1989) (a PG rating) and write a paragraph on the toll stress takes on the individuals portrayed in the movie.
  5. Have students go to and take the Locus of Control & Attribution Style Test - Revised. This gives you the opportunity to discuss the role that LOC has on explanatory styles and thus, resiliency in the face of negative events occurring in your world.


Suggested Films

1.      NOVA, Dying to be Thin:

  1. NOVA, Keep the Weight Off (site and video):
  2. Health Matters – Stress Management (using MBSR):
  3. A clip from Discovery channel on bulimia nervosa:
  4. A Health Matters 30minute clip on PTSD:
  5. Adaptive value of stress: The Science of Stress Physiology Emotions Fight Flight:
  6. Diana Schwarzbein, M.D. talking about Adrenal Gland Burnout:
  7. How the Body Works : The Adrenal Cortex and Medulla:
  8. Coping With Stress - Stress Eating and Premature Aging:
  9. John Gray: How Men and Women Cope with Stress Differently:


Suggested Websites

  1. John Pennebaker’s homepage:
  2. Mindfulness-Based Stress Reduction:
  3. National Mental Health Information Center’s page for eating disorders:
  4. Teen Source eating disorder hotline links (you may want to make this available for your students in a PPT or online):
  5. Mayo Clinic article on how exercise lowers depression:
  6. Here is a stress handout from the University of Iowa’s Counseling Center:
  7. NIH site on stress and health:
  8. BBC site on stress and health:
  9. A coping with stress tip sheet from Mental Health America:
  10. American Heart Association’s site on stress and heart disease:


Suggested Readings

Antonovsky A. (1979). Health, Stress, and Coping. San Francisco: Jossey-Bass Publishers.

Carver, C.S., Scheier, M.F., & Weintraub, J.K. (1989). Assessing coping strategies: A theoretically based approach. Journal of Personality and Social Psychology, 56, 267-283.

Chan, C., Tso, I.F., Ho, R.T.H., Ng, S.M., Chan, C.H.Y., Chan, J.C.N., Lai, J.C.L., & Evans,

P.D.  (2006). The effect of a one-hour Eastern stress management session on salivary cortisol. Stress and Health, 22, 45-49.

Cohen, F., Kearny, K.A., Zegans, L.S., Kemeny, M.E., Neuhaus, J.M., &

Rotter, J.B. (1966). Generalized expectancies for internal versus external control of reinforcement. Journal of Educational Research, 74(3), 185-190.

DeGood, D.E. (1975). Cognitive control factors in vascular stress responses. Psychophysiology,

12, 399-401.

Heina, A., et. al. Relationship between cortisol and serotonin metabolites and transporters in alcoholism (correction of alcolholism). Pharmacopsychiatry 35.4 (2002):127-34.

Houston, B.K. (1972). Control over stress, locus of control, and response to stress. Journal of Personality and Social Psychology, 21, 249-255.

Manuck, S.B, Harvey, L.H, Lechleiter, S.L,, & Neal, K.S. (1978). Effects of coping on blood pressure responses to threat of aversive stimulation. Psychophysiology, 15, 544-549.

Pennebaker, J.W. (1997). Opening up: The Healing Power of Expressing Emotions,

revised edition. New York: Guilford Press.

Pennebaker, J.W. (Ed.) (1995). Emotion, Disclosure, and Health. Washington, DC:

American Psychological Association.

Peterson, C., Seligman, M.E.P., & Vaillant, G.E. (1988). Pessimistic explanatory style is a risk

factor for physical illness: A thirty-five- year longitudinal study. Journal of Personality and Social Psychology, 55, 23-27.

Slatcher, R.B. & Pennebaker, J.W. (2006). How do I love thee? Let me count the words: The social effects of expressive writing. Psychological Science, 17, 660-664.

Schooler, C. (1987).  Psychological effects of complex environments during the life span: A review and theory. Schooler, C. & Schaie, K.W. (Eds). Cognitive functioning and social structure over the life course (24-49). Norwood, NJ: Ablex Publishing Co.

Scheier, M.F. & Carver, C.S. (1985). Optimism, coping, and health: Assessment and implications of generalized outcome expectancies. Health Psychology, 4, 219-247.

Scheier, M.F. & Carver, C.S. (1992). Effects of optimism on psychological and physical well-being: Theoretical overview and empirical update. Cognitive Therapy and Research, 16, 201-228.

Schultz, R., Heckhausen, J., & O’Brian, A.T. (1994) Control and the disablement process in the elderly. Journal of Social Behavior and Personality, 9, 139-152.

Taylor, S.E., & Aspinwall, L.G. (1990). Psychological aspects of chronic illness. In G.R. VandenBos & P.T. Costa, Jr. (Eds.), Psychological aspects of serious illness (3-60). Washington, DC: American Psychological Association.

Wallston, K.A., Wallston, B.S., & DeVellis, R. (1978). Development of the multidimensional Health Locus of Control Scales. Health Education Monographs, 6, 161-170.