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PART IV. Stress Management

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Stress and Performance Seymour Levine Stanford University School of Medicine

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page ~ The literature concerning stress is extensive and complex, extending through fields as varied as clinical applied psychology, anthropology, sociology, psychosomatic medicine, industrial relations, and epidemiology. Not included in this list are, of course, the extensive studies dealing with the biochemical and physiological of the responses to stress. These responses have been involved in mechanisms as basic as immunological function, metabolic function, and fundamental psychological processes, such as memory and learning. Since one of the primary problems in stress research is conceptual, and this problem takes many forms, there is a great deal of confusion in the field. Because stress researchers lack a common vocabulary, each writer must define his/her own terms, and the reader must scrutinize each article carefully in order to understand the writer's vocabulary. The lack of a uniform and consistent vocabulary is a substantial impediment to progress and adds materially to the confusion in the field. Although the term "stress" is used throughout the literature, it is apparent that this term has multiple meanings, depending upon the particular field in which the concept is being investigated. Within the context of this report, we shall attempt to use one set of operational definitions to define stress, and at least to be consistent with our own definitions of the primary psychological variables that induce many of the profound long-term effects commonly attributed to stress. Stress can be approached from a purely behavioral perspective, and it effects studies on primarily behavioral outcomes. However, stress has also been viewed predominantly as a physiological and psychosomatic process, and the outcomes arestudies on either pathophysiological processes or basic biological processes. This report, however, will focus on an integration of these two perspectives and present a psychobiological view of stress.

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Page 3 It is important to note that, historically, the concept of stress has been predominantly implicated with changes in the endocrine systems. Initially, the changes were specifically related either to increased secretion of catecholamines or to activation of the pituitary-adrenal system. The problems are best illustrated by examining the concept of stress beginning with Selye's (1936) early work in which he defined a general adaptation syndrome (GAS) in rodents. This nonspecific response occurred after diverse noxious agents, such as exposure to cold, surgical injury, spinal shock, and muscular exercise. The essential argument was that the response did not depend upon the type of agent that produced it; rather, like inflammation, it was deemed as nonspecific. GAS was divided into three stages: an alarm reaction, a stage of resistance, and a stage of exhaustion. The initial stage included activation of the pituitary-adrenal system and eventually resulted in adrenal hypertrophy, thymicolymphatic involution, and gastric ulceration if the noxious stimuli persisted. If the response to the aversive situation was sustained, physiological resistance ultimately developed, and it was hypothesized that stressed subjects would enter a third stage--exhaustion--which occurred 1-3 months after the initial exposure. Problems with this view have occurred at several levels. First, there was an early emphasis on the physical and chemical aspects of the stressful stimuli, and we now know that psychosocial stimuli are also potent elicitors of the stress response. Second, Selye has received much criticism for the "nonspecificity" view because, with modern hormone assays, it is now possible to detect differential endocrine responses to certain stimuli. Further, the importance of the final stage of exhaustion has been questioned. Diseases due to exhaustion of this syndrome are rare, and, with the exception of a few animal models (e.g.,

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Page 4 intruders in wild rat colonies ), have not been demonstrated as a response deco psychosocial stimuli (Allen, 1972). Moreover, a number of physicians have studied moribund patients and have found that adrenal exhaustion did not occur even at death. Rather, there is usually increased adrenal output immediately before and after death (Sandberg et al., 1956~. The dramatic picture described by Selye is emphatically different from the present day concept of stress in the lay literature, which includes the daily troubles and anxieties of commuters and executives. The broader use of the term has resulted in an urgency to reduce or eliminate stress in both personal and professional arenas, even though Selye (1974) himself has minimized the significance of this type of stress and stated that its absence occurs only after death. This paradoxical situation reveals that we do not have a clear and generally accepted definition. As a consequence, there is a serious communication problem and increasing talk about a crisis in stress research (Wolf et al., 1979). At the very least, there is a growing impatience with the present state of vagueness in an area so vitally important for issues of health and quality of life. We believe that much of the controversy over stress theory can be eliminated through clarification of the "afferent limb," that is, by focusing on the nature of the stimuli that provoke physiological responses rather than on the physiological responses themselves. This type of investigation requires an unusual integration of physiology and psychology--disciplines which have traditionally been separated--and puts the major emphasis on psychological variables.

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Page 5 One of the purposes of this report is to examine the importance of psychological variables that have been determined to have profound endocrinological consequences both in animals and humans. In fact, the major conceptual framework pervading this report is that one of the primary aspects of stressful stimuli eliciting an endocrine response is psychological in nature. This perspective is derived from Mason's (1968, 1975a,b) review of psychoendocrine research, particularly involving the pituitary-adrenal cortical system. As mentioned above, much of the early stress research had emphasized the nonspecificity of the organism's response to a wide variety of physical stressors (Selye, 1950). However, even in the 1950s, it was becoming increasingly apparent that psychological factors were importantly involved. For example, in one study, Renold et al. (1951) examined the physiological response of participants in the Harvard Boat Race. Utilizing a traditional measure of that period, the decline in eosinophils following stress, they found that eosinophils in the crew members were markedly lower 4 hours after the race. This decline could have been attributed solely to the exercise and physical strain, but the investigators also discovered that the coxswains and coaches had similar eosinophil drops, even though their stress was purely psychological. In Mason's major review of the stress literature in 1968, he pointed out that much of the prior work, including the experiments on physical stimuli, shared one important characteristic, namely, that a typical aspect of the stressful experience was exposure to novel, strange, or unfamiliar environments. Therefore, the common thread that may have explained the animals' response was the psychological dimension of the stimuli, rather than the particular physical trauma to which they had been exposed. In subsequent research, Mason (1975a,b) was able to show that when animals are exposed to the

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Page 6 stimuli in such a way that they do not experience distress or novelty, then typical stressors such as heat or fasting do not necessarily result in activation of the pituitary-adrenal system. The concept that psychological variables can activate, and inhibit, the endocrine system has subsequently received much support in experimental studies on both animals and humans. PITUITARY-ADRENAL SYSTEM Although the response to stress can best be defined as a syndrome, which includes many changes in neurochemical and metabolic processes, for the purposes of this report we will focus on the response of the pituitary-adrenal system. It is important to remember, however, that we are utilizing this as a model system. There is abundant evidence indicating that the hormone function of other endocrine systems--including insulin, growth hormone, and prolactin--can also be influenced by psychological variables. In addition, it has been demonstrated recently that the endorphins are also extremely responsive to stress. In fact, it appears that almost all of the stimuli capable of eliciting an ACTH response from the pituitary are also capable of releasing beta endorphins (Guillemin et al., 1977). There are two reasons for focusing on the pituitary-adrenal system in illness. First, there is an extensive data base showing the effects of psychological variables on the pituitary-adrenal system. Second, and perhaps more important, is the profound influence that adrenal hormones have on many basic functions related to health. There have been many attempts in recent years to resolve the issue of the primary stimuli that elicit the endocrine response, in particular pituitary-adrenal responses, which occur under conditions of stress. As Mason

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Page 7 (1975a) pointed '.Ut , when the psychologically threatening or arousing aspects of the situation were altered, classical stresses such as fasting and heat no longer activated the pituitary-adrenal system. In the case of heat, there was, in fact, a reduction in the corticoids when the mode of presentation was gradual. The importance of the rate of presentation of a particular stimulus was also demonstrated in another experiment that used a potent physiological insult to induce adrenocortical activity. Hemorrhage in the magnitude of 10 ml/kg at the rate of 6.6 ml/kg/min actively stimulates the adrenal cortex of the dog. In contrast, if the same ultimate volume of blood loss is achieved at a much-slower rate of hemorrhage (i.e., 0.3 ml/kg/min), the pituitary-adrenal system does not activate (Gann, 1969). That rapid hemorrhaging induces adrenocortical activity, while slow rates of hemorrhaging do not, once again indicates that the rate of stimulus change is one important parameter for the induction of pituitary-adrenal activity. The fact that dexamethasone blocks the pituitary-adrenal response at a high rate of hemorrhaging clearly indicates that neuroendocrine systems are involved and that the effect was not mediated peripherally. Regardless of the specific explanation that accounts for these results, their general significance cannot be underestimated. More recent studies on psychoendocrine responses have indicated further that it may be possible to use adrenal activity as a measure of specific emotional responses, rather than simply as a reflection of undifferentiated arousal (Hennessy and Levine, 1979; Mason, 1975a,b). In addition, studies on psychological stress bring out one point quite clearly; the great individual differences typically observed in response to a given stressor can best be explained in terms of cognitive mechanisms . For example, a sub, echo s perception

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Page 8 of a stressor AS Z three_, or the coping responses that are available to the subject, may well determine the physiological response. It may be insufficient, therefore, to merely describe the stimulus operations involved in producing a stressor. A psychobiological approach to understanding endocrine function cannot escape making reference to cognitive processes. In his new description of arousal theory, Berlyne (1960, 1967) provides a framework for the description of the processes by which stimulators of arousal (and thus, activators of the pituitary-adrenal response) operate. Novelty, uncertainty, and conflict are considered primary determinants of arousal. These have been labeled by Berlyne as collative factors, because in order to evaluate them, it is necessary to compare similarities and differences between stimulus elements (novelty), or between stimulus-evoked expectations (uncertainty). The basic cognitive process involved in stimulation of the pituitary-adrenal system, then, is one of comparison. To a large extent, the cognitive processes of comparison can be best understood by adding the concept of uncertainty, although there are some differences between uncertainty and novelty. Uncertaintv seems to be a major factor underlying many psychological responses. The processes involving neuroendocrine activation under conditions of uncertainty are best explained by a model elaborated by Sokolov (1960) to account for the general process of habituation. The pattern of habituation is familiar to most people. A subject is presented with an unexpected stimulus and shows an alerting reaction. Physiological components of this orienting reaction are well known--general activation of the brain, decreased blood flow into the extremities, changes in electrical resistance of the skin, and increases in both adrenomedullary and cortical hormones. If the stimulus is frequently repeated,

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Page 9 all of these reactions gradually dominion and eventually disappear, and the subject is said to be habituated. It does appear, however, that physiological responses may habituate more slowly than the observed behavioral reactions. Sokolov's model, in essence, is based on a matching sys~ce~n in which new stimuli or situations are compared with a representation in the central nervous system of prior events. This matching process results in the development of expectancies whereby the organism is either habituated or gives an alerting arousal reaction (Pribram and Helges, 1969~. Thus, the habituated organism has an internal representation of prior events with which to deal with the environment--expectancies--and if the environment does not contain any new contingencies, the habituated organism no longer responds with the physiological responses related to the alerting reaction. Activation of the pituitary-adrenal system by any change in expectancy can also be accounted for by invoking the powerful explanatory capacity of the Sokolov model. NOVELTY AND UNCERTAINTY Exposure of an animal to novelty is one of the most potent experimental conditions leading to an increase in pi~cuitary-adrenal activity. Novelty can be classified as a collative variable, since the recognition of any stimulus situation as being novel requires a comparison between present stimulus events and those experienced in the past. Increases in pituitary-adrenal activity in response to novelty have been demonstrated in humans as well as animals. For example, increased adrenocortical activity, as evidenced by elevated levels of circulating cortisol, are observed in individuals during their first exposure to procedures involved in drawing blood at a blood bank. However, if they have had

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Influence Strategies Dean G. Pruitt, Jennifer Crocker, and Deborah Hanes State University of New York at Buffalo