Stress is how your brain and body respond to a challenge or demand. When you are stressed, your body releases chemicals called hormones. The hormones make you alert and ready to act. They can raise your blood pressure, heart rate, and blood sugar levels. This response is sometimes called a "fight or flight" response.

Everyone gets stressed from time to time. There are different types of stress. It can be short-term or long-term. It can be caused by something that happens once or something that keeps happening.

Not all stress is bad. In fact, it can help you survive in a dangerous situation. For example, one kind of stress is the jolt you may feel when a car pulls out in front of you. This jolt of hormones helps you quickly hit the brakes to avoid an accident. A little short-term stress can sometimes be helpful. For example, the stress of having a deadline for school or your job may push you to get your work done on time. Once you finish it, that stress goes away.

But stress that lasts a long time can harm your health.

Everyone feels stressed from time to time, but what is stress? How does it affect your overall health? And what can you do to manage your stress?

Stress is how the brain and body respond to any demand. Any type of challenge—such as performance at work or school, a significant life change, or a traumatic event—can be stressful.

Stress can affect your health. It is important to pay attention to how you deal with minor and major stressors, so you know when to seek help.

Here are five things you should know about stress.

1. Stress affects everyone.

Everyone experiences stress from time to time. There are different types of stress—all of which carry physical and mental health risks. A stressor may be a one-time or short-term occurrence, or it can happen repeatedly over a long time. Some people may cope with stress more effectively and recover from stressful events more quickly than others.

Examples of stress include:

• Routine stress related to the pressures of school, work, family, and other daily responsibilities.
• Stress brought about by a sudden negative change, such as losing a job, divorce, or illness.
• Traumatic stress experienced during an event such as a major accident, war, assault, or natural disaster where people may be in danger of being seriously hurt or killed. People who experience traumatic stress may have very distressing temporary emotional and physical symptoms, but most recover naturally soon after.

2. Not all stress is bad.

In a dangerous situation, stress signals the body to prepare to face a threat or flee to safety. In these situations, your pulse quickens, you breathe faster, your muscles tense, and your brain uses more oxygen and increases activity—all functions aimed at survival and in response to stress. In non-life-threatening situations, stress can motivate people, such as when they need to take a test or interview for a new job.

3. Long-term stress can harm your health.

Coping with the impact of chronic stress can be challenging. Because the source of long-term stress is more constant than acute stress, the body never receives a clear signal to return to normal functioning. With chronic stress, those same lifesaving reactions in the body can disturb the immune, digestive, cardiovascular, sleep, and reproductive systems. Some people may experience mainly digestive symptoms, while others may have headaches, sleeplessness, sadness, anger, or irritability.

Over time, continued strain on your body from stress may contribute to serious health problems, such as heart disease, high blood pressure, diabetes, and other illnesses, including mental disorders such as depression or anxiety.

4. There are ways to manage stress.

If you take practical steps to manage your stress, you may reduce the risk of negative health effects. Here are some tips that may help you to cope with stress:

• Be observant. Recognize the signs of your body’s response to stress, such as difficulty sleeping, increased alcohol and other substance use, being easily angered, feeling depressed, and having low energy.
• Talk to your health care provider or a health professional. Don’t wait for your health care provider to ask about your stress. Start the conversation and get proper health care for existing or new health problems. Effective treatments can help if your stress is affecting your relationships or ability to work.
• Get regular exercise. Just 30 minutes per day of walking can help boost your mood and improve your health.
• Try a relaxing activity. Explore relaxation or wellness programs, which may incorporate meditation, muscle relaxation, or breathing exercises. Schedule regular times for these and other healthy and relaxing activities.
• Set goals and priorities. Decide what must get done now and what can wait. Learn to say “no” to new tasks if you start to feel like you’re taking on too much. Try to be mindful of what you have accomplished at the end of the day, not what you have been unable to do.
• Stay connected. You are not alone. Keep in touch with people who can provide emotional support and practical help. To reduce stress, ask for help from friends, family, and community or religious organizations.
• Consider a clinical trial. Researchers at the National Institute of Mental Health (NIMH) and other research facilities across the country are studying the causes and effects of psychological stress as well as stress management techniques.

5. If you’re overwhelmed by stress, ask for help from a health professional.

You should seek help right away if you have suicidal thoughts, are overwhelmed, feel you cannot cope, or are using drugs or alcohol more frequently as a result of stress. Your doctor may be able to provide a recommendation.

Long-term stress, or chronic stress, lasts for weeks, months, or longer. As you go about your life, your body is acting as if you're being threatened.

Causes of long-term stress include:

• Routine stress from the demands of work, school, family needs, money problems, and other daily pressures that don't stop.
• Stress from sudden, difficult changes in your life, such as divorce, illness, losing your job, or other unhappy life events that often have a long impact.
• Traumatic stress, which may happen when you're in danger of serious harm or death. Examples include being in a bad accident, a war, a flood, earthquake, or other frightening event. This type of stress can cause a long-lasting problem called post-traumatic stress disorder (PTSD).

People respond to stress in different ways. If you're stressed for a long time you may notice that you are:

• Getting sick more often than usual because stress weakens your body's ability to fight germs
• Having stomach problems or trouble digesting food
• Having trouble sleeping
• Having headaches
• Feeling sad, angry, or easily upset

When stress keeps going, your body acts as if you're always in danger. That's a lot of strain that may play a part in developing serious health problems, including:

• Depression
• Anxiety
• Heart disease
• High blood pressure
• Diabetes (high blood sugar)

It's possible to get used to the symptoms of stress and not even realize there's a problem. So when there's a lot of stress in your life, it's important to pay attention to how it affects you so you can do something about it.

The stress response consists of a coordinated but complex system of physiological reactions that are called upon as needed. These reactions are beneficial at times because they prepare us to deal with potentially dangerous or threatening situations (for example, recall our old friend, the fearsome bear on the trail). However, health is affected when physiological reactions are sustained, as can happen in response to ongoing stress.

Psychophysiological Disorders

If the reactions that compose the stress response are chronic or if they frequently exceed normal ranges, they can lead to cumulative wear and tear on the body, in much the same way that running your air conditioner on full blast all summer will eventually cause wear and tear on it. For example, the high blood pressure that a person under considerable job strain experiences might eventually take a toll on his heart and set the stage for a heart attack or heart failure. Also, someone exposed to high levels of the stress hormone cortisol might become vulnerable to infection or disease because of weakened immune system functioning (McEwen, 1998).

Physical disorders or diseases whose symptoms are brought about or worsened by stress and emotional factors are called psychophysiological disorders. The physical symptoms of psychophysiological disorders are real and they can be produced or exacerbated by psychological factors (hence the psycho and physiological in psychophysiological). A list of frequently encountered psychophysiological disorders is provided in Table.

In addition to stress itself, emotional upset and certain stressful personality traits have been proposed as potential contributors to ill health. Franz Alexander (1950), an early-20th-century psychoanalyst and physician, once postulated that various diseases are caused by specific unconscious conflicts. For example, he linked hypertension to repressed anger, asthma to separation anxiety, and ulcers to an unconscious desire to “remain in the dependent infantile situation—to be loved and cared for” (Alexander, 1950, p. 102). Although hypertension does appear to be linked to anger (as you will learn below), Alexander’s assertions have not been supported by research. Years later, Friedman and Booth-Kewley (1987), after statistically reviewing 101 studies examining the link between personality and illness, proposed the existence of disease-prone personality characteristics, including depression, anger/hostility, and anxiety. Indeed, a study of over 61,000 Norwegians identified depression as a risk factor for all major disease-related causes of death (Mykletun et al., 2007). In addition, neuroticism—a personality trait that reflects how anxious, moody, and sad one is—has been identified as a risk factor for chronic health problems and mortality (Ploubidis & Grundy, 2009).

Below, we discuss two kinds of psychophysiological disorders about which a great deal is known: cardiovascular disorders and asthma. First, however, it is necessary to turn our attention to a discussion of the immune system—one of the major pathways through which stress and emotional factors can lead to illness and disease.

Stress and the Immune System

In a sense, the immune system is the body’s surveillance system. It consists of a variety of structures, cells, and mechanisms that serve to protect the body from invading toxins and microorganisms that can harm or damage the body’s tissues and organs. When the immune system is working as it should, it keeps us healthy and disease free by eliminating bacteria, viruses, and other foreign substances that have entered the body (Everly & Lating, 2002).

Immune System Errors

Sometimes, the immune system will function erroneously. For example, sometimes it can go awry by mistaking your body’s own healthy cells for invaders and repeatedly attacking them. When this happens, the person is said to have an autoimmune disease, which can affect almost any part of the body. How an autoimmune disease affects a person depends on what part of the body is targeted. For instance, rheumatoid arthritis, an autoimmune disease that affects the joints, results in joint pain, stiffness, and loss of function. Systemic lupus erythematosus, an autoimmune disease that affects the skin, can result in rashes and swelling of the skin. Grave’s disease, an autoimmune disease that affects the thyroid gland, can result in fatigue, weight gain, and muscle aches (National Institute of Arthritis and Musculoskeletal and Skin Diseases [NIAMS], 2012).

In addition, the immune system may sometimes break down and be unable to do its job. This situation is referred to as immunosuppression, the decreased effectiveness of the immune system. When people experience immunosuppression, they become susceptible to any number of infections, illness, and diseases. For example, acquired immune deficiency syndrome (AIDS) is a serious and lethal disease that is caused by human immunodeficiency virus (HIV), which greatly weakens the immune system by infecting and destroying antibody-producing cells, thus rendering a person vulnerable to any of a number of opportunistic infections (Powell, 1996).

Stressors and Immune Function

The question of whether stress and negative emotional states can influence immune function has captivated researchers for over three decades, and discoveries made over that time have dramatically changed the face of health psychology (Kiecolt-Glaser, 2009). Psychoneuroimmunology is the field that studies how psychological factors such as stress influence the immune system and immune functioning. The term psychoneuroimmunology was first coined in 1981, when it appeared as the title of a book that reviewed available evidence for associations between the brain, endocrine system, and immune system (Zacharie, 2009). To a large extent, this field evolved from the discovery that there is a connection between the central nervous system and the immune system.

Some of the most compelling evidence for a connection between the brain and the immune system comes from studies in which researchers demonstrated that immune responses in animals could be classically conditioned (Everly & Lating, 2002). For example, Ader and Cohen (1975) paired flavored water (the conditioned stimulus) with the presentation of an immunosuppressive drug (the unconditioned stimulus), causing sickness (an unconditioned response). Not surprisingly, rats exposed to this pairing developed a conditioned aversion to the flavored water. However, the taste of the water itself later produced immunosuppression (a conditioned response), indicating that the immune system itself had been conditioned. Many subsequent studies over the years have further demonstrated that immune responses can be classically conditioned in both animals and humans (Ader & Cohen, 2001). Thus, if classical conditioning can alter immunity, other psychological factors should be capable of altering it as well.

Hundreds of studies involving tens of thousands of participants have tested many kinds of brief and chronic stressors and their effect on the immune system (e.g., public speaking, medical school examinations, unemployment, marital discord, divorce, death of spouse, burnout and job strain, caring for a relative with Alzheimer’s disease, and exposure to the harsh climate of Antarctica). It has been repeatedly demonstrated that many kinds of stressors are associated with poor or weakened immune functioning (Glaser & Kiecolt-Glaser, 2005; Kiecolt-Glaser, McGuire, Robles, & Glaser, 2002; Segerstrom & Miller, 2004).

When evaluating these findings, it is important to remember that there is a tangible physiological connection between the brain and the immune system. For example, the sympathetic nervous system innervates immune organs such as the thymus, bone marrow, spleen, and even lymph nodes (Maier, Watkins, & Fleshner, 1994). Also, we noted earlier that stress hormones released during hypothalamic-pituitary-adrenal (HPA) axis activation can adversely impact immune function. One way they do this is by inhibiting the production of lymphocytes, white blood cells that circulate in the body’s fluids that are important in the immune response (Everly & Lating, 2002).

Some of the more dramatic examples demonstrating the link between stress and impaired immune function involve studies in which volunteers were exposed to viruses. The rationale behind this research is that because stress weakens the immune system, people with high stress levels should be more likely to develop an illness compared to those under little stress. In one memorable experiment using this method, researchers interviewed 276 healthy volunteers about recent stressful experiences (Cohen et al., 1998). Following the interview, these participants were given nasal drops containing the cold virus (in case you are wondering why anybody would ever want to participate in a study in which they are subjected to such treatment, the participants were paid $800 for their trouble). When examined later, participants who reported experiencing chronic stressors for more than one month—especially enduring difficulties involving work or relationships—were considerably more likely to have developed colds than were participants who reported no chronic stressors (Figure).

Other studies have demonstrated that stress slows down wound healing by impairing immune responses important to wound repair (Glaser & Kiecolt-Glaser, 2005). In one study, for example, skin blisters were induced on the forearm. Subjects who reported higher levels of stress produced lower levels of immune proteins necessary for wound healing (Glaser et al., 1999). Stress, then, is not so much the sword that kills the knight, so to speak; rather, it’s the sword that breaks the knight’s shield, and your immune system is that shield.

Cardiovascular Disorders

The cardiovascular system is composed of the heart and blood circulation system. For many years, disorders that involve the cardiovascular system—known as cardiovascular disorders—have been a major focal point in the study of psychophysiological disorders because of the cardiovascular system’s centrality in the stress response (Everly & Lating, 2002). Heart disease is one such condition. Each year, heart disease causes approximately one in three deaths in the United States, and it is the leading cause of death in the developed world (Centers for Disease Control and Prevention [CDC], 2011; Shapiro, 2005).

The symptoms of heart disease vary somewhat depending on the specific kind of heart disease one has, but they generally involve angina—chest pains or discomfort that occur when the heart does not receive enough blood (Office on Women’s Health, 2009). The pain often feels like the chest is being pressed or squeezed; burning sensations in the chest and shortness of breath are also commonly reported. Such pain and discomfort can spread to the arms, neck, jaws, stomach (as nausea), and back (American Heart Association [AHA], 2012a) (Figure).

A major risk factor for heart disease is hypertension, which is high blood pressure. Hypertension forces a person’s heart to pump harder, thus putting more physical strain on the heart. If left unchecked, hypertension can lead to a heart attack, stroke, or heart failure; it can also lead to kidney failure and blindness. Hypertension is a serious cardiovascular disorder, and it is sometimes called the silent killer because it has no symptoms—one who has high blood pressure may not even be aware of it (AHA, 2012b).

Many risk factors contributing to cardiovascular disorders have been identified. These risk factors include social determinants such as aging, income, education, and employment status, as well as behavioral risk factors that include unhealthy diet, tobacco use, physical inactivity, and excessive alcohol consumption; obesity and diabetes are additional risk factors (World Health Organization [WHO], 2013).

Over the past few decades, there has been much greater recognition and awareness of the importance of stress and other psychological factors in cardiovascular health (Nusair, Al-dadah, & Kumar, 2012). Indeed, exposure to stressors of many kinds has also been linked to cardiovascular problems; in the case of hypertension, some of these stressors include job strain (Trudel, Brisson, & Milot, 2010), natural disasters (Saito, Kim, Maekawa, Ikeda, & Yokoyama, 1997), marital conflict (Nealey-Moore, Smith, Uchino, Hawkins, & Olson-Cerny, 2007), and exposure to high traffic noise levels at one’s home (de Kluizenaar, Gansevoort, Miedema, & de Jong, 2007). Perceived discrimination appears to be associated with hypertension among African Americans (Sims et al., 2012). In addition, laboratory-based stress tasks, such as performing mental arithmetic under time pressure, immersing one’s hand into ice water (known as the cold pressor test), mirror tracing, and public speaking have all been shown to elevate blood pressure (Phillips, 2011).

Are You Type A or Type B?

Sometimes research ideas and theories emerge from seemingly trivial observations. In the 1950s, cardiologist Meyer Friedman was looking over his waiting room furniture, which consisted of upholstered chairs with armrests. Friedman decided to have these chairs reupholstered. When the man doing the reupholstering came to the office to do the work, he commented on how the chairs were worn in a unique manner—the front edges of the cushions were worn down, as were the front tips of the arm rests. It seemed like the cardiology patients were tapping or squeezing the front of the armrests, as well as literally sitting on the edge of their seats (Friedman & Rosenman, 1974). Were cardiology patients somehow different than other types of patients? If so, how?

After researching this matter, Friedman and his colleague, Ray Rosenman, came to understand that people who are prone to heart disease tend to think, feel, and act differently than those who are not. These individuals tend to be intensively driven workaholics who are preoccupied with deadlines and always seem to be in a rush. According to Friedman and Rosenman, these individuals exhibit Type A behavior pattern; those who are more relaxed and laid-back were characterized as Type B (Figure). In a sample of Type As and Type Bs, Friedman and Rosenman were startled to discover that heart disease was over seven times more frequent among the Type As than the Type Bs (Friedman & Rosenman, 1959).

The major components of the Type A pattern include an aggressive and chronic struggle to achieve more and more in less and less time (Friedman & Rosenman, 1974). Specific characteristics of the Type A pattern include an excessive competitive drive, chronic sense of time urgency, impatience, and hostility toward others (particularly those who get in the person’s way).

An example of a person who exhibits Type A behavior pattern is Jeffrey. Even as a child, Jeffrey was intense and driven. He excelled at school, was captain of the swim team, and graduated with honors from an Ivy League college. Jeffrey never seems able to relax; he is always working on something, even on the weekends. However, Jeffrey always seems to feel as though there are not enough hours in the day to accomplish all he feels he should. He volunteers to take on extra tasks at work and often brings his work home with him; he often goes to bed angry late at night because he feels that he has not done enough. Jeffrey is quick tempered with his coworkers; he often becomes noticeably agitated when dealing with those coworkers he feels work too slowly or whose work does not meet his standards. He typically reacts with hostility when interrupted at work. He has experienced problems in his marriage over his lack of time spent with family. When caught in traffic during his commute to and from work, Jeffrey incessantly pounds on his horn and swears loudly at other drivers. When Jeffrey was 52, he suffered his first heart attack.

By the 1970s, a majority of practicing cardiologists believed that Type A behavior pattern was a significant risk factor for heart disease (Friedman, 1977). Indeed, a number of early longitudinal investigations demonstrated a link between Type A behavior pattern and later development of heart disease (Rosenman et al., 1975; Haynes, Feinleib, & Kannel, 1980).

Subsequent research examining the association between Type A and heart disease, however, failed to replicate these earlier findings (Glassman, 2007; Myrtek, 2001). Because Type A theory did not pan out as well as they had hoped, researchers shifted their attention toward determining if any of the specific elements of Type A predict heart disease.

Extensive research clearly suggests that the anger/hostility dimension of Type A behavior pattern may be one of the most important factors in the development of heart disease. This relationship was initially described in the Haynes et al. (1980) study mentioned above: Suppressed hostility was found to substantially elevate the risk of heart disease for both men and women. Also, one investigation followed over 1,000 male medical students from 32 to 48 years. At the beginning of the study, these men completed a questionnaire assessing how they react to pressure; some indicated that they respond with high levels of anger, whereas others indicated that they respond with less anger. Decades later, researchers found that those who earlier had indicated the highest levels of anger were over 6 times more likely than those who indicated less anger to have had a heart attack by age 55, and they were 3.5 times more likely to have experienced heart disease by the same age (Chang, Ford, Meoni, Wang, & Klag, 2002). From a health standpoint, it clearly does not pay to be an angry young person.

After reviewing and statistically summarizing 35 studies from 1983 to 2006, Chida and Steptoe (2009) concluded that the bulk of the evidence suggests that anger and hostility constitute serious long-term risk factors for adverse cardiovascular outcomes among both healthy individuals and those already suffering from heart disease. One reason angry and hostile moods might contribute to cardiovascular diseases is that such moods can create social strain, mainly in the form of antagonistic social encounters with others. This strain could then lay the foundation for disease-promoting cardiovascular responses among hostile individuals (Vella, Kamarck, Flory, & Manuck, 2012). In this transactional model, hostility and social strain form a cycle (Figure).

For example, suppose Kaitlin has a hostile disposition; she has a cynical, distrustful attitude toward others and often thinks that other people are out to get her. She is very defensive around people, even those she has known for years, and she is always looking for signs that others are either disrespecting or belittling her. In the shower each morning before work, she often mentally rehearses what she would say to someone who said or did something that angered her, such as making a political statement that was counter to her own ideology. As Kaitlin goes through these mental rehearsals, she often grins and thinks about the retaliation on anyone who will irk her that day.

Socially, she is confrontational and tends to use a harsh tone with people, which often leads to very disagreeable and sometimes argumentative social interactions. As you might imagine, Kaitlin is not especially popular with others, including coworkers, neighbors, and even members of her own family. They either avoid her at all costs or snap back at her, which causes Kaitlin to become even more cynical and distrustful of others, making her disposition even more hostile. Kaitlin’s hostility—through her own doing—has created an antagonistic environment that cyclically causes her to become even more hostile and angry, thereby potentially setting the stage for cardiovascular problems.

In addition to anger and hostility, a number of other negative emotional states have been linked with heart disease, including negative affectivity and depression (Suls & Bunde, 2005). Negative affectivity is a tendency to experience distressed emotional states involving anger, contempt, disgust, guilt, fear, and nervousness (Watson, Clark, & Tellegen, 1988). It has been linked with the development of both hypertension and heart disease. For example, over 3,000 initially healthy participants in one study were tracked longitudinally, up to 22 years. Those with higher levels of negative affectivity at the time the study began were substantially more likely to develop and be treated for hypertension during the ensuing years than were those with lower levels of negative affectivity (Jonas & Lando, 2000). In addition, a study of over 10,000 middle-aged London-based civil servants who were followed an average of 12.5 years revealed that those who earlier had scored in the upper third on a test of negative affectivity were 32% more likely to have experienced heart disease, heart attack, or angina over a period of years than were those who scored in the lowest third (Nabi, Kivimaki, De Vogli, Marmot, & Singh-Manoux, 2008). Hence, negative affectivity appears to be a potentially vital risk factor for the development of cardiovascular disorders.

Depression and the Heart

For centuries, poets and folklore have asserted that there is a connection between moods and the heart (Glassman & Shapiro, 1998). You are no doubt familiar with the notion of a broken heart following a disappointing or depressing event and have encountered that notion in songs, films, and literature.

Perhaps the first to recognize the link between depression and heart disease was Benjamin Malzberg (1937), who found that the death rate among institutionalized patients with melancholia (an archaic term for depression) was six times higher than that of the population. A classic study in the late 1970s looked at over 8,000 manic-depressive persons in Denmark, finding a nearly 50% increase in deaths from heart disease among these patients compared with the general Danish population (Weeke, 1979). By the early 1990s, evidence began to accumulate showing that depressed individuals who were followed for long periods of time were at increased risk for heart disease and cardiac death (Glassman, 2007). In one investigation of over 700 Denmark residents, those with the highest depression scores were 71% more likely to have experienced a heart attack than were those with lower depression scores (Barefoot & Schroll, 1996). Figure illustrates the gradation in risk of heart attacks for both men and women.

After more than two decades of research, it is now clear that a relationship exists: Patients with heart disease have more depression than the general population, and people with depression are more likely to eventually develop heart disease and experience higher mortality than those who do not have depression (Hare, Toukhsati, Johansson, & Jaarsma, 2013); the more severe the depression, the higher the risk (Glassman, 2007). Consider the following:

• In one study, death rates from cardiovascular problems was substantially higher in depressed people; depressed men were 50% more likely to have died from cardiovascular problems, and depressed women were 70% more likely (Ösby, Brandt, Correia, Ekbom, & Sparén, 2001).
• A statistical review of 10 longitudinal studies involving initially healthy individuals revealed that those with elevated depressive symptoms have, on average, a 64% greater risk of developing heart disease than do those with fewer symptoms (Wulsin & Singal, 2003).
• A study of over 63,000 registered nurses found that those with more depressed symptoms when the study began were 49% more likely to experience fatal heart disease over a 12-year period (Whang et al., 2009).

The American Heart Association, fully aware of the established importance of depression in cardiovascular diseases, several years ago recommended routine depression screening for all heart disease patients (Lichtman et al., 2008). Recently, they have recommended including depression as a risk factor for heart disease patients (AHA, 2014).

Although the exact mechanisms through which depression might produce heart problems have not been fully clarified, a recent investigation examining this connection in early life has shed some light. In an ongoing study of childhood depression, adolescents who had been diagnosed with depression as children were more likely to be obese, smoke, and be physically inactive than were those who had not received this diagnosis (Rottenberg et al., 2014). One implication of this study is that depression, especially if it occurs early in life, may increase the likelihood of living an unhealthy lifestyle, thereby predisposing people to an unfavorable cardiovascular disease risk profile.

It is important to point out that depression may be just one piece of the emotional puzzle in elevating the risk for heart disease, and that chronically experiencing several negative emotional states may be especially important. A longitudinal investigation of Vietnam War veterans found that depression, anxiety, hostility, and trait anger each independently predicted the onset of heart disease (Boyle, Michalek, & Suarez, 2006). However, when each of these negative psychological attributes was combined into a single variable, this new variable (which researchers called psychological risk factor) predicted heart disease more strongly than any of the individual variables. Thus, rather than examining the predictive power of isolated psychological risk factors, it seems crucial for future researchers to examine the effects of combined and more general negative emotional and psychological traits in the development of cardiovascular illnesses.

Asthma

Asthma is a chronic and serious disease in which the airways of the respiratory system become obstructed, leading to great difficulty expelling air from the lungs. The airway obstruction is caused by inflammation of the airways (leading to thickening of the airway walls) and a tightening of the muscles around them, resulting in a narrowing of the airways (Figure) (American Lung Association, 2010). Because airways become obstructed, a person with asthma will sometimes have great difficulty breathing and will experience repeated episodes of wheezing, chest tightness, shortness of breath, and coughing, the latter occurring mostly during the morning and night (CDC, 2006).

According to the Centers for Disease Control and Prevention (CDC), around 4,000 people die each year from asthma-related causes, and asthma is a contributing factor to another 7,000 deaths each year (CDC, 2013a). The CDC has revealed that asthma affects 18.7 million U.S. adults and is more common among people with lower education and income levels (CDC, 2013b). Especially concerning is that asthma is on the rise, with rates of asthma increasing 157% between 2000 and 2010 (CDC, 2013b).

Asthma attacks are acute episodes in which an asthma sufferer experiences the full range of symptoms. Asthma exacerbation is often triggered by environmental factors, such as air pollution, allergens (e.g., pollen, mold, and pet hairs), cigarette smoke, airway infections, cold air or a sudden change in temperature, and exercise (CDC, 2013b).

Psychological factors appear to play an important role in asthma (Wright, Rodriguez, & Cohen, 1998), although some believe that psychological factors serve as potential triggers in only a subset of asthma patients (Ritz, Steptoe, Bobb, Harris, & Edwards, 2006). Many studies over the years have demonstrated that some people with asthma will experience asthma-like symptoms if they expect to experience such symptoms, such as when breathing an inert substance that they (falsely) believe will lead to airway obstruction (Sodergren & Hyland, 1999). As stress and emotions directly affect immune and respiratory functions, psychological factors likely serve as one of the most common triggers of asthma exacerbation (Trueba & Ritz, 2013).

People with asthma tend to report and display a high level of negative emotions such as anxiety, and asthma attacks have been linked to periods of high emotionality (Lehrer, Isenberg, & Hochron, 1993). In addition, high levels of emotional distress during both laboratory tasks and daily life have been found to negatively affect airway function and can produce asthma-like symptoms in people with asthma (von Leupoldt, Ehnes, & Dahme, 2006). In one investigation, 20 adults with asthma wore preprogrammed wristwatches that signaled them to breathe into a portable device that measures airway function. Results showed that higher levels of negative emotions and stress were associated with increased airway obstruction and self-reported asthma symptoms (Smyth, Soefer, Hurewitz, Kliment, & Stone, 1999). In addition, D’Amato, Liccardi, Cecchi, Pellegrino, & D’Amato (2010) described a case study of an 18-year-old man with asthma whose girlfriend had broken up with him, leaving him in a depressed state. She had also unfriended him on Facebook , while friending other young males. Eventually, the young man was able to “friend” her once again and could monitor her activity through Facebook. Subsequently, he would experience asthma symptoms whenever he logged on and accessed her profile. When he later resigned not to use Facebook any longer, the asthma attacks stopped. This case suggests that the use of Facebook and other forms of social media may represent a new source of stress—it may be a triggering factor for asthma attacks, especially in depressed asthmatic individuals.

Exposure to stressful experiences, particularly those that involve parental or interpersonal conflicts, has been linked to the development of asthma throughout the lifespan. A longitudinal study of 145 children found that parenting difficulties during the first year of life increased the chances that the child developed asthma by 107% (Klinnert et al., 2001). In addition, a cross-sectional study of over 10,000 Finnish college students found that high rates of parent or personal conflicts (e.g., parental divorce, separation from spouse, or severe conflicts in other long-term relationships) increased the risk of asthma onset (Kilpeläinen, Koskenvuo, Helenius, & Terho, 2002). Further, a study of over 4,000 middle-aged men who were interviewed in the early 1990s and again a decade later found that breaking off an important life partnership (e.g., divorce or breaking off relationship from parents) increased the risk of developing asthma by 124% over the time of the study (Loerbroks, Apfelbacher, Thayer, Debling, & Stürmer, 2009).

Tension Headaches

A headache is a continuous pain anywhere in the head and neck region. Migraine headaches are a type of headache thought to be caused by blood vessel swelling and increased blood flow (McIntosh, 2013). Migraines are characterized by severe pain on one or both sides of the head, an upset stomach, and disturbed vision. They are more frequently experienced by women than by men (American Academy of Neurology, 2014). Tension headaches are triggered by tightening/tensing of facial and neck muscles; they are the most commonly experienced kind of headache, accounting for about 42% of all headaches worldwide (Stovner et al., 2007). In the United States, well over one-third of the population experiences tension headaches each year, and 2–3% of the population suffers from chronic tension headaches (Schwartz, Stewart, Simon, & Lipton, 1998).

A number of factors can contribute to tension headaches, including sleep deprivation, skipping meals, eye strain, overexertion, muscular tension caused by poor posture, and stress (MedicineNet, 2013). Although there is uncertainty regarding the exact mechanisms through which stress can produce tension headaches, stress has been demonstrated to increase sensitivity to pain (Caceres & Burns, 1997; Logan et al., 2001). In general, tension headache sufferers, compared to non-sufferers, have a lower threshold for and greater sensitivity to pain (Ukestad & Wittrock, 1996), and they report greater levels of subjective stress when faced with a stressor (Myers, Wittrock, & Foreman, 1998). Thus, stress may contribute to tension headaches by increasing pain sensitivity in already-sensitive pain pathways in tension headache sufferers (Cathcart, Petkov, & Pritchard, 2008).

Have you ever wondered why people who are stressed often seem to have a haggard look about them? A pioneering study from 2004 suggests that the reason is because stress can actually accelerate the cell biology of aging.

Stress, it seems, can shorten telomeres, which are segments of DNA that protect the ends of chromosomes. Shortened telomeres can inhibit or block cell division, which includes growth and proliferation of new cells, thereby leading to more rapid aging (Sapolsky, 2004). In the study, researchers compared telomere lengths in the white blood cells in mothers of chronically ill children to those of mothers of healthy children (Epel et al., 2004). Mothers of chronically ill children would be expected to experience more stress than would mothers of healthy children. The longer a mother had spent caring for her ill child, the shorter her telomeres (the correlation between years of caregiving and telomere length was r = -.40). In addition, higher levels of perceived stress were negatively correlated with telomere size (r = -.31). These researchers also found that the average telomere length of the most stressed mothers, compared to the least stressed, was similar to what you would find in people who were 9–17 years older than they were on average.

Numerous other studies since have continued to find associations between stress and eroded telomeres (Blackburn & Epel, 2012). Some studies have even demonstrated that stress can begin to erode telomeres in childhood and perhaps even before children are born. For example, childhood exposure to violence (e.g., maternal domestic violence, bullying victimization, and physical maltreatment) was found in one study to accelerate telomere erosion from ages 5 to 10 (Shalev et al., 2013). Another study reported that young adults whose mothers had experienced severe stress during their pregnancy had shorter telomeres than did those whose mothers had stress-free and uneventful pregnancies (Entringer et al., 2011). Further, the corrosive effects of childhood stress on telomeres can extend into young adulthood. In an investigation of over 4,000 U.K. women ages 41–80, adverse experiences during childhood (e.g., physical abuse, being sent away from home, and parent divorce) were associated with shortened telomere length (Surtees et al., 2010), and telomere size decreased as the amount of experienced adversity increased (Figure).

Efforts to dissect the precise cellular and physiological mechanisms linking short telomeres to stress and disease are currently underway. For the time being, telomeres provide us with yet another reminder that stress, especially during early life, can be just as harmful to our health as smoking or fast food (Blackburn & Epel, 2012).

A new study shows that stress really can give you gray hair. Researchers found that the body’s fight-or-flight response plays a key role in turning hair gray.

Your hair color is determined by pigment-producing cells called melanocytes. New melanocytes are made from melanocyte stem cells that live in the hair follicle at the base of your hair strand.

As we age, these stem cells gradually disappear. The researchers showed that stress also leads to the loss of these pigment-producing stem cells in mice.

Nerves in your sympathetic nervous system—which is responsible for the body’s fight-or-flight response—go throughout the body, including into hair follicles. The study showed that stress causes the release of the chemical norepinephrine into the follicle.

Norepinephrine affects the melanocyte stem cells living there. It causes them to rapidly turn into pigment cells and move out of the hair follicles. Without stem cells left to create new pigment cells, new hair turns gray or white.

“When we started to study this, I expected that stress was bad for the body—but the detrimental impact of stress that we discovered was beyond what I imagined,” says Dr. Ya-Chieh Hsu of Harvard University, who led the study. “After just a few days, all of the melanocyte stem cells were lost. Once they’re gone, you can’t regenerate pigments anymore. The damage is permanent.”

Simple things that improve your mental health may be helpful in managing long-term stress, such as:

• Get regular exercise. A 30-minute daily walk can help you feel better and help keep your immune system strong, so you don't get sick.
• Try relaxing activities. You could look for an app or wellness program that uses breathing, meditation, or muscle relaxation exercises.
• Get enough sleep every night.
• Avoid too much caffeine.
• Decide what you need to do now and what can wait. And focus on what you got done each day, not on what you weren't able to do.
• Ask your family or friends for support.

When you’re under stress, your body reacts by releasing hormones that produce the “fight-or-flight” response. Your heart rate and breathing rate go up and blood vessels narrow (restricting the flow of blood). Occasional stress is a normal coping mechanism. But over the long-term, stress may contribute to or worsen a range of health problems including digestive disorders, headaches, sleep disorders, and other symptoms.

In contrast to the stress response, the relaxation response slows the heart rate, lowers blood pressure, and decreases oxygen consumption and levels of stress hormones. In theory, voluntarily creating the relaxation response through regular use of relaxation techniques could counteract the negative effects of stress.

1. Relaxation techniques are generally safe, but there is limited evidence of usefulness for specific health conditions. Research is under way to find out more about relaxation and health outcomes.

2. Relaxation techniques include a number of practices such as progressive relaxation, guided imagery, biofeedback, self-hypnosis, and deep breathing exercises. The goal is similar in all: to consciously produce the body's natural relaxation response, characterized by slower breathing, lower blood pressure, and a feeling of calm and well-being.

3. Relaxation techniques often combine breathing and focused attention to calm the mind and the body. These techniques may be most effective when practiced regularly and combined with good nutrition, regular exercise, and a strong social support system.

4. Most relaxation techniques can be self-taught and self-administered. Most methods require only brief instruction from a book or experienced practitioner before they can be done without assistance.

5. Do not use relaxation techniques as a replacement for conventional care or to postpone seeing a doctor about a medical problem. Talk to your health care providers if you are considering using a relaxation technique for a particular health condition. This will help ensure coordinated and safe care.

Many of us are facing challenges that can be stressful, overwhelming, and cause strong emotions in adults and children. Public health actions, such as social distancing, can make us feel isolated and lonely and can increase stress and anxiety.

After a traumatic event, people may have strong and lingering reactions. Learning healthy ways to cope and getting the right care and support can help reduce stressful feelings and symptoms.

The symptoms may be physical or emotional. Common reactions to a stressful event can include:

• Disbelief
• Feelings of fear, shock, anger, sadness, worry, numbness, or frustration
• Changes in appetite, energy, desires, and interests
• Difficulty sleeping or nightmares, concentrating, and making decisions
• Physical reactions, such as headaches, body pains, stomach problems, and skin rashes
• Worsening of chronic health problems
• Worsening of mental health conditions
• Increased use of tobacco, alcohol, and other substances

It is natural to feel stress, anxiety, grief, and worry during traumatic events such as mass shootings, natural disasters, or pandemics. Below are ways that you can help yourself, others, and your community manage stress.

Healthy Ways to Cope with Stress

Feeling emotional and nervous or having trouble sleeping and eating can all be normal reactions to stress. Here are some healthy ways you can deal with stress:

• Take breaks from watching, reading, or listening to news stories, including those on social media. It’s good to be informed but hearing about the traumatic event constantly can be upsetting. Consider limiting news to just a couple of times a day and disconnecting from phone, tv, and computer screens for a while.
• Take care of yourself. Eat healthy, exercise, get plenty of sleep, and give yourself a break if you feel stressed out.
• Take care of your body.
  • Take deep breaths, stretch, or meditate.
  • Try to eat healthy, well-balanced meals.
  • Exercise regularly.
  • Get plenty of sleep.
  • Avoid excessive alcohol, tobacco, and substance use.
  • Continue with routine preventive measures (such as vaccinations, cancer screenings, etc.) as recommended by your healthcare provider.
  • Get vaccinated against COVID-19 as soon as possible; get a booster shot if you are age 18 or older.
• Make time to unwind. Try to do some other activities you enjoy.
• Talk to others. Talk with people you trust about your concerns and how you are feeling. Share your problems and how you are feeling and coping with a parent, friend, counselor, doctor, or pastor.
• Connect with your community- or faith-based organizations.
• Avoid drugs and alcohol. These may seem to help, but they can create additional problems and increase the stress you are already feeling.
• Recognize when you need more help. If problems continue or you are thinking about suicide, talk to a psychologist, social worker, or professional counselor.

Helping Others Cope

Taking care of yourself can better equip you to take care of others. During times of social distancing, it is especially important to stay connected with your friends and family. Helping others cope with stress through phone calls or video chats can help you and your loved ones feel less lonely or isolated.

Helping Children and Youth Cope with Stress

Children and youth often struggle with how to cope with stress. Youth can be particularly overwhelmed when their stress is connected to a traumatic event—like a natural disaster, family loss, school shootings, or community violence. Parents, caregivers, and educators can take steps to provide stability and support that help young people feel better.

Tips

Tips for Parents and Caregivers
It is natural for children to worry when scary or stressful events happen in their lives. Talking to your children about these events can help put frightening information into a more balanced setting. Monitor what children see and hear about stressful events happening in their lives. Here are some suggestions to help children cope:

• Maintain a normal routine. Helping children wake up, go to sleep, and eat meals at regular times provide them a sense of stability.
• Talk, listen, and encourage expression. Listen to your child’s thoughts and feelings and share some of yours. After a traumatic event, it is important for children to feel they can share their feelings and that you understand their fears and worries.
• Watch and listen. Be alert for any change in behavior. Any changes in behavior may be signs that your child is having trouble and may need support.
• Stressful events can challenge a child’s sense of safety and security. Reassure your child about his or her safety and well-being. Discuss ways that you, the school, and the community are taking steps to keep them safe.
• Connect with others. Talk to other parents and your child’s teachers about ways to help your child cope. It is often helpful for parents, schools, and health professionals to work together for the well-being of all children in stressful times.

Tips for Kids and Teens
After a traumatic event, it is normal to feel anxious about your safety and security. Even if you were not directly involved, you may worry about whether this type of event may someday affect you. Check out the tips below for some ideas to help deal with these fears.

• Talk to and stay connected to others. Talking with someone you trust can help you make sense out of your experience. If you are not sure where to turn, call your local crisis intervention center or a national hotline.
• Take care of yourself. Try to get plenty of sleep, eat right, exercise, and keep a normal routine.
• Take information breaks. Pictures and stories about a disaster can increase worry and other stressful feelings. Taking breaks from the news, Internet, and conversations about the disaster can help calm you down.

Tips for School Personnel
School personnel can help their students restore their sense of safety by talking with the children about their fears. Other tips for school personnel include:

• Reach out and talk. Create opportunities to have students talk, but do not force them. You can be a model by sharing some of your own thoughts as well as correct misinformation.
• Watch and listen. Be alert for any change in behavior. Are students withdrawing from friends? Acting out? These changes may be early signs that a student is struggling and needs extra support from the school and family.
• Maintain normal routines. A regular classroom and school schedule can provide a sense of stability and safety. Encourage students to keep up with their schoolwork and extracurricular activities but do not push them if they seem overwhelmed.
• Take care of yourself. You are better able to support your students if you are healthy, coping and taking care of yourself first. Eat healthy, exercise, get plenty of sleep, and give yourself a break if you feel stressed out.

Life can get challenging sometimes, and it’s important for kids (and adults!) to develop strategies for coping with stress or anxiety. This stress catcher “fortune teller” offers some strategies children can practice and use to help manage stress and other difficult emotions.

Create Your Stress Catcher

Download and print the PDF template, and then follow these steps to create your own personal stress catcher.

• Step 1. Color the stress catcher (on page 2), and cut out the square.
• Step 2. Place the stress catcher face down. Fold each corner to the opposite corner and then unfold to create two diagonal creases in the square.
• Step 3. Fold each corner toward the center of the square so that the numbers and colors are facing you. Turn over the square, and again fold each corner into the center so that the color names are visible.
• Step 4. Fold the square in half so that the color names are touching, and the numbers are on the outside. Now open it and fold it in half the other way.
• Step 5. Insert your thumb and first finger of each hand (pinching motion) under the number flaps.
• Step 6. Close the stress catcher so only the numbers show.

Use Your Stress Catcher

• Pick a number, and open and close the stress catcher that number of times.
• Next, pick a color and spell out the color name, opening and closing the stress catcher for each letter.
• Then pick a color that is visible and open that flap.
• Read what it says, and practice the coping strategy.
• This game can be played with one or two players and is a way to practice coping strategies.

Get help if you're having severe symptoms for 2 weeks or more, including:

• Trouble sleeping
• Changes in your eating that cause unwanted changes in your weight
• Troubles getting out of bed because of your mood
• Difficulty focusing your thoughts
• Losing interest in things you usually enjoy
• Not being able to do your usual daily activities

Always get help right away if stress is causing you to:

• Have thoughts of harming yourself
• Feel you can't cope
• Use drugs or alcohol more often than usual

Your health care provider may refer you to a mental health professional such as a psychologist or social worker.