Despite these direct behavioral pathways to health, most discussions of adaptive and mal-adaptive coping refer to the creation or reduction of physiological changes over extended periods of time (Ursin and Olff, 1993). In addressing such effects of stress and coping, one might focus at several levels of abstraction. The focus could be on episodic change in some endocrine or immune parameter, emergence of an intermediate disease state such as atherosclerosis, or eventual emergence of full-blown clinical events such as heart attacks. Outcomes at all these levels have been examined. Here we provide just a few relevant examples at several levels.
One set of physiological parameters that has received attention concerns the stress hormone Cortisol. In general, problem-focused and approach coping styles are related to lower overall levels of cortisol, more favorable diurnal cortisol rhythms, and faster recovery to normal patterns after a stressor (Mikolajczak et al, 2007; Nicolson, 1992; O'Donnell et al, 2008; Sjogren et al, 2006). A number of qualities that reflect social integration and support have also been linked to favorable cortisol profiles. Use of social support relates to lower daily cortisol levels (O'Donnell et al, 2008). Social isolation (living alone and little contact with friends and family) predicts a greater cortisol response at awakening and greater cortisol output over the day (Grant et al, 2009). Higher levels of religiosity have also been associated with favorable cortisol patterns in women with fibromyalgia, even after controlling for social support (Dedert et al, 2004).
Coping responses have also been linked to variations in immune system functioning. For example, among HIV patients, those who showed difficulty in recognizing and expressing their emotions had higher levels of an immune marker related to HIV disease progression (Temoshok et al, 2008). Also among HIV patients, those expressing disengagement tendencies had higher viral loads and lower immune cell counts (Wald et al, 2006). In a non-patient sample, instrumental coping was linked to better immune system functioning, along with lower HPA activation (Olff et al, 1995).
Another intermediate physiological condition that has received a good deal of attention is atherosclerosis. A good deal is known about stress and atherosclerosis, though less about coping. Even mild chronic stress promotes atherosclerosis in laboratory animals, a process that seems to be mediated by HPA activation, reflected in elevated stress hormones (Kumari et al, 2003). Inflammatory immune responses, which are induced by stress, are central to development of atherosclerosis (Libby, 2006), acting as a mediator between stress and atherosclerosis (Black, 2006; see Grippo and Johnson, 2009, for review).
Chronic occupational stress consistently predicts hypertension and atherosclerosis (Everson-Rose and Lewis, 2005; Sparrenberger et al, 2009), but social disruptions can also create chronic stress, with similar results. For example, both social isolation and crowding promote atherosclerosis in monkeys (Shively et al, 1989). Similar relationships have been found between social disruption (social isolation and lack of perceived social support) and atherosclerosis in humans (Everson-Rose and Lewis, 2005; Smith and Ruiz, 2002).
Another body of work examines disease progression. Studies have shown that denial coping and lower satisfaction with social support relate to the progression from HIV to AIDS (Leserman et al, 2000). Optimism, active coping, and spirituality show some evidence of predicting slower disease progression (Ironson and Hayward, 2008). A meta-analysis of coping among men with prostate cancer found that approach coping (both problem-focused and emotion-focused) improved physical outcomes such as self-reported fatigue and physical well-being, and that avoidance coping was associated with lower self-reported physical functioning (Roesch et al, 2005).
Cardiovascular disease is unusual in that there are both gradually developing outcomes (e.g., atherosclerosis) and also more abrupt outcomes (e.g., heart attacks). Negative emotional states have been linked to atherosclerosis (Everson-Rose and Lewis, 2005; Suls and Bunde, 2005) and also to triggering of acute cardiac events (Steptoe and Brydon, 2009). The latter effect is not limited to high arousal emotions such as anger. Acute depressed mood is also a trigger of cardiac events (Steptoe et al, 2006). Fitting this, bereavement is an acute stressor that has been long associated with elevated rates of cardiac events (Parkes, 1964). The acute stressor need not be death, disaster, or war, however. A recent study showed that watching a stressful soccer match more than doubled the risk of cardiac events for men in Germany (Wilbert-Lampen et al, 2008).
Enough research has examined coping and health-related outcomes in nonclinical samples to warrant a meta-analysis (Penley et al, 2002). This analysis found that certain kinds of problem-focused coping (self-control and use of social support) related positively to diverse kinds of good health outcomes (ranging from self-reports of symptoms to objective illness-related measures), while other types of coping (e.g., confrontive coping and wishful thinking) related to poorer health outcomes. There were also cases in which the controllability of the stressor and whether the stressor was acute or chronic moderated the relationship between coping and outcomes. For example, distancing was related to poorer health outcomes when the stressor was chronic and controllable; taking responsibility was related to poorer outcomes when the stressor was acute and uncontrollable.
Another meta-analysis was reported even more recently, on a more focused set of studies (Moskowitz et al, 2009). All of these studies examined persons with HIV. Outcomes were categorized as emotional, health-related behavior, and physical. Coping that involved direct action and positive reappraisal had consistently positive relations to better results across all categories of outcome. Disengagement coping was consistently associated with poorer outcomes.
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