Stress: Any stimulus, internal state, situation, or event with an observable
individual reaction, usually in the form of positively adapting or negatively adapting to a new or different situation in one’s environment. The concept generally refers to the nature of an experience, resulting from the person interacting in the context of their his or her environment, through either physiological overarousal or underarousal, with an outcome of psychologi- cal or physiological distress (bad stress outcome) or eustress (good stress outcome). Stressors range from minor to major and can be positive or negative events. Generally, stressors are life events such as daily annoy- ances, pressures at home or on the job, marital discord and conflicts, emer- gencies, motor vehicle accidents, illness, and injury. Positive stressful life events and transitions include birth of a child, a graduation ceremony, a family vacation, and a job promotion.
Mason (1975) developed one of the most inclusive operational definitions of stress, stressors, and stressful experiences. Mason delineated a conceptual framework and application of three different definitions of stress to unravel some of the confusion with general usage of the concept. Stress may be caused by (1) an internal state of the organism, also known as strain based on both the physiological and psychological reactions; (2) an external event
or stressor, such as combat trauma and natural disasters; major life events, such as marriage, divorce, and being laid off; noxious environmental stress- ors, such as air pollution and overcrowding; or role strain, such as a bad marriage; or (3) an experience that arises from a transaction between a per- son and his or her environment, particularly where there is a mismatch or poor fit between the individual’s resources and the perceived challenge, threat, or need (Mason, 1975).
Hans Selye (1956) concluded from his influential physiological research, “Stress is part of life. It is a natural by-product of all our activities. . . . The secret of life is the successful adjustment to ever-changing stress” (pp. 299–300). According to Selye’s general adaptation syndrome, there are gen- erally three stages in the human body’s reaction to extreme stress. First is the alarm reaction, in which the body stirs its defense mechanisms—the glands, hormones, and nervous system—into action. Second is the adaptation stage, when the body fights back (e.g., the arteries can harden when the heart is under pressure). Third is the exhaustion stage, when the body’s defenses seem to be unable to cope, and the individual becomes seriously ill and may die (Selye, 1956). Selye concludes that the best way to survive and thrive is to adapt and respond in positive ways to the stress of life.
Stressors frequently are characterized as ranging from minor to major and as negative or positive stimuli or events. They are inclusive of daily problems. Sometimes they appear as pressure; at other times, stressors are described as disturbing annoyances. Events such as intense marital strife/discord, physical illness of family members and friends, hospitalization of family members, caring for children and loved ones, accidents, emergencies, being responsible for a special needs child or terminally ill aging parent, job pressure to per- form, financial difficulties, and even moving across town or severe weather can present as stressors. The challenges that are framed by stress, both posi- tive and negative, provide defining structures for meaning in our day-to-day lives. The complete absence of stress can lead to boredom and lack of mean- ing in one’s life. Too much stress, or a pile-up of multiple stressors without effective coping, frequently can have a detrimental impact on an individual’s physical and mental health.
Some careers, such as rescue work, emergency service work, surgical and emergency medicine, and law enforcement, are known to be highly stressful and physically demanding. In these high-stress jobs, people may thrive, be continually reenergized, and experience occupational growth, or they may encounter vicarious traumatization. Dr. Hans Selye, a Nobel Laureate and founder of the International Institute of Stress in Montreal, in an interview with Modern Maturity magazine (Wixen, 1978) stated that he thrives on and enjoys considerable satisfaction from an extremely demanding schedule. Directly prior to the interview, Dr. Selye had spoken at a major medical conference in Europe, slept four hours, then traveled 2,500 miles to Houston and his next interview and conference speaking engagement. The next day
he flew to Montreal and two days later began a nine-day speaking tour throughout Scandinavia. Dr. Selye never tries to avoid stress; instead, he indicated that stress gives him pleasure and a great degree of satisfaction (Wixen, 1978). In contrast, Regehr’s (2001) recent article focuses on vicari- ous traumatization of the hidden victims of disaster and emergency rescue work and the positive and negative effects of group crisis intervention and critical incident stress debriefings with worker stress reactions and the symp- toms of PTSD. Regehr systematically reviews the strengths and limitations of crisis debriefing groups.
When intensely stressful life events and well-documented physiological events are placed in motion, these physiological responses to stressors are best described as a chain of biochemical reactions that have the potential to impact all major organ systems. Stress begins in the brain. Reaction to per- ceived stressful or emergency events triggers what Walter Cannon (1927) described as the fight or flight response. In response to neurochemical mes- sages, a complex chain reaction is triggered, impacting specifically serotonin, norepinephrine, and dopamine. Adrenal glands release adrenaline and other hormones. The immediate physiological response is an increased heart rate and blood pressure, dilated pupils, and a heightened sense of alertness. These responses are linked to the survival mechanism of the human and have been present since the beginning of humankind (Chrousos & Gold, 1992; Haddy & Clover, 2001; McEwen, 1995).
Many have attempted to answer the question of the impact of stress. Sim- ply put, how much stress is too much? There appears to be no definitive answer, as the same amount and type of stress may lead to negative conse- quences for one individual and have little to no impact on another. Thomas Holmes and Richard Rahe (1967) constructed a social readjustment rating scale after asking hundreds of people from a variety of backgrounds their response to changing life events and to rank the relative degree of adjustment necessary to address these life-change units (LCUs). For example, a child leav- ing for college= 28 LCUs; job promotion = 31 LCUs; marital separation = 56 LCUs; and death of a spouse= 100 LCUs. An accumulation of 200 or more LCUs in a single year increases the incidence of psychosomatic disorders. Dohrenwend and Dohrenwend (1974) trace the relationship between stressful life events and physical illnesses as well as psychiatric disorders. Their review of the research indicates that a pile-up of certain types of stress- ful life events is correlated with depression, heart disease, and attempted suicide. There is some research evidence that specific types of stressful life events, such as marriage, marked trouble with your boss, being incarcerated, and death of a spouse, can play a significant role in the causation of several psychosomatic and psychiatric disorders (Dohrenwend & Dohrenwend, 1974). However, it should be noted that Dohrenwend and Dohrenwend doc- ument the methodological flaws and sampling biases in many of the early studies and aptly recommend greater use of prospective designs and con-
trolled studies and development of reliable and measurable attributes of stressful life events and environmentally anchored measures.
Specific psychic stress: May be defined as a specific personality response
or an unconscious conflict that causes a homeostatic disequilibria contrib- uting to the development of psychosomatic disorder. (Kaplan & Sadock, 1998, p. 826)
The changes that the body experiences in response to stress have long been thought to present a remarkable health threat. Franz Alexander (1950) hypothesized that unconscious conflicts are associated with certain psycho- somatic disorders. For example, Friedman and Rosenman (1959) identified the high-strung, so-called Type A personality as a stress response that predis- poses a person to coronary disease. Clinical studies continue to confirm the connection between stress and vulnerability to illness, for instance, in de- creased resistance to infection. There is remarkable evidence that persons under intense stress for long periods of time are more susceptible to the common cold. Recent research demonstrated some of the impact of stress on the immune system’s ability to fight illness. One such study demonstrated that women who scored highest on psychological stress scales had a shortage of cytokines, a set of proteins produced by the immune system to aid in the healing process. Despite recent advances, medical researchers are unable to explain the highly individualized response to stress. Many conclude that en- vironmental factors combined with genetic makeup and innate coping skills are the best determinants of an individual’s personal reaction to stress (Pow- ell & Matthews, 2002).
Crisis: An acute disruption of psychological homeostasis in which one’s
usual coping mechanisms fail and there exists evidence of distress and functional impairment. The subjective reaction to a stressful life experience that compromises the individual’s stability and ability to cope or function. The main cause of a crisis is an intensely stressful, traumatic, or hazardous event, but two other conditions are also necessary: (1) the individual’s per- ception of the event as the cause of considerable upset and/or disruption; and (2) the individual’s inability to resolve the disruption by previously used coping mechanisms. Crisis also refers to “an upset in the steady state.” It often has five components: a hazardous or traumatic event, a vulnerable state, a precipitating factor, an active crisis state, and the resolution of the crisis. (Roberts, 2002, p. 1)
This definition of crisis is particularly applicable to persons in acute crisis because these individuals usually seek help only after they have experienced a hazardous or traumatic event and are in a vulnerable state, have failed to lessen the crisis through customary coping methods, lack family or commu- nity social supports, and want outside help. Acute psychological or situa-
tional crisis episodes may be viewed in various ways, but the definition we are using emphasizes that a crisis can be a turning point in a person’s life. Crisis intervention occurs when a counselor, behavioral clinician, or thera- pist enters into the life situation of an individual or family to alleviate the impact of a crisis episode by facilitating and mobilizing the resources of those directly affected. Rapid assessment and timely intervention on the part of crisis counselors, social workers, psychologists, or child psychiatrists is of paramount importance. Crisis intervenors should be active and directive while displaying a nonjudgmental, accepting, hopeful, and positive attitude. Crisis intervenors need to help crisis clients to identify protective factors, inner strengths, psychological hardiness, or resiliency factors that can be uti- lized for ego bolstering. Effective crisis intervenors are able to gauge the seven stages of crisis intervention, while being flexible and realizing that several stages of intervention may overlap. Crisis intervention should culmi- nate in a restoration of cognitive functioning, crisis resolution, and cognitive mastery (Roberts, 2000a).
Acute Stress Disorder: The development of characteristic anxiety, dissocia-
tive and other symptoms that occurs within one month after exposure to an extreme traumatic stressor. As a response to the traumatic event, the individual develops dissociative symptoms. Individuals with Acute Stress Disorder may have a decrease in emotional responsiveness, often finding it difficult or impossible to experience pleasure in previously enjoyable activ- ities, and frequently feel guilty about pursuing usual life tasks. (American Psychiatric Association [APA], 2000)
Beyond a physiological response to stress, a sudden remarkable stressor (e.g., physical violence or threatened physical violence) can provoke more that a flight-or-fight response, triggering a psychiatric illness referred to as Acute Stress Disorder. A combined grouping of dissociative and anxiety symptoms with the avoidance of reminders of the traumatic event character- ize this anxiety disorder. Dissociative symptoms are frequently present and include emotional detachment, temporary loss of memory, derealization, and depersonalization. Potential anxiety-based symptoms associated with Acute Stress Disorder may include but are not limited to irritability, confused and disordered thoughts, sleep disturbance, and being easily startled. The emer- gence of symptoms occurs within one month of a traumatic event. Associ- ated features in the diagnostic criteria are symptoms that significantly inter- fere with normal social or vocational functioning. Symptoms associated with Acute Stress Disorder last between two days and four weeks. This disorder is a relatively new diagnostic category. It was introduced in 1994 in an effort to differentiate time-limited reaction to trauma and to provide clear delinea- tion between brief stress reactions from extended reactions to trauma from PTSD (APA, 2000).
Trauma: Psychological trauma refers to human reactions to traumatic
stress, violent crimes, infectious disease outbreaks, and other dangerous and life-threatening events. For psychological trauma to occur, the individ- ual’s adaptive pathways become shut off as a result of overexposure to stress hormones. Persistent hyperarousal mechanisms related to the trau- matic event continually reoccur and are amplified by traumatic recollec- tions stored in the brain. The victims of trauma find themselves rapidly alternating their mental states between relatively calm and peaceful states to states of intense anxiety, agitation, anger, hypervigilance, and extreme arousal. (Roberts, 2002a, pp. 2–3)
Psychological trauma, or the human trauma response, can take place soon after observing or being the victim of a traumatic stressor or event. This is usually the case in Acute Stress Disorder. However, many times, individuals have a delayed reaction to a traumatic event, and this delay of several weeks to several months usually surfaces in the form of symptoms of psychological trauma such as avoidance of familiar surroundings, intense fears, sudden breaking of appointments, social isolation, trance-like states, sleep distur- bances and repeated nightmares, depressive episodes, and hyperarousal.
According to Terr (1994), there are two types of trauma among children. Type I refers to victims who have experienced and suffered from a single traumatic event, such as the 26 Chowchilla, California, children who were kidnapped in 1976 and buried alive in their school bus for almost 27 hours. Type II trauma refers to experiencing multiple traumatic events, such as on- going and recurring incest, child abuse, or family violence. The exception is an extremely horrific single traumatic occurrence that is marked by multiple homicides and includes dehumanizing sights (e.g., dismembered bodies), pierc- ing sounds, and strong odors (fire and smoke).
The American Academy of Experts in Traumatic Stress (ATSM) is a mul- tidisciplinary network of professionals dedicated to formulating and extend- ing the use of traumatic stress reduction protocols with emergency respond- ers (e.g., police, fire, EMS, nurses, disaster response personnel, psychologists, social workers, funeral directors, and clergy). Dr. Mark D. Lerner, a clinical psychologist and president of ATSM, and Dr. Raymond D. Shelton, Director of Emergency Medical Training at the Nassau County (New York) Police Training Academy and director of professional development for ATSM, pro- vide the following guidance for addressing psychological trauma quickly during traumatic events:
All crisis intervention and trauma treatment specialists are in agreement that before intervening, a full assessment of the situation and the individ- ual must take place. By reaching people early, during traumatic exposure, we may ultimately prevent acute traumatic stress reactions from becoming chronic stress disorders. The first three steps of Acute Traumatic Stress Management (ATSM) are: (1) assess for danger/safety for self and others;
(2) consider the type and extent of property damage and/or physical injury and the way the injury was sustained (e.g., a terroristic explosion); and (3) evaluate the level of responsiveness—is the individual alert, in pain, aware of what has occurred, or in emotional shock or under the influence of drugs? (Lerner & Shelton, 2001, pp. 31–32)
Personal impact in the aftermath of potentially stressful and crisis-produc- ing events can be measured by:
• Spatial dimensions: The closer the person is to the center of the tragedy, the greater the stress. Similarly, the closer the person’s relationship is to the homicide victim, the greater the likelihood of entering into a crisis state.
• Subjective crime clock: The greater the duration (estimated length of time exposed and estimated length of exposure to sensory experiences, e.g., an odor of gasoline combined with the smell of a fire) that an indi- vidual is affected by the community disaster, violent crime, or other tragedy, the greater the stress.
• Reoccurrence (perceived): The greater the perceived likelihood that the tragedy will happen again, the greater the likelihood of intense fears, which contribute to an active crisis state on the part of the survivor (Young, 1995).
Posttraumatic Stress Disorder: A set of typical symptoms that develop after
a person sees, is involved in, or hears of “an extreme traumatic stressor.” PTSD is an acute, chronic, delayed, debilitating, and complex mental dis- order. It includes altered awareness, detachment, dissociative states, ego fragmentation, personality changes, paranoid ideation, trigger events, and vivid intrusive traumatic recollections. PTSD is often comorbid with major depression, dysthymia, alcohol or substance abuse, and generalized anxiety disorder. The person reacts to this experience with fear and helplessness, sleep disturbances, hyperarousal and hypervigilance, persistently reliving the event through graphic and magnified horrific flashbacks and intrusive thoughts, and unsuccessful attempts to avoid being reminded of it. The symptoms must last for more than a month and must significantly affect important areas of life. (APA, 2000)
Some stressors are so severe that almost anyone is susceptible to the over- whelming effects of the experience. PTSD can arise from war experiences, torture, natural disasters, terrorism, rape, assault, or serious accidents. A recent example reflective of this is the random sniper shootings in Rockville, Maryland, and Virginia. In today’s society, television is spreading individual reaction to traumatic stressors. Examples of this can be seen daily when persons cast their eyes to the sky in fear as a jet flies over or stoop low beside their car while pumping gasoline. The complete impact of vicarious stressors as delivered through multimedia bombardment is not examined in this chapter; however, this subject warrants further examination.
The history of PTSD begins with Jacob DaCosta’s 1871 paper “On Irrita- ble Heart,” describing the symptoms of stress witnessed in Civil War sol- diers. The disorder was referred to as “traumatic neurosis,” resulting from the strong influence of psychoanalysis. This was replaced by the term “shell shock” during World War I, as psychiatrists hypothesized this was the im- pact of brain trauma resulting from the percussion blows of exploding bombshells. It was not until 1941, when the survivors of the Coconut Grove nightclub fire began to demonstrate symptoms of nervousness, nightmares, and graphic recollections of the tragedy, that the definition was expanded to include operational fatigue, delayed grief, and combat neurosis. It was not until the return of Vietnam War veterans that the notion of posttrau- matic disorder emerged in its current context. Throughout the history of this disorder one inescapable fact has been present: The appearance of the disor- der was roughly correlated with the severity of the disorder, with the most severe stressors resulting in the emergence of characteristic symptomatology in 75% of the victims.
The critical feature of PTSD is the development of characteristic symp- toms following exposure to an extreme traumatic stressor involving direct