1. What Is Stress?
2. Sources of Stress
   1. Stressors
   2. Life Domains
      1. Family
      2. Work
      3. School
3. Stress Responses
   1. Psychological Responses
   2. Physiological Responses
   3. Behavioral Responses
4. The Connection Between Stressors and Stress Responses
   1. Mediating Processes
      1. Appraisal
      2. Coping
   2. Moderating Factors
      1. Personality Traits
      2. Health Habits
      3. Coping Skills
      4. Social Support
      5. Material Resources
      6. Genetics and Early Family Experiences
      7. Demographic Variables
      8. Preexisting Stressors
5. Problems Associated With Stress
   1. Burnout
   2. Mental Disorders
      1. Anxiety Disorders
      2. Mood Disorders
      3. Substance-Related Disorders
   3. Physical Illnesses
      1. Immune System Suppression
      2. Cardiovascular Diseases
      3. Cancer
6. Stress Management
   1. Professional Help or Self-Help?
   2. The Process of Change
   3. Stress Management Techniques
      1. Cognitive-Behavioral Approaches
         1. Cognitive Restructuring
         2. Coping Skills Therapies
         3. Problem-Solving Therapies
      2. Relaxation
      3. Exercise
      4. Diet and Nutrition
      5. Medication

I. What Is Stress?

Stress is the combination of psychological, physiological, and behavioral reactions that people have in response to events that threaten or challenge them. Stress can be good or bad. Sometimes, stress is helpful, providing people with the extra energy or alertness they need. Stress could give a runner the edge he or she needs to persevere in a marathon, for example. This good kind of stress is called eustress. Unfortunately, stress is often not helpful and can even be harmful when not managed effectively. Stress could make a salesperson buckle under the pressure while trying to make a sales pitch at an important business meeting, for example. Moreover, stress can increase the risk of developing health problems, such as cardiovascular disease and anxiety disorders. This bad kind of stress is called distress, the kind of stress that people usually are referring to when they use the word stress.

A convenient way to think about stress is in terms of stressors and stress responses. Stressors are events that threaten or challenge people. They are the sources of stress, such as having to make decisions, getting married, and natural disasters. Stress responses are psychological, physiological, and behavioral reactions to stressors. Anxiety, depression, concentration difficulties, and muscle tension are all examples of stress responses.

The connection between stressors and stress responses, however, is not as straight forward as it may seem. Mediating processes, for instance, stand in between stressors and stress responses. Whether stressors lead to stress responses depends on mediating processes like how people appraise potential stressors and how well people are able to cope with the negative impact of stressors. Furthermore, a number of moderating factors, such as personality traits and health habits, influence the the links between stressors and stress responses. These mediating processes and moderating factors help determine whether people experience stress-related problems like burnout, mental disorders, and physical illness and are the focus of many stress management techniques that emphasize cognitive-behavioral approaches, relaxation, exercise, diet and nutrition, and medication.

II. Sources of Stress

Stressors, the sources of stress, include three types of events, referred to as daily hassles, major life events, and catastrophes. Additionally, specific types of stressors occur within certain domains in life, such as family, work, and school.

A. Stressors

Daily hassles are the little hassles or annoyances that occur practically everyday, such as having to make decisions, arguing with friends and family, trying to meet deadlines at school or work, and stepping on a piece of bubble gum that someone carelessly spitted out. Although a wide variety of daily hassles can be sources of stress, they often involve conflicts between behaviors people may or may not want to do. If someone is experiencing an approach-approach conflict, that person has to choose between two attractive alternatives, such as going on vacation or buying a new computer. If someone is experiencing an avoidance-avoidance conflict, that person has to choose between two unattractive alternatives, such as having a pet "put to sleep" or spending the money on an expensive surgical procedure for it. If someone is experiencing an approach-avoidance conflict, that person has to choose whether to engage in an activity that has both attractive and unattractive qualities, such as mowing the lawn, an activity that would result in a nice lawn but would not be enjoyable to do ^{(Miller, as cited in 99)}.

In particular, daily hassles that involve interpersonal conflicts seem to have an impact that lasts longer than does that of most other daily hassles ⁽²⁵⁾. Additionally, according to a survey of middle-aged adults ⁽⁸⁷⁾, the top ten daily hassles are as follows:

1. Concerns about weight
2. Health of a family member
3. Rising prices of common goods
4. Home maintenance
5. Too many things to do
6. Misplacing or losing things
7. Yard work or outside home maintenance
8. Property, investments, or taxes
9. Crime
10. Physical appearance

In general, major life events do not appear to be significant sources of stress ⁽¹¹⁸⁾. Accordingly, major life events generally do not tend to be related to the health problems that accompany stress ^{(96; 148)}. Under some circumstances, however, major life events can be sources of stress. Whether major life events involve positive or negative feelings, for instance, is relevant. Major life events that are positive tend to have either trivially stressful or actually beneficial effects ^{(156; 164)}, but major life events that are negative can be stressful and are associated with medical problems ⁽¹⁴¹⁾. Examples of major life events are getting married, getting divorced, and being fired from a job.

Although they do not happen very often, when catastrophes do occur, they can be tremendous sources of stress. One major type of catastrophe is natural disasters. After people are exposed to natural disasters, they are more anxious, have more bodily complaints, drink more alcohol, and have more phobias ⁽¹³⁸⁾. A group of Stanford University students who completed a survey before and after the 1989 San Francisco earthquake, for example, were more stressed afterwards than they were beforehand ⁽¹¹⁵⁾. War is another type of catastrophe. It is one of the most stressful catastrophes that you could ever endure. Between 16% and 19% of the veterans who served during Operation Desert Storm, for example, had symptoms of posttraumatic stress disorder (PTSD), such as recurrent memories, nightmares, restricted emotions, sleep disturbances, and irritability ⁽¹⁶⁰⁾. PTSD is a mental disorder (described later) characterized by the reexperiencing of stress responses associated with an earlier traumatic event like withstanding a natural disaster or being assaulted.

Compared to the impact of other types of events, the cumulative effect of daily hassles over time are probably the most significant sources of stress ^{(33; 87; 98; 174)}. An obvious reason why major life events and catastrophes are probably less significant sources of stress is that people just do not experience them as often. It is not every day that a person spends time in prison or retires from a job, for instance. Likewise, people do not have to and possibly never will face the repercussions of a nuclear war, for instance, on a daily basis.

B. Life Domains

1. Family

Specific types of stressors that family members are exposed to through their family include a lack of parent-child emotional bonding, parental workload, misbehavior of children, teenage pregnancy, lack of emotional closeness between spouses, poor communication between spouses, tension between spouses, divorce, remarriage, and maternal depression ^{(48; 64; 116)}. Additionally, a family member's job can interfere with his or her home life ⁽⁶⁴⁾.

Marital conflict is a good example of a daily hassle that is specifically related to the family. Marital conflict tends to occur when spouses come from different social and economic backgrounds and the spouse of higher status emphasizes his or her superiority. Marital conflict often occurs in the context of unequal occupational statuses, for instance ⁽¹²¹⁾.

Teenage pregnancy, particularly the unplanned pregnancy of an unmarried, teenage daughter, is a good example of a major life crisis that is specifically related to the family. Regarding teenagers who follow through with the pregnancy, this event leads to several premature role transitions, such as the teenager becoming a young mother and the mother becoming a young grandmother ⁽⁴⁸⁾. These kinds of role transitions tend to be sources of distress in the family if new mothers are still teenagers but sources of eustress if new mothers are age 20 or older ^{(30; 76)}. In cases in which teenagers terminate the pregnancy, they tend to find it especially stressful if they perceive a lack of support from their parents or the father of the child, are less sure of their decision and coping abilities beforehand, blame themselves for the pregnancy, or delay until the second trimester ⁽⁴⁾.

2. Work

The specific types of stressors that employees are exposed to in the workplace fall into four categories of demands: task demands, interpersonal demands, role demands, and physical demands ⁽¹³⁹⁾. Among these categories, work overload, boundary extension, role ambiguity, role conflict, and career development are particularly relevant stressors ⁽¹¹⁷⁾. Additionally, an employee's home-life can interfere with his or her job ⁽⁶⁴⁾.

Work overload is a good example of a daily hassle that is particularly relevant in the workplace. When employees feel overwhelmed from trying to work on more tasks than they can handle or from trying to work on tasks that are too difficult for them, they are suffering from work overload. Work overload is common after layoffs among the remaining workers who are assigned more tasks. It is also common among newly appointed managers who feel unprepared for their new, unfamiliar roles ⁽¹³⁹⁾.

Boundary extension is another good example of a daily hassle that is particularly relevant in the workplace. Some jobs, such as public relations and sales, require employees to work with people in other occupational settings. Such boundary extension can be difficult for employees, especially if it involves any of the following difficulties:

• Dealing with very diverse organizations
• Maintaining frequent and long-term relations with people in other organizations
• Interacting in complex and dynamic environments
• Not having screening mechanisms like secretaries or voice mail
• Participating in nonroutine activities
• Trying to meet demanding performance standards ⁽¹³⁹⁾

Two more good examples of daily hassles that are particularly relevant in the workplace are role ambiguity and role conflict. When employees are unsure about what is expected of them, how to perform their job, or what the consequences of their job performance are, they are experiencing role ambiguity. When employees finds it difficult to perform their job effectively because of the multiple explanations about their job performance, they are experiencing role conflict. Role conflict takes place in five basic ways:

• Receiving conflicting or incompatible expectations from another employee
• Receiving different expectations from two or more other employees
• Receiving expectations that lead to incompatible roles
• Receiving too many expectations, expectations leading to too many roles, or expectations leading to roles that are too complicated
• Having values and beliefs that conflict with expectations ⁽¹³⁹⁾

Career development is a good example of a major life event specifically related to work. Changing jobs or occupations can be stressful. People may feel frustrated and afraid, for example, after being laid off or fired from their job. Similarly, employees may feel belittled or embarrassed after being demoted. These feeling may be even more damaging for employees if such changes in occupational status interfere with their family life ⁽¹³⁹⁾.

3. School

As with work, work overload, role ambiguity, and role conflict are daily hassles that are particularly relevant to students. Students in college, for instance, often feel overwhelmed from having too many assignments or assignments that are too difficult. Additionally, they sometimes experience role ambiguity in poorly designed courses or from poor instructors and sometimes experience role conflict from instructors who seem to believe that the students in their classes are not taking any other classes. According to two surveys ^{(8; 93)}, the following stressors are particularly relevant for college students:

• Final grades
• Excessive homework
• Term papers
• Examinations
• Study for examinations
• Time demands
• Professors
• Class environment

Among children and adolescents, transitions from one stage of schooling to another are major life events that can be significant stressors. The transition from elementary school to junior high or middle school, for instance, can be a significant stressor ^{(32; 49)}.

III. Stress Responses

Although the presence of stressors does not mean that stress responses will necessarily follow, when they do, stress responses are the way in which people react to stressors. They are the experience of being stressed. Stress responses can be divided into three categories: psychological responses, physiological responses, and behavioral responses.

A. Psychological Responses

When people react to stressors, a wide variety of cognitive and emotional responses can occur. Examples of cognitive responses are as follows:

• Concentration problems
• Indecision
• Forgetfulness
• Sensitivity to criticism
• Self-critical thoughts
• Rigid attitudes

Examples of emotional responses are as follows:

• Nervousness
• Tension
• Irritability
• Anger
• Hostility
• Sadness
• Guilt
• Shame
• Moodiness
• Loneliness
• Jealousy ^{(23; 99; 129)}

B. Physiological Responses

Physiological responses follow what is called the general adaptation syndrome (GAS) ^{(150; 151)}. The GAS has three stages: alarm, resistance, and exhaustion.

The first stage, alarm, is basically the fight-or-flight response, the various physiological changes that prepare the body to attack or to flee a threatening situation. The sympathetic branch of the autonomic nervous system (the part of the nervous system that induces the physiological changes that accompany arousal) is activated and prompts the release of two catecholamines (one of several types of neurotransmitters, molecules released from active nerve cells that influence the activity of other nerve cells), epinephrine (also called adrenaline) and norepinephrine (also called noradrenaline), from the adrenal medulla (the inner part of the adrenal glands sitting atop the kidneys). Additionally, glucocorticoids (stress hormones) like cortisol are released from the adrenal cortex (the outer part of the adrenal glands) ^{(31; 126)}.

The following examples of physiological changes characterizes the alarm stage:

• Increased heart rate
• Increased blood pressure
• Rapid or irregular breathing
• Muscle tension
• Dilated pupils
• Sweating
• Dry mouth
• Increased blood sugar levels ⁽²³⁾

In the second stage, resistance, the body tries to calm itself and restrain the fight-or-flight response from the alarm stage. These changes allow people to deal with stressors more effectively over a longer period of time ⁽²³⁾.

When the body eventually runs out of energy from trying to resist stressors, the exhaustion stage takes over. In this stage, the body admits defeat and suffers the negative consequences of the stressors, such as a decreased capacity to function correctly, less sleep, or even death ⁽²³⁾.

C. Behavioral Responses

People act differently when they are reacting to stressors. Sometimes, the behaviors are somewhat subtle, such as the following responses:

• Strained facial expressions
• A shaky voice
• Tremors or spasms
• Jumpiness
• Accident proneness
• Difficulty sleeping
• Overeating or loss of appetite ^{(23; 116; 129)}

Behavioral responses are more obvious when people take advantage of the preparatory physiological responses of the fight-or-flight response. One side of the fight-or-flight response is that it prepares people to "fight", and people sometimes take advantage of that feature and behave aggressively toward other people. Unfortunately, this aggression is often direct toward family members. After Hurricane Andrew devastated south Florida in 1992, for example, reports of domestic violence doubled. The other side of the fight-or-flight response is that it prepares people for "flight" ^{(23; 116; 129)}.

The following behavioral responses are examples of how people try to escape threatening situations:

• Quiting jobs
• Dropping out of school
• Abusing alcohol or other drugs
• Attempting suicide
• Commiting crimes ^{(23; 116; 129)}

IV. The Connection Between Stressors and Stress Responses

Stressors prompt stress responses, right? Well, it depends. A number of conscious and unconscious things occur in our inner world that determine whether a stressor in the external world will trigger our stress response. These inner world happenings are referred to as mediating processes and moderating factors.

A. Mediating Processes

Mediating processes in our inner mind/body world begin to influence the quality and intensity of our stress response from the moment we are exposed to a stressor. Consider, for example, a person who discovers that his or her cat neglected to use the litter box. Whether or not this person appraises the problem as something he or she can establish control over may help determine whether he or she becomes angry. Mediating processes include appraisal and coping.

1. Appraisal

Once people become aware of a stressor, the next step is appraisal. How a stressor is appraised influences the extent to which stress responses follow it ⁽⁹⁸⁾. In fact, many stressors are not inherently stressful ⁽¹⁷³⁾. Stressors can be interpreted as harm or loss, as threats, or as challenges. When stressors have not already led to harm or loss but have the potential to do so, it is usually less stressful for people if the stressors are seen positively as challenges rather than negatively as threats ^{(66; 98; 134)}. The influence of appraisal does have its limits, though. For example, although people who suffer from chronic pain tend to be able to enjoy more physical activity if they view their pain as a challenge they can overcome, appraisal does not matter if the pain is severe ⁽⁸⁵⁾.

Moreover, thinking negatively about the influence of past stressors is associated with a greater vulnerability to future stressors ⁽⁷¹⁾. Consider, for example, people with PTSD. Among victims of sexual or physical assault with PTSD, those who have trouble recovering tend to have more negative appraisals of their actions during the assault, of others' reactions after the assault, and of their initial PTSD symptoms ⁽⁴⁶⁾.

An important aspect of appraisal is how predictable and controllable a stressor is judged to be. Regarding predictability, not knowing if or when a stressor will come usually makes it more stressful, especially if it is intense and of a short duration ⁽¹⁾. After a spouse passes away, for example, the other spouse tends to feel more disbelief, anxiety, and depression if the death was sudden than if it was anticipated weeks or months in advance ⁽¹²⁰⁾. Similarly, during the Vietnam War, for example, wives of soldiers who were missing in action felt worse than did wives of soldiers who were prisoners of war or had been killed ^{(Hunter, as cited in 23)}. Regarding control, believing that a stressor is uncontrollable usually makes it more stressful. Alternatively, believing that a stressor is controllable, even if it really is not, tends to make it less stressful ⁽¹⁶⁶⁾. When people are exposed to loud noises, for example, they tend to see it as less stressful when they are able to stop it, even if they do not bother to stop it ⁽⁶⁷⁾.

How much more stressful a stressor becomes from feeling a lack of control over it depends, however, on the extent to which the cause of the stressor is seen as stable or unstable, global or specific, and internal or external. Stable and unstable causes represent causes that are enduring and temporary, respectively. Global and specific causes represent causes that are relevant to many events and relevant to a single occasion, respectively. Internal or external causes represent causes that are the result of personal characteristics and behaviors or the result of environmental forces, respectively. The more stable and global the cause of a stressor seems, the more people feel and behave as though they are helpless. Likewise, the more internal the cause of a stressor seems, the worse people feel about themselves. Together, these feelings and behaviors contribute to a depressive reaction to the stressor ⁽²⁾.

Consider, for example, a case in which a guy's girlfriend breaks up with him and he thinks that his love life is always in the dumps (i.e., a stable interpretation), that nobody really cares about him (i.e., a global interpretation), and that he must not be a dateable guy (i.e., an internal interpretation). Such an interpretation could contribute to a depressive reaction, such as him coming to the conclusion that he might as well not try because there is nothing he can do about it and that he is pretty much a lost cause ⁽²⁷⁾.

2. Coping

After a stressor has been appraised, the next step, if necessary, is coping. How well people are able to cope with stressors influences the extent to which stress responses follow them. Coping strategies can be divided into two broad categories: problem-focused coping and emotion-focused coping ^{(98, 122)}. Problem-focused coping involves trying to manage or to alter stressors, and emotion-focused coping involves trying to regulate the emotional responses to stressors. Although people tend to use both forms of coping in most cases ⁽⁶⁰⁾, the relative use of each of these forms of coping largely depends on the context. Problem-focused coping is more appropriate for problems in which a constructive solution can be found, such as family-related or work-related problems. Alternatively, emotion-focused coping is more appropriate for problems that just have to be accepted, such as physical health problems ⁽¹⁶⁸⁾.

Problem-focused coping strategies include the following three types:

• Confronting, which means changing a stressful situation assertively. For example, "I stood my ground and fought for what I wanted."
• Seeking social support, which means obtaining emotional comfort and information from other people. For example, "I talked to someone to find out more about the situation."
• Planful problem solving, which means solving a stressful problem through deliberate problem-focused strategies. For example, "I made a plan of action and followed it" ^{(61; 62; 162)}

The seeking of social support, in particular, appears to be a valuable problem-focused coping strategy. Social support has been shown to help with stressors like cancer, crowding, military combat, natural disasters, and AIDS ⁽²³⁾.

Emotion-focused coping strategies include the following five types:

• Self-controlling, which means regulating one's feelings. For example, "I tried to keep my feelings to myself."
• Distancing, which means detaching oneself from a stressful situation. For example, "I didn't let it get to me; I tried not to think about it too much."
• Positively reappraising, which means finding positive meaning in a stressful experience by focusing on personal growth. For example, "I changed my mind about myself."
• Accepting responsibility, which means acknowledging one's role in a stressful problem. For example, "I realized I brought the problem on myself."
• Escaping/Avoiding, which means wishful thinking or escaping or avoiding a stressful situation by way of activities like eating, drinking, or using alcohol or other drugs. For example, "I wished that the situation would go away or somehow be over with" ^{(61; 62; 162)}

B. Moderating Factors

Moderating factors influence the strength of the stress responses induced by stressors or the direction of the relation between stressors and stress responses. Regarding the previous example about the cat and the litter box, how angry the person becomes after finding out that his or her cat neglected to use the litter box may depend on, for instance, how anxious or tense he or she is in general. Mediating processes include appraisal and coping. Moderating factors include personality traits, health habits, coping skills, social support, material resources, genetics and early family experiences, demographic variables, and preexisting stressors.

1. Personality Traits

Two general personality traits, positive affectivity (also called extroversion) and negative affectivity (also called neuroticism), are particularly relevant to stress. People who are high in positive affectivity tend to have positive feelings like enthusiasm and energy ⁽¹⁷¹⁾, feelings that characterize eustress. People who are high in negative affectivity tend to have negative feelings like anxiety and depression ⁽¹⁷⁰⁾, feelings that characterize distress. In particular, negative affectivity is associated with the ineffective use of coping strategies ^{(24; 109)} and susceptibility to daily stressors ⁽²⁶⁾.

Another personality trait relevant to stress is optimism, a general tendency to expect that things will work out for the best ^{(144; 145)}. Optimism is associated with stress resistance. Students who are optimistic, for example, tend to have fewer physical responses to stressors at the end of an academic term than do students who are pessimistic ⁽⁹⁾. Even when taking into account other personality traits like negative affectivity, perceived control, and self-esteem, optimism is still associated with a lack of stress responses like depression ⁽¹⁴⁶⁾.

As stated previously, appraising the causes of a stressor as stable, global, and internal contributes to a depressive reaction to the stressor. Such appraisals are usually made by people who have a general tendency for this kind of appraisal, referred to as a pessimistic explanatory style or a depressive explanatory style ⁽²⁷⁾. Such people tend to have more depressive reactions to stressors in general ⁽¹⁶¹⁾.

Hardiness is composed of a set of three related personality traits: control, commitment, and challenge. Control refers to the belief in people that they can influence their internal states and behavior, influence their environment, and bring about desired outcomes. Commitment refers to the tendency for people to involve themselves in what they encounter. Challenge refers to the willingness in people to change and try new activities, which provides opportunities for personal growth ^{(129; 163)}. Hardiness is associated with stress resistance ^{(91; 92)}. In particular, hardiness is associated with favorable appraisals of potential stressors ^{(5; 172)} and effective use of coping strategies ⁽¹⁷⁵⁾. Of the three personality traits that comprise hardiness, control appears to be the most important ^{(35; 58)}. For instance, when people feel unable to control their environment, cortisol levels rise in the body ⁽¹³⁵⁾. This process can take place in response to crowding, for example, in places like high-density residential neighborhoods, prisons, and college dormitories ^{(57; 119)}.

Self-esteem, how people tend to feel about themselves, is another personality trait that is relevant to stress. Self-esteem is one factor that can influence the relation between daily hassles and emotional responses to stressors ⁽⁴¹⁾. Additionally, low self-esteem is associated with increased blood pressure in response to stressors ⁽¹⁴⁷⁾ and other physiological responses that often occur in response to stressors, such as trembling hands, pounding heart, pressures or pains in the head, sweating hands, and dizziness ⁽¹³⁷⁾. Low self-esteem also has an important role in depression ⁽¹⁷⁾.

Power motivation is also a personality trait that is relevant to stress. People who have a strong need for power are described as competitive and aggressive, interested in the accumulation of things and memberships, and prefer action over reflection ⁽¹⁰⁷⁾. Power motivation is associated with stress responses to stressors ⁽⁵⁹⁾. Inhibited power motivation, having a strong need for power that is not being satisfied, for instance, is associated with physiological responses that often occur in response to stressors like high levels of norepinephrine ⁽¹⁰⁸⁾ and high diastolic blood pressure ⁽¹⁰⁶⁾.

2. Health Habits

People are particularly resistant to stress if they lead a healthy lifestyle, which includes a healthy diet, physical fitness, and enough rest and relaxation. In particular, people who lead a healthy lifestyle have the energy they need to cope with stressors ⁽⁹⁸⁾.

A healthy diet is an important factor in stress resistance, and meals can be a time to reduce stress by relaxing and socializing. Moreover, an unhealthy diet often leads to weight gain, which can become a stressor itself. A healthy diet involves making time for meals, eating meals that have a variety of foods but plenty of grains, fruits, and vegetables and that are low in fat, salt, and sugar, avoiding caffeine, not drinking alcohol, and not smoking cigarettes ⁽⁵⁴⁾. Additionally, the following nutrients are essential to keep stress under control: carbohydrates, protein, linoleic acid (vegetable fat), B vitamins, vitamin C, vitamin E, gamma-aminobutyric acid (GABA) ^{(11; 54)}.

Physical fitness makes people less vulnerable to stress responses ⁽²⁹⁾. Stressors tend to prompt weaker physiological responses, such as lower levels of cardiovascular arousal, in people who are physically fit than they do in people who are not physically fit ^{(40; 79)}. Similarly, stressors tend to prompt weaker psychological responses, such as lower levels of anxiety, emotionality, and depression, in people who are physically fit than they do in people who are not physically fit ^{(43; 53; 79; 82; 103)}.

When people relax and allow themselves to rest, they enter a state of reduced psychological and physiological arousal ⁽¹⁴⁰⁾. Because this state is basically the opposite of a stressful state, a person who is relaxed and continues to relax when exposed to a stressor usually ends up preventing the stress responses or reducing their intensity. Furthermore, rest allows people to unwind and recover from stressful experiences, giving them the energy they need to deal with stress ^{(Stoyva & Budzynski, as cited in 157)}.

3. Coping Skills

If people do not have adequate coping skills, they cannot cope effectively with stressors and the stress responses that follow. In such cases, coping strategies cannot act as effective mediating processes. Two examples of coping skills are problem-solving skills and social skills.

Problem-solving skills include the following abilities:

• Looking for information
• Identifying problems and figuring out possible ways they could be solved
• Comparing the various problem-solving strategies
• Considering the various strategies with respect to desired or anticipated outcomes
• Selecting problem-solving strategies to use

Problem-solving skills are important coping resources because they enable people to handle the problems posed by stressors ⁽⁹⁸⁾.

Social skills are also important coping resources because social interaction is part of so many stressful situations. They refer to the ability to communicate and behave with other people in ways that are socially appropriate and effective. Moreover, they can help people with problem solving in social situations by giving them more control over the relevant social interactions, such as increasing the likelihood of other people cooperating and offering support ⁽⁹⁸⁾.

4. Social Support

People tend to respond better to stressors if they have a social support network, other people that they can rely on for support, than if they do not ⁽¹⁴⁹⁾. Four types of social support are as follows:

• Appraisal support, which helps people better understand stressors and identify coping strategies that may be appropriate
• Tangible support, which takes place when other people provide material support, such as money and goods and services
• Information support, which takes place when other people provide specific information about stressors and appropriate coping strategies
• Emotional support, which reassures people that they are valuable and cared for by other people ⁽¹⁶³⁾

Social support is not always beneficial, though. For social support to be beneficial, people must believe that other people care about them and are willing to help them ^{(125; 97)}. Additionally, social support networks can sometimes become annoying, disruptive, or interfering and actually end up increasing stress ⁽²⁸⁾, such as when they provide too much support or the wrong kind of support ⁽²³⁾.

5. Material Resources

Material resources refer to money and the goods and services that money can buy. Material resources generally increase the coping options available to people and to improve the access to and effectiveness of legal, medical, financial, and other professional assistance. People who have money tend to cope well with stressors, especially if they know how to use it. Even if they do not spend it, the comfort of simply having money available is associated with a lack of vulnerability to stressors ⁽⁹⁸⁾.

6. Genetics and Early Family Experiences

The genes and childhood experiences that people have seem to have an influence on several moderating factors ^{(143; 163)}. The general tendency to experience positive and negative affectivity ⁽¹²³⁾, to be optimistic ⁽¹²⁷⁾, to use active coping strategies like planful problem solving and seeking social support ⁽⁸⁸⁾, or to rely on social support networks ⁽⁸⁹⁾, for example, is partially inherited. Likewise, the general tendency to feel a sense of personal control ⁽¹⁶⁵⁾, to use denial to cope with stressors ⁽⁸⁸⁾, or to respond to stressors with hostility and anger ⁽³⁾, for example, is partially do to family experiences during childhood. Furthermore, genetic and familial influences themselves can be moderating factors in the stress process. The general tendency to have mental disorders that involve anxiety or depression, for example, is influenced by genetic and familial factors ⁽⁷²⁾.

7. Demographic Variables

Demographic variables like age, ethnicity, gender, socioeconomic status, occupational status, and urban/rural have an influence on several moderating factors ⁽¹⁴³⁾. Regarding positive and negative affectivity, for instance, people tend to experience them less with age, Blacks tend to experience less positive affectivity with age than do people of other ethnicities, and women tend to experience negative affectivity more than men do ^{(39; 52)}. Additionally, people of lower socioeconomic status or who live in urban areas tend to experience more negative affectivity than do people of higher socioeconomic status or who live in rural areas, respectively ⁽⁵²⁾. Regarding self-esteem, for instance, people of higher occupational status tend to have higher self-esteem than do those of lower occupational status ^{(94; 95)}.

Furthermore, the demographic variables themselves can be moderating factors in the stress process ⁽⁸⁴⁾. Regarding gender differences in coping, for instance, men tend to use the following types of coping:

• Problem-focused coping strategies
• Planned and rational actions
• Positive thinking
• Personal growth
• Humor
• Daydreaming
• Fantasies

Women tend to use the following types of coping:

• Emotion-focused coping strategies
• Self-blame
• Expression of emotions
• Seeking of social support
• Wishful thinking ⁽¹⁶⁷⁾

Additionally, people of lower socioeconomic status tend to encounter more stressors, to have less social support, and to be less in control of their environment than people of higher socioeconomic status tend to ^{(45; 155)}.

8. Preexisting Stressors

The influence that one stressor has depends in part on other ongoing stressors ⁽¹⁶³⁾. Chronic stressors, in particular, seem to intensify the impact of other stressors that people are exposed to at the same time ^{(56; 100)}. Sometimes, however, chronic stressors may actually improve resistance to other minor stressors because they seem less important in comparison ⁽¹⁶³⁾ but only when the other stressors occur in unrelated contexts ⁽⁷⁰⁾.

V. Problems Associated With Stress

Stress responses are potentially harmful, especially if they are severe or extend over a long period of time. When stressors end up leading to stress responses, a number of problems can arise, such as burnout, mental disorders, and physical illnesses. Moreover, stress responses, such as emotional responses like anxiety and worry and cognitive responses like having a poor or hopeless attitude, can even worsen any pain that people may be feeling ⁽⁹⁹⁾.

A. Burnout

Burnout is an increasingly intense pattern of psychological, physiological, and behavioral dysfunction in response to a continuous flow of stressors or chronic stress ^{(110; 142)}. It is commonly found among employees and professionals who have a high degree of personal investment in work and high performance expectations. In the initial stages, people often have a variety of physiological and behavioral symptoms and lose interest and confidence in their work. The following physiological symptoms may occur:

• Shortness of breath
• Loss of appetite or weight
• Headache
• Fatigue and exhaustion

The following behavioral symptoms may occur:

• Lack of interest in fellow employees
• Risky behavior
• Mood swings

In the later stages, people often do the following things:

• Abuse alcohol and other drugs
• Smoke excessively
• Drink more caffeinated beverages
• Become more rigid in their thinking
• Lose faith in the abilities of co-workers, management, the organization, and themselves
• Become less productive ⁽¹¹⁷⁾

Another concept, ego depletion, is very similar to burnout. In fact, it may represent an underlying feature of burnout. The idea behind ego depletion is that acts of volition—making choices and decisions, taking responsibility, initiating and inhibiting behavior, and making plans of action and carrying them out—draw on a limited supply of volitional energy that is available inside people. Consequently, if people deplete this resource too much, it is no longer very easy to do what they need to do to handle stress, such as trying to use coping strategies in response to stressors ⁽¹⁴⁾.

B. Mental Disorders

Mental disorders are the result of a varying combination of sources, one of which being stress. Examples of other sources are as follows:

• Chemical imbalances
• Inherited characteristics
• Early learning experiences
• Brain damage
• Psychological traits

The diathesis-stress model explains how stress contributes to the onset of mental disorders. According to this model, chemical imbalances, inherited characteristics, and early learning experiences can make it more likely for people to get mental disorders but whether they do depends on the stressors they encounter ⁽¹¹⁴⁾.

People sometimes have symptoms of mental disorders, but they usually do not meet the criteria or are not clinically significant, severe enough to necessitate treatment. Before a person can be diagnosed with a mental disorder, his or her problematic thoughts, feelings, and actions must meet the criteria for the mental disorder and must prevent adequate social, occupation, or other forms of functioning ⁽⁷⁾. Accordingly, answering yes to any of the following questions may suggest clinical significance:

• Is the behavior considered strange within the person's own culture?
• Does the behavior cause personal distress?
• Does the behavior interfere with what the person is trying to accomplish?
• Is the person a danger to self or others?
• Is the person legally responsible for his or her acts? ⁽¹⁷⁷⁾

Stress may play a causal role in a wide variety of mental disorders. Some of the mental disorders in which stress appears to have a causal role are anxiety disorders, mood disorders, and substance-related disorders.

1. Anxiety Disorders

Anxiety disorders are characterized by anxiety, either as the primary symptom or the primary cause of other symptoms ⁽⁸⁰⁾. The presence or absence of panic attacks or agoraphobia is a critical aspect of several disorders. A panic attack " is a discrete period in which there is the sudden onset of intense apprehension, fearfulness, or terror, often associated with feelings of impending doom. During these attacks, symptoms such as shortness of breath, palpitations, chest pain or discomfort, choking or smothering sensations, and fear of 'going crazy' or losing control are present" ^{(7, p. 393)}. Agoraphobia "is anxiety about, or avoidance of, places or situations from which escape might be difficult (or embarrassing) or in which help may not be available in the event of having a Panic Attack or panic-like symptoms" ^{(7, p. 393)}.

Twelve different anxiety disorders can be diagnosed:

• Panic disorder without agoraphobia "is characterized by recurrent unexpected Panic Attacks about which there is persistent concern" ^{(7, p. 393)}.
• Panic disorder with agoraphobia "is characterized by both recurrent unexpected Panic Attacks and Agoraphobia" ^{(7, p. 393)}.
• Agoraphobia without history of panic disorder "is characterized by the presence of Agoraphobia and panic-like symptoms without a history of unexpected Panic Attacks" ^{(7, p. 393)}.
• Specific phobia "is characterized by clinically significant anxiety provoked by exposure to a specific feared object or situation, often leading to avoidance behavior" ^{(7, p. 393)}.
• Social phobia "is characterized by clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior" ^{(7, p. 393)}.
• Obsessive-compulsive disorder "is characterized by obsessions (which cause marked anxiety or distress) and/or by compulsions (which serve to neutralize anxiety)" ^{(7, p. 393)}.
• Posttraumatic stress disorder "is characterized by the reexperiencing of an extremely traumatic event accompanied by symptoms of increased arousal and by avoidance of stimuli associated with the trauma" ^{(7, p. 393)}.
• Acute stress disorder "is characterized by symptoms similar to those of Posttraumatic Stress Disorder that occur immediately in the aftermath of an extremely traumatic event" ^{(7, p. 393)}.
• Generalized anxiety disorder "is characterized by at least 6 months of persistent and excessive anxiety and worry" ^{(7, p. 393)}.
• Anxiety disorder due to a general medical condition "is characterized by prominent symptoms of anxiety that are judged to be a direct physiological consequence of a general medical condition" ^{(7, p. 394)}.
• Substance-induced anxiety disorder "is characterized by prominent symptoms of anxiety that are judged to be a direct physiological consequence of a drug of abuse, a medication, or toxin exposure" ^{(7, p. 394)}.
• Anxiety disorder not otherwise specified is used as a diagnosis when anxiety symptoms do not meet the criteria for other disorders or when there is inadequate or contradictory information about anxiety symptoms ⁽⁷⁾.

Regarding the causal role of stress in anxiety disorders, stressors appear to have a causal influence ^{(12; 101)}. The specific way in which stressors lead to the onset of anxiety disorders, however, varies depending on the type of anxiety disorder ⁽⁵⁵⁾. Additionally, posttraumatic stress disorder can be thought of as a prolonged and severe stress response to a catastrophe or to a chronic intense stressor ⁽¹⁷⁷⁾.

2. Mood Disorders

Mood disorders involve disturbances in mood that range from depression to mania ⁽⁸⁰⁾. The number of major depressive episodes, manic episodes, mixed episodes, or hypomanic episodes is a critical aspect of several mood disorders. Major depressive episodes involve "at least 2 weeks of depressed mood accompanied by a characteristic pattern of depressive symptoms" ^{(63, p. 194)}. Mixed episodes involve "at least 1 week of elevated, euphoric, or irritable mood accompanied by a characteristic pattern of manic symptoms" ^{(63, p. 194)}. Mixed episodes involve "at least 1 week of a mixture of manic and depressive symptoms" ^{(63, p. 194)}. Hypomanic episodes involve "at least 4 days of elevated, euphoric, or irritable mood that is less severe than a manic episode" ^{(63, p. 194)}.

Ten different mood disorders can be diagnosed:

• Major depressive disorder "is characterized by one or more Major Depressive Episodes" ^{(7, p. 317)}.
• Dysthymic disorder "is characterized by at least 2 years of depressed mood for more days than not, accompanied by additional depressive symptoms that do not meet criteria for a Major Depressive Episode" ^{(7, p. 317)}.
• Depressive disorder not otherwise specified is used as a diagnosis when the depressive symptoms do not meet the criteria for other disorders or when there is inadequate or contradictory information about the depression symptoms ⁽⁷⁾.
• Bipolar I disorder "is characterized by one or more Manic or Mixed Episodes, usually accompanied by Major Depressive Episodes" ^{(7, p. 317)}.
• Bipolar II disorder "is characterized by one or more Major Depressive Episodes accompanied by at least one Hypomanic Episode" ^{(7, p. 318)}.
• Cyclothymic disorder "is characterized by at least 2 years of numerous periods of hypomanic symptoms that do not meet criteria for a Manic Episode and numerous periods of depressive symptoms that do not meet criteria for a Major Depressive Episode" ^{(7, p. 318)}.
• Bipolar disorder not otherwise specified is used as a diagnosis when the bipolar symptoms do not meet the criteria for other disorders or when there is inadequate or contradictory information about the bipolar symptoms ⁽⁷⁾.
• Mood disorder due to a general medical condition "is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a general medical condition" ^{(7, p. 318)}.
• Substance-induced mood disorder "is characterized by a prominent and persistent disturbance in mood that is judged to be a direct physiological consequence of a drug of abuse, a mediation, another somatic treatment for depression, or toxin exposure" ^{(7, p. 318)}.
• Mood disorder not otherwise specified is used as a diagnosis when the mood symptoms do not meet the criteria for other disorders or when there is inadequate or contradictory information about the mood symptoms ⁽⁷⁾.

Regarding the causal role of stress in mood disorders, negative major life events tend to precede depression ⁽¹⁷⁷⁾. In fact, compared to the number of negative major life events experienced by people who are not depressed, people who become depressed experience two to three times as many shortly beforehand ⁽⁷³⁾.

3. Substance-Related Disorders

Substance-related disorders are characterized by the use of drugs like alcohol, cocaine, heroin, and other substances people use to alter the way they think, feel, and act ⁽¹³⁾. Substance-related disorders fall into two categories: substance use disorders and substance-induced disorders. Substance use disorders are characterized by a problematic pattern of substance use, involving dependence on or abuse of substances. Substance-induced disorders are characterized by reactions to the effect of substances on the central nervous system, involving intoxication, withdrawal, and sets of substance-induced features that resemble other disorders ^{(63, 1995)}. Regarding the causal role of stress in substance-related disorders, the need to reduce stress may be one of the initial causes of substance abuse ⁽²³⁾.

C. Physical Illnesses

Stress is a health hazard. Stress can lead to a variety of physical illnesses and related health problems. In fact, stress has a negative impact on virtually every organ system in the body:

• Cardiovascular system
• Respiratory system
• Endocrine system
• Gastrointestinal tract
• Male and female reproductive systems
• Immune system ⁽⁸¹⁾

Some physical illnesses, such as peptic ulcers, are caused by physiological responses to stressors. Other physical illnesses, such as asthma and skin rashes, however, can occur in the absence of stress but are aggravated by it. Regarding the changes in body chemistry that accompany physiological responses to stressors, increased levels of glucocorticoids are usually more harmful to a person's health than are increased levels of epinephrine and norepinephrine. Prolonged exposure to high levels of glucocorticoids can lead to the following problems:

• Increased blood pressure
• Damaged muscle tissue
• Infertility
• Inhibitted growth
• Immune system suppression
• Brain damage
• Accelerated aging ⁽³¹⁾

In particular, stress appears to be a cause of immune system suppression and cardiovascular diseases and an influence on the course of cancer.

1. Immune System Suppression

Physiological response to stressors can impair the function of the immune system, which leaves people vulnerable illness-promoting substances like viruses, bacteria, and fungi. When a married person dies, for example, it is often the case that his or her spouse dies soon afterward from an infection ⁽³¹⁾. Additionally, people who are more stressed are more likely to catch a cold than are people who are less stressed, for example ^{(36; 37)}.

2. Cardiovascular Diseases

Cardiovascular diseases typically involve high blood pressure and a high level of cholesterol in the blood. People with cardiovascular diseases are prone to have heart attacks and strokes ⁽³¹⁾. A certain pattern of psychological responses to stressors, referred to as cynical hostility, is a risk factor for coronary heart disease and heart attacks ⁽¹⁵³⁾. Cynical hostility is characterized by the following thoughts and feelings:

• Suspiciousness
• Resentment
• Frequent anger
• Antagonism
• Distrust of others ^{(154; 176)}

3. Cancer

Although stress may not cause cancer, it can contribute to it by weakening the body's natural defenses against cancerous cells ⁽⁸⁶⁾. Furthermore, this influence may be particularly strong for people who have major depression, feel hopeless, and are indifferent toward the pain ⁽³⁸⁾. For example, mastectomy patients who are determined to overcome their breast cancer tend to be more likely to survive than mastectomy patients who feel hopeless and are indifferent toward the pain tend to be ^{(75; 124)}.

VI. Stress Management

To avoid the problems associated with stress, people need to manage their stress. Before they can manage their stress, however, they need to decide whether they need professional help or whether self-help is enough. Once people decide on a source of help, regardless of the source of the help and the stress management techniques involved, a series of steps are involved in the process of change.

A. Professional Help or Self-Help?

When trying to manage stress, it is often difficult for people to decide whether self-help will be enough or whether they should seek professional help. In practice, people usually turn to self-help instead of professional help. The public appears to be very accepting of self-help resources ^{(128; 169)}. Self-help is not always the best way to manage stress, though. Sometimes professional help is necessary. Professional help is probably necessary if self-help fails or does not offer any worthwhile solution or if the problems associated with stress develop into mental disorders or physical illness.

When people realize that they do in fact need to seek professional help, how do they know what type of professional to turn to? A wide range of professionals is available to people with stress-related problems, ranging from medical doctors to mental health professionals. A medical doctor, such as a general practitioner or a specialist, is a good choice when stress leads to symptoms that may indicate physical illnesses. A mental health professional, such as clinical psychologist or a psychiatrist, is a good choice when stress leads to symptoms that may indicate a mental disorder. Clinical psychologists and psychiatrists along with other mental health professionals like counseling psychologists can also provide assistance with stress management in general, not just with mental disorders that may accompany stress. Other mental health professionals like marriage and family counselors, social workers, nurses, clergypersons, and telephone crisis counselors may also be able to provide some assistance with stress management.

Clinical or counseling psychologists usually earn a Ph.D., doctor of philosophy, (or sometimes a Psy.D., doctor of psychology, or Ed.D, doctor of education.) in psychology. Psychiatrists earn an M.D., medical doctor, degree. Compared to psychiatrists, clinical psychologists tend to focus more on the aspects of mental disorders that involve problematic thoughts, feelings, and actions and problems with relationships with other people. They also usually receive more extensive training in therapy. Psychiatrists, however, tend to view mental disorders as medical problems that should be treated with drugs and typically receive less training in actual therapy ^{(13; 99)}. Whether a clinical psychologist or a psychiatrist or both is more appropriate, depends on a person's specific problems. Whereas clinical psychologists and psychiatrists often deal with mental disorders, counseling psychologists customarily deal with adjustment issues and issues related to employment that are encountered by relatively healthy people ⁽¹³⁾.

It is also important to realize that, if people need to seek professional help from a mental health professional, it does not necessarily mean that they are "crazy." Although many mental health professionals do treat people with mental disorders that people generally associate with being "crazy," such as schizophrenia, many mental health professionals help people with other problems associated with stress. In fact, some mental health professionals specialize in stress management and see people who only need help with stress. Furthermore, it is important to remember that any legitimate professional is also a great resource for a person who wants advice on how to avoid the problems associated with stress.

B. The Process of Change

Five stages are involved in changing behaviors that contribute to health-related problems, such as the problems associated with stress:

1. Precontemplation: People do not notice a problem and have no intention of changing it any time soon.
2. Contemplation: People realize they have a problem behavior that should be changed and are seriously thinking about changing it.
3. Preparation: People have a strong intention to change it, have specific plans for changing it, and have already taken preliminary steps toward changing it.
4. Action: People are successfully working on changing the problem behavior.
5. Maintenance: People take steps to make sure the new behavior remains and the problem behavior does not return ⁽¹³¹⁾.

Although progress through these stages may appear simple and straightforward, it usually is not. People usually cycle through these stages several times before they are able to stay in the maintenance stage ⁽¹³⁰⁾. Whether people are able to move from one stage to the next depends a great deal on decisional balance, the relative impact of the advantages and disadvantages on the decision about whether to change a behavior or leave it as it is ⁽¹³²⁾.

C. Stress Management Techniques

Countless stress management techniques have been used for stress management. These techniques usually involve cognitive-behavioral approaches, relaxation, exercise, diet and nutrition, and/or medication.

1. Cognitive-Behavioral Approaches

Cognitive-behavioral approaches to stress management attempt to change stress-related thoughts, feelings, and actions. Cognitive-behavioral techniques traditionally have been used within the context of three types of therapies: cognitive restructuring, coping skills therapies, and problem-solving therapies ^{(Mahoney & Arnkoff, as cited in 44)}. More recently, however, the same principles have been incorporated into self-help methods.

a. Cognitive Restructuring

The goal of cognitive restructuring is to establish patterns of thinking that are more adaptive ⁽⁴⁴⁾ and less stress provoking. Examples of cognitive restructuring are rational-emotive therapy ⁽⁵⁰⁾, rational behavior therapy ⁽¹⁰⁴⁾, cognitive therapy ^{(16, 18, 19, 20)}, self-instructional training ^{(Meichenbaum, as cited in 44, 111, 112)}, and structural psychotherapy ⁽⁷⁴⁾.

A fundamental concept in rational-emotive therapy is the ABC model. According to this model, consequences (C; i.e., stress responses) occur as a result of beliefs (B; i.e., appraisals) about antecedents (A; i.e., stressors). The main purpose of rational-emotive therapy is to is identify irrational beliefs (i.e., stress-provoking appraisals) and reveal why they do not make sense ⁽⁵⁰⁾. A unique feature of rational-emotive therapy is the philosophical emphasis of its major goals ⁽⁴⁴⁾:

• Self-interest
• Social interest
• Self-direction
• Tolerance of self and others
• Flexibility
• Acceptance of uncertainty
• Commitment to vital interests
• Self-acceptance
• Scientific thinking
• Realistic expectations in life ⁽⁵¹⁾.

Rational behavior therapy is essentially the same as rational-emotive therapy, but it lacks the obvious philosophical emphasis of rational-emotive therapy and focuses on neuropsychophysiology (psychological relevance of brain functioning) and learning theory ⁽⁴⁴⁾. A central concept in rational behavior therapy is that rational self-talk, which originates in the left hemisphere of the brain, is converted by the right hemisphere of the brain into appropriate emotional behavioral reactions ⁽¹⁰⁴⁾.

Both rational behavior therapy and self-instructional training involve self-talk, but self-instructional training involves a specific type of self-talk, self-instruction. The idea behind self-instructional training is that commands made to oneself can be used in basic behavioral modification processes like reinforcement (receiving a reward for desired behavior) ^{(Meichenbaum, as cited in 44)}. Clients are taught six types of skills:

• Problem definition
• Problem approach
• Attention focussing
• Coping statements
• Error-correcting options
• Self-reinforcement ^{(Kendall & Bemis, as cited in 44)}

In cognitive therapy, people learn to replace distorted appraisals of events with more realistic appraisals ⁽⁴⁴⁾. Ten principles underlie cognitive therapy:

• Principle No. 1: It is based on a continuously developing description of the client and his or her problems.
• Principle No. 2: It requires a good relationship between the therapist and the client.
• Principle No. 3: It emphasizes that the therapist and the client should work together and actively participate.
• Principle No. 4: It is goal orientated and problem focused.
• Principle No. 5: It initially emphasizes the present, focussing on current problems and current stressful situations.
• Principle No. 6: It strives to teach the client to be his or her own therapist and emphasizes relapse prevention.
• Principle No. 7: It aims to be time limited, involving a limited number of sessions.
• Principle No. 8: The sessions are structured.
• Principle No. 9: It teaches clients to identify, evaluate, and respond to dysfunctional thoughts and beliefs.
• Principle No. 10: It uses a variety of techniques to change thoughts, feelings, and actions ⁽²⁰⁾.

In particular, clients are taught the following skills:

• Monitoring automatic thoughts
• Recognizing the relations between thoughts, feelings, and actions
• Testing the validity of automatic thoughts
• Substituting more realistic thoughts for distorted thoughts
• Learning to identify and change the underlying assumptions or beliefs that make themselves more likely to engage in faulty thinking patterns ^{(Kendall & Bemis, as cited in 44)}

Structural psychotherapy is similar to cognitive therapy, but requires that an understanding of the development of and current role of the clients knowledge of himself or herself and the world be established ⁽⁷⁴⁾.

b. Coping Skills Therapies

The goal of coping skills therapies is to develop a set of skills designed to help people cope with a variety of stressful situations ⁽⁴⁴⁾. Examples of coping skills therapies are systematic rational restructuring ^{(68; 69)}, anxiety-management training ⁽¹⁵⁹⁾, and stress inoculation training ^{(111; 112; Meichenbaum, as cited in 44)}.

The purpose of systematic rational restructuring, an extension of systematic desensitization (reducing fears through gradual exposure to feared stimuli paired with positive coping experiences ⁽¹³⁾), is to provide clients with more effective coping abilities by teaching them how to change the thoughts that occur automatically in anxiety-provoking situations. Systematic rational restructuring consists of five stages:

1. Exposure to anxiety-provoking situations through imagery or role-playing
2. Self-evaluation of anxiety level
3. Monitoring of anxiety-provoking thoughts
4. Rational reevaluation of the anxiety-provoking thoughts
5. Self-evaluation of anxiety level following the rational reevaluation ^{(Godfried, as cited in 44)}

Though anxiety-management training, clients learn to use relaxation and competency skills to control anxiety without paying any attention to the anxiety-provoking stimuli ⁽¹⁵⁹⁾. Clients visualize anxiety-provoking scenes that may be unrelated to their specific problem and then practice relaxation skills and imagine responding intelligently ⁽¹⁵⁸⁾.

The rationale for stress inoculation training is that, if clients can learn how to cope with mild levels of stress, they will be prepared for or "inoculated" against uncontrollable levels of stress ⁽⁴⁴⁾. Stress inoculation training consists of three stages:

1. Conceptualization phase: Therapists establish a working relationship with clients and help them understand the nature of stress.
2. Skills acquisition and rehearsal phase: Clients develop and rehearse a variety of coping skills, such as relaxation, cognitive restructuring, problem solving, and self-instruction.
3. Application and follow-through phase: Clients practice using their coping skills in response to real or imagined stressors ⁽¹¹²⁾.

c. Problem-Solving Therapies

The goal of problem-solving therapies is to develop general strategies for solving a wide range of problems. Problem-solving therapies are essentially a combination of cognitive restructuring and coping skills therapies ⁽⁴⁴⁾. In general, problem-solving therapy involves fives stages:

1. General orientation or "set": a vague familiarity with the problem
2. Problem definition and formulation: determining exactly what the problem is
3. Generation of alternatives: coming up with several possible ways to try to solve the problem
4. Decision making: deciding which method to use to try to solve the problem
5. Verification: evaluating how well the chosen method worked to solve the problem ⁽⁴⁷⁾

Examples of problem-solving therapies are personal science ^{(Mahoney, as cited in 44)} and self-control therapy ^{(65; 133)}.

Personal science teaches clients to use the skills used by researchers to solve problems. The mnemonic SCIENCE represents seven basic skills:

• S: Specify general problem area
• C: Collect data
• I: Identify patterns or sources
• E: Examine options
• N: Narrow and experiment
• C: Compare data
• E: Extend, revise, and replace ^{(Mahoney, as cited in 44)}

Self-control therapy uses a variety of techniques to teach clients how to correct six potential deficits in self-control behavior across three phases of self-control that relate to depression. In the self-monitoring phase, potential deficits include selectively paying attention to negative events and selectively paying attention to immediate instead of delayed consequences of behaviors. In the self-evaluation phase, potential deficits include being overly critical of oneself and inaccurate conclusions about responsibility. In the self-reinforcement phase, potential deficits include not rewarding oneself sufficiently and punishing oneself too much ^{(65; 133)}.

2. Relaxation

The purpose of relaxation techniques is to reduce stress responses. Sometimes it is easy to relax just by getting a massage, listening to calming music, or admiring peaceful works of art. Similarly, simple environmental or ergonomic changes in people's lives can be relaxing by allowing their interactions with specific objects and their surroundings in general to be less strenuous. Other times, however, people have trouble relaxing and need to learn relaxation techniques. Relaxation techniques include progressive muscle relaxation, autogenic relaxation, meditation, the relaxation response, diaphragmatic breathing, biofeedback, self-hypnosis.

Progressive muscle relaxation is accomplished by focusing on muscle groups one at a time and tensing them for a few seconds, releasing the tension, and focusing on the resulting feelings of relaxation ^{(23; 83)}.

Autogenic relaxation is accomplished by focusing on blood flow and tense muscle groups and suggesting to oneself that he or she is becoming more relaxed and warm ⁽¹³⁾.

In most types of meditation, people use special techniques to focus their attention on one thing until they stop thinking about anything and experience nothing but "pure awareness" ⁽²¹⁾. People who meditate seem to have fewer problems associated with stress, such as general anxiety, high blood pressure, and insomnia ⁽¹⁵⁾. The relaxation response is a stripped-down version transcendental meditation, a form of mediation in which attention is focused on softly repeating a specific vocalization (the mantra). The relaxation response isolates this aspect of transcendental meditation ⁽¹³⁾, and has been shown to reduce the stress hormones levels ^{(21; 22)}

Diaphragmatic breathing is sustained, slow, rhythmical, breathing that emphasizes the use of the diaphragm ⁽⁵⁴⁾. It can be thought of as a special way of breathing with your stomach area instead of your chest area.

With biofeedback, special equipment records stress-related physiological activity in people like heart rate, blood pressure, and muscle tension and relays this information back to them as a tone that changes frequency or a meter reading. The person uses this information to learn to control these physiological processes and reduce the stress responses ^{(Budzynski & Stoyva, as cited in 23)}

Self-hypnosis is exactly what it sounds like, hypnotizing oneself. Self-hypnosis can be used to give oneself suggestions of relaxation. Hypnosis is a highly relaxing state in which people are more responsive to suggestions ⁽⁹⁰⁾. People display five main changes while under hypnosis:

• Reduced planfulness: They do not initiate actions as much.
• Attention is redistributed: They tend to pay attention exclusively to the voice of the hypnotist (which is their own voice during self-hypnosis).
• Improved ability to fantasize: They are better able to vividly imagine scenes or to relive remembered events.
• Better role-taking ability: It is easier for them to act like other types of people, such as people of different ages or the opposite sex.
• Reduced reality testing: They are less likely to question the truthfulness of statements and are more willing to accept apparent distortions of reality ^{(77; 78)}.

3. Exercise

Aerobic exercise, weight lifting, yoga, and tai chi are examples of forms of exercise that can help with stress.

Aerobic exercise uses the large muscle groups in continuous, repetitive motions and involves increased oxygen intake and increased breathing and heart rates. Aerobic exercises include the following types of exercise:

• Running
• Swimming
• Brisk walking
• Bicycling
• Rowing
• Jumping rope ⁽¹⁷⁷⁾

An exercise program aimed at improving physical fitness should include aerobic exercise 3 to 4 times a week for 20 to 30 minutes preceded and followed by a 5- to 10-minute warm-up and cool-down period, respectively ^{(6; 152)}.

Weight lifting can be used to enhance muscular strength or muscular endurance. Muscular strength is how much force muscles can exert, and muscular endurance is how long muscles can work before getting too tired ⁽¹⁰⁾. Strength training involves lifting heavier weights for fewer repetitions. Endurance training involves lifting lighter weights for more repetitions ⁽⁴²⁾. An exercise program aimed at improving physical fitness should include strength training with 8 to 12 repetitions of 8 to 10 types of lifts at least twice a week ^{(American College of Sports Medicine, as cited in 10)}.

Yoga involves aspects of meditation and special physical and breathing techniques used to control bodily processes like heart rate and blood pressure ⁽⁹⁹⁾. It is one of the six orthodox systems of Indian philosophy ⁽¹³⁶⁾. Yoga is not a religion, though; it is a way of life, combining the body, mind, and spirit ⁽⁵⁴⁾.

Tai chi (also called tai chi chuan) is a style of martial art based on the Chinese philosophy of Taoism. According to tai chi principles, everything in the universe is made up of two opposing yet united forces, yin and yang. Tai chi movements are intended to build up the Qi, the intrinsic energy that runs throughout the body along pathways know as meridians. The object is to harmonize the body and mind and become aware of internal conflicts that may be causing tension ^{(54; 102)}.

4. Diet and Nutrition

Switching to a diet that is healthier can relieve stress for people who do not already have a healthy diet already, especially for people who are overweight. No dietary secrets or miracle diets can lead to long-term stress reduction (or weight loss). People just need to eat right ⁽⁵⁴⁾. The following recommendations may be helpful for people who want to improve their diet:

• Eat more fresh fruits and vegetables, enough so that fresh fruits and vegetables make up 50% to 75% of your diet.
• Avoid processed foods and all foods that are stressful for the body, such as artificial sweeteners, carbonated soft drinks, chocolate, eggs, fried foods, junk foods, pork, red meat, sugar, white flour products, foods containing preservatives or heavy spices, and chips and similar snack foods.
• Try getting rid of dairy products from your diet for 3 weeks. Then, slowly add them back into your diet and see if stress responses coincide with them.
• Avoid caffeine.
• Avoid alcohol, nicotine, and mood-altering drugs.
• Follow a monthly fasting program, but make sure you know what you are doing! ⁽¹¹⁾

Additionally, the following herbs are useful for relief from stress and problems associated with stress:

• Lemon balm is a general remedy for stress and helps with stress-related digestive problems.
• Damiana is a general remedy for stress and helps with anxiety and depression after long-term stress.
• Skullcap is a general remedy for stress and helps with headaches and panic attacks.
• St. John's wort is a general remedy for stress, depression in particular.
• Motherwort helps with panic attacks.
• Linden helps with panic attacks and a fast or irregular heart beat.
• Dan shen help with a fast or irregular heart beat.
• Valerian helps with chronic anxiety and hyperactivity.
• Codonopsis helps with nervous exhaustion, muscle tension, and headaches.
• Ginseng (also called panax ginseng) and Siberian ginseng help with short-term stress.
• Withania helps with long-term stress and recovery from illness and fatigue. ⁽³⁴⁾
• Catnip causes drowsiness.
• Chamomile is a gentle relaxant and helps with stress-related digestive problems.
• Hops helps with nervousness and restlessness.
• Kava kava relaxes the mind and the rest of the body.
• Passionflower is calming.
• Polygala root is soothing and calming.
• Sour jujube seed is soothing and calming. ⁽¹¹⁾

Regarding herbs, it is important to remember that they can interact with medications that people may be taking and may have adverse sideeffects for some people. Advice from a professional, such as a physician or an herbalist, should be sought before taking herbs.

5. Medication

Over-the-counter pain relievers are used frequently by many people to relieve the pain of some problems associated with stress ⁽¹³⁾. Regarding prescription drugs for stress, amitriptyline, an antidepressant drug, has been used to treat tension headaches ⁽¹¹³⁾. Additionally, a wide variety of prescription drugs are used to treat mental disorders and physical illnesses associated with stress. Anxiety and depressive disorders, for instance, are often treated with antianxiety agents and antidepressants, respectively. Examples of antianxiety agents are as follows:

• Benzodiazepines
• Buspirone
• Clomipramine
• Clonidine
• Hydroxyzine
• Meprobamate (and other beta-blockers)
• Propranolol

Examples of antidepressants are as follows:

• Heterocyclic (or multicyclic) antidepressants (HCAs): tricyclic antidepressants (TCAs), maprotiline, and amoxapine
• Selective serotonin reuptake inhibitors (SSRIs)
• Monoamine-oxidase inhibitors (MAOIs)
• Atypical antidepressants: bupropion, nefazodone trazodone, venlafaxine ⁽¹⁰⁵⁾

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