Table Of ContentThe Nature and
Treatment of the
Stress Response
A Practical Guide for Clinicians
The Nature and
Treatment of the
Stress Response
A Practical Guide for Clinicians
Jr.
George S. Everly,
University of Maryland
College Park. Maryland
and
Robert Rosenfeld
Walter Reed Army Medical Center
Washington, D.C.
with
Roger J. Allen
Lora C. Brown
Steven A. Sobelman
Harold J. Wain
PLENUM PRESS· NEW YORK .AND LONDON
Library of Congress Cataloging in Publication Data
Everly, George S 1950-
The nature and treatment of the stress response.
Includes index.
1. Stress (Psychology) 2. Stress (Physiology)l. Rosenfeld, Robert, 1945- joint
author. II. Title. [DNLM: 1. Stress, Psychological. 2. Stress, Psychological-Therapy.
WM 172 E93nJ
BF575.S75E88 616'.001'9 80-28550
ISBN-13: 978-1-4613-3242-8 e-lSBN-13: 978-1-4613-3240-4
001: 10.1007/978-1-4613-3240-4
First Printmg-March 1981
Second Printmg-February 1983
© 1981 Plenum Press, New York
Softcover reprint of the hardcover 1s t edition 1981
A DIvision of Plenum Publishing Corporation
233 Spring Street, New York, N.Y. 10013
All rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the publisher
To MARIDETH ROSE EVERLY, the new love in our lives
and to BECKY and JESSICA
Preface
Barely more than twenty years ago the inquiry into the nature and
implications of the psychophysiologic stress response seemed to be
restricted to laboratory animals. Today, however, scientists from a
wide range of disciplines are studying stress and its implications for
human health and disease. This may be because our technical ability
actually to measure the phenomenon has increased, as has our
understanding of human psychophysiology. Just as important, how
ever, may be the fact that we have entered a new era of disease.
According to Kenneth Pelletier, we have entered upon an era in
which stress plays a dominant role in the determination of human
disease. Pelletier has stated that up to 90% of all disease may be
stress-related. Whether this estimation seems inflated or not, the fact
remains that clinicians of all kinds, including physicians, psychologists,
physical therapists, social workers, and counselors, are daily being
confronted with clients suffering from excessive psychophysiologic
stress arousal. This fact has created a need to know more about the
stress response and its treatment.
Although more and more health-care professionals are directly or
indirectly working with clients who manifest excessive stress, there
has been no text previously written which attempted to condensE'
between the covers of a single volume a practical, clinically compre
hensive discussion of what stress is (as best we currently understand
it) and how to treat it when it becomes excessive.
This book was created to serve two basic functions: first, as a
reference for practicing clinicians-whether they be physicians, psy-
vii
viii PREFACE
chologists, nurses, physical therapists, social workers, counselors, or
health educators of any type; second, as a textbook for the growing
number of courses which deal with the management or treatment of
excessive stress. Our intent is not to present the final, definitive word
on the subject but to offer the first practical digest of clinical
interventions into the problem of excessive psychophysiological stress
arousal. We must be quick to add that, in writing such a condensed
text, the need arises to take a generic view of many topics. On the one
hand, this can be a refreshing presentation of old issues that may yield
new insight; on the other, in condensing material as must be done to
create such a text, occasional omissions are inevitable. Therefore,
wherever useful, we have chosen to cite primary sources, more
elaborate discussions, or complete reviews in order to give the reader
the advantage of access to more detailed information as it pertains to
the issues discussed herein.
Because clinical practice is sometimes an art as well as a science,
we have chosen occasionally to include our own "useful clinical
perspectives," sometimes known as biases. However, when such
perspectives are based on a wide range of clinical experience, they may
prove of some value to the less experienced clinician.
This text, then, represents a digest covering many of the most
commonly used, and a few relatively new, clinical interventions into
the problem of excessive psychophysiologic stress arousal. Our main
purpose is to provide an up-to-date, practical, and clinically useful
guide to the nature and treatment of the stress response.
GEORGE S. EVERLY, JR., PH.D.
ROBERT ROSENFELD, M.D.
Washington, D. C.
Acknowledgmen ts
We should like to thank the following individuals for their help in
making this book possible: Betty Donovan, for meeting the unrealistic
deadlines we placed on her typing skills, and for keeping a smile on her
face through the entire process; Dr. Daniel Stern, for reviewing a
portion of the manuscript; Flora Beaudet, for the illustrations in
Chapters 1 and 2; Henry Schoebel, for the illustrations in Chapter 10;
Jim Donnelly, for his technical assistance; Leonard R. Pace, our friend
at Plenum, for his encouragement and support, as well as his
professional insight; and finally our families, for their understanding
and support.
ix
Contents
Part One
The Stress Response and Its Treatment 1
Chapter 1
What is Stress? 3
Defining Stress ........................................... 3
Treating Excessive Stress-Clinical Assumptions ............. 4
Plan of the Book .......................................... 9
Part Two
The Nature of the Stress Response 11
Chapter 2
The Nervous Systems and the Stress Response 13
The Organization of the Human Nervous Systems ........... 14
Introduction to the Stress Response. . . . . . . . . . . . . . . . . . . . . . . . . 19
The Initiation of the Stress Response-CNS
Mechanisms ...................................... 19
Neural Axes-Stress Response via Direct Neural
Innervation of End-Organs. . . . . . . . . . . . . . . . . . . . . . . . . 21
"Fight or Flight" Response-The Neuroendocrine
Axis ............................................. 23
xi
xii CONTENTS
Endrocrine Axes and the "General Adaptation
Syndrome" ....................................... 25
Posterior Pituitary Axis ................................ 28
Summary-The Stress Response ........................... 29
Chapter 3
Fr om Stress to Disease 33
Theoretical Bases for the Development of Stress-Related
Diseases .......................................... 33
Lachman's Model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Sternbach's Model. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Gastrointestinal Disorders ....................... ,.,....... 36
Peptic Ulcers .......................................... 37
Ulcerative Colitis ...................................... 38
Cardiovascular Disorders .................................. 38
Respiratory Disorders ..................................... 39
Allergy............................................... 39
Bronchial Asthma ..................................... 40
Hyperventilation ...................................... 40
Musculoskeletal Disorders ................................. 41
Skin Disorders ............................................ 41
The Immune System ...................................... 42
Psychological Manifestations of the Stress Response. . . . . . . . . . 42
Summary................................................. 44
Chapter 4
The Measurement of the Stress Response 47
Chemical Measurement. ...... .. .............. .. .. .. .... ... 47
17-0HCS ............................................ 48
Catecholamines ....................................... 48
Electromyographic Measurement ........................... 49
Cardiovascular Measurement .............................. 50
Electrodermal Measurement ............................... 51
Psychological Measurement ................................ 52
Minnesota Multiphasic Personality Inventory (MMPI) .... 52
The Sixteen Personality Factor (16 P-F) ................. 53
Taylor Manifest Anxiety Scale (T AS) ................... 54
CONTENTS xiii
State-Trait Anxiety Inventory (ST AI) .... . . . . . . . . . . . . . . . 54
Affect Adjective Checklist (AACL) ...................... 54
Subjective Stress Scale (SSS) ........................... 54
Profile of Mood States (POMS) ......................... 55
Law of Initial Value ....................................... 55
Summary................................................. 56
Part Three
The Treatment of the Stress Response 59
Chapter 5
Self-Responsibility as a Therapeutic Force 61
Human Development and Self-Responsibility ................ 61
Philosophical Perspectives on Self-Responsibility ............. 62
Self-Responsibility and Excessive Stress ..................... 63
The Role of Therapeutic Client Education ................... 65
The Role of Counseling and Psychotherapy .................. 68
Summary................................................. 69
Chapter 6
Dietary Recommendations and the Stress Response 71
Summary................................................. 76
Chapter 7
The Pharmacological Treatment of the Stress Response 77
Sedative-Hypnotics-An Introductory History ............... 78
The Barbiturate Sedative-Hypnotic Agents .................. 79
Nonbarbiturate Sedative-Hypnotics ......................... 81
The Antianxiety Agents ................................... 82
The Propanediols .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
The Benzodiazepines .................................. 83
Antihistamines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Beta Adrenergic Blocking Agents ....................... .84
Tricyclic Antidepressants .............................. 85
Phenothiazines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Summary and Conclusions ................................. 87
