STRESS AND HEALTH
Stress and Illness.
To study how stress and healthy and unhealthy behaviors influence health and illness, psychologists and physicians created the interdisciplinary field of behavioral medicine, integrating behavioral and medical knowledge. Health psychology provides psychology’s contribution to behavioral medicine. For psychologists, health is more than “merely the slowest possible rate at which one can die”. Health psychologists ask: How do our emotions and personality influence our risk of disease? What attitudes and behaviors help prevent illness and promote health and wellbeing? How do our perceptions of a situation determine the stress we feel? How can we reduce or control stress?
Stress is a slippery concept. We sometimes use the word informally to describe threats or challenges (“Ben was under a lot of stress”), and at other times our responses (“Ben experienced acute stress”). To a psychologist, the dangerous truck ride was a stressor. Ben’s physical and emotional responses were a stress reaction. And the process by which he related to the threat was stress.
Thus, stress is not just a stimulus or a response. It is the process by which we appraise and cope with environmental threats and challenges. Stress arises less from events themselves than from how we appraise them. One person, alone in a house, dismisses its creaking sounds and experiences no stress; someone else suspects an intruder and becomes alarmed. One person regards a new job as a welcome challenge; someone else appraises it as risking failure. When short-lived, or when perceived as challenges, stressors can have positive effects.
A momentary stress can mobilize the immune system for fending off infections and healing wounds. Stress also arouses and motivates us to conquer problems. Championship athletes, successful entertainers, and great teachers and leaders all thrive and excel when aroused by a challenge. Having conquered cancer or rebounded from a lost job, some people emerge with stronger self-esteem and a deepened spirituality and sense of purpose. Indeed, some stress early in life is conducive to later emotional resilience.
Adversity can beget growth. But stressors can also threaten us. And experiencing severe or prolonged stress may harm us. Children’s physiological responses to severe child abuse put them at later risk of chronic disease. Those who had post-traumatic stress reactions to heavy combat in the Vietnam War went on to suffer greatly elevated rates of circulatory, digestive, respiratory, and infectious diseases.
The Stress Response System
Medical interest in stress dates back to Hippocrates. Walter Cannon confirmed that the stress response is part of a unified mind-body system. He observed that extreme cold, lack of oxygen, and emotion-arousing incidents all trigger an outpouring of the stress hormones epinephrine and norepinephrine from the central core of the adrenal glands. This is but one part of the sympathetic nervous system’s response. When alerted by any of a number of brain pathways, the sympathetic nervous system, as we have seen, increases heart rate and respiration, diverts blood from digestion to the skeletal muscles, dulls pain, and releases sugar and fat from the body’s stores—all to prepare the body for the wonderfully adaptive response that Cannon called fight or flight.
Since Cannon’s time, physiologists have identified an additional stress response system. On orders from the cerebral cortex (via the hypothalamus and pituitary gland), the outer part of the adrenal glands secrete glucocorticoid stress hormones such as cortisol. The two stress hormone systems work at different speeds, explains biologist Robert Sapolsky: “In a fight-or-flight scenario, epinephrine is the one handing out guns; glucocorticoids are the ones drawing up blueprints for new aircraft carriers needed for the war effort.” The epinephrine guns were firing at high speed during an experiment inadvertently conducted by British Airways on an April 23, 1999, flight from San Francisco to London. Three hours after takeoff, a mistakenly played message told passengers the plane was about to crash into the sea. Although the flight crew immediately recognized the error and tried to calm the terrified passengers, several required medical assistance. These passengers can empathize with those on a 2005 JetBlue flight as it circled Southern California for hours with faulty landing gear. Many of the plane’s passengers became severely distressed, some crying, by the “surreal” experience of watching onboard satellite TV news broadcasts speculating on their fate.
There are alternatives to fight-or-flight. One is a common response to the stress of a loved one’s death: Withdraw. Pull back. Conserve energy. Faced with an extreme disaster, such as a ship sinking, some people become paralyzed by fear. Another stress response, especially common among women, report Shelley Taylor and her colleagues, is to seek and give support: Tend and befriend.
Facing stress, men more often than women tend to socially withdraw, turn to alcohol, or become aggressive. Women more often respond to stress by nurturing and banding together, which Taylor attributes partly to oxytocin, a stress-moderating hormone associated with pair-bonding in animals and released by cuddling, massage, and breastfeeding in humans.
Canadian scientist Hans Selye’s 40 years of research on stress extended Cannon’s findings and helped make stress a major concept in both psychology and medicine. Selye studied animals’ reactions to various stressors, such as electric shock, surgical trauma, and immobilizing restraint. He discovered that the body’s adaptive response to stress was so general—like a single burglar alarm that sounds no matter what intrudes—that he called it the general adaptation syndrome (GAS).
Selye saw the GAS as having three phases. Let’s say you suffer a physical or emotional trauma. In Phase 1, you experience an alarm reaction due to the sudden activation of your sympathetic nervous system. Your heart rate zooms. Blood is diverted to your skeletal muscles. You feel the faintness of shock. With your resources mobilized, you are now ready to fight the challenge during Phase 2, resistance.
Your temperature, blood pressure, and respiration remain high, and there is a sudden outpouring of hormones. If persistent, the stress may eventually deplete your body’s reserves during Phase 3, exhaustion. With exhaustion, you are more vulnerable to illness or even, in extreme cases, collapse and death.
Few medical experts today quarrel with Selye’s basic point: Although the human body comes designed to cope with temporary stress, prolonged stress can produce physical deterioration. The brain’s production of new neurons slows. In one study, women who suffered enduring stress as caregivers for children with serious disorders displayed a symptom that is a normal part of the aging process—shorter bits of DNA at the ends of their chromosomes. When these DNA pieces, called telomeres, get too short, the cell can no longer divide, and it ultimately dies. The most stressed women had cells that looked a decade older than their chronological age, which may help explain why severe stress seems to age people. Even fearful, easily stressed rats have been found to die sooner (after about 600 days) than their more confident siblings, which average 700-day life spans. Such findings serve as further incentives to today’s health psychologists, as they ask: What causes stress? And how does stress affect us?
Stress and the Heart.
Elevated blood pressure is just one of the factors that increase the risk of coronary heart disease, the closing of the vessels that nourish the heart muscle. Although infrequent before 1900, this condition became by the 1950s North America’s leading cause of death, and it remains so today. In addition to hypertension and a family history of the disease, many behavioral and physiological factors—smoking, obesity, a high-fat diet, physical inactivity, and an elevated cholesterol level—increase the risk of heart disease. The psychological factors of stress and personality also play a big role.
In a now-classic study, Meyer Friedman, Ray Rosenman, and their colleagues tested the idea that stress increases vulnerability to heart disease. They measured the blood cholesterol level and clotting speed of 40 U.S. tax accountants. They found that from January through March, both of these coronary warning indicators were completely normal. Then, as the accountants began scrambling to finish their clients’ tax returns before the April 15 filing deadline, their cholesterol and clotting measures rose to dangerous levels. In May and June, with the deadline past, the measures returned to normal. The researchers’ hunch had paid off:
Stress predicted heart attack risk.
The stage was set for Friedman and Rosenman’s classic nine-year study of more than 3000 healthy men aged 35 to 59. At the start of the study, they interviewed each man for 15 minutes about his work and eating habits. During the interview, they noted the man’s manner of talking and other behavioral patterns. Those who seemed the most reactive, competitive, hard-driving, impatient, time-conscious, supermotivated, verbally aggressive, and easily angered they called Type A. The roughly equal number who were more easygoing they called Type B. Which group do you suppose turned out to be the most coronary prone?
By the time the study was complete, 257 men had suffered heart attacks; 69 percent of them were Type A. Moreover, not one of the “pure” Type Bs—the most mellow and laid-back of their group—had suffered a heart attack.
As often happens in science, this exciting discovery provoked enormous public interest. But after the honeymoon period, in which the finding seemed definitive and revolutionary, other researchers began asking: Is the finding reliable? If so, what is the toxic component of the Type A profile: Time-consciousness? Competitiveness? Anger?
More recent research has revealed that Type A’s toxic core is negative emotions—especially the anger associated with an aggressively reactive temperament. Type A individuals are more often “combat ready.”
You may recall from this chapter’s discussion of anger that when we are harassed or challenged, our active sympathetic nervous system redistributes bloodflow to our muscles and away from internal organs such as the liver, which normally removes cholesterol and fat from the blood. Thus, a Type A person’s blood may contain excess cholesterol and fat that later get deposited around the heart. Further stress—sometimes conflicts brought on by the person’s own abrasiveness—may trigger the altered heart rhythms that, in those with weakened hearts, can cause sudden death.
Hostility also correlates with other risk factors, such as smoking, drinking, and obesity. In important ways, people’s minds and hearts interact. The effect of an anger-prone personality appears most noticeably in studies in which interviewers assess verbal assertiveness and emotional intensity. One study of young and middle-aged adults found that those who react with anger over little things are the most coronary-prone, and suppressing negative emotions only heightens the risk. Another study followed 13,000 middle-aged people for 5 years. Among those with normal blood pressure, people who had scored high on anger were three times more likely to have had heart attacks, even after researchers controlled for smoking and weight. The link between anger and heart attacks also appeared in a study that followed 1055 male medical students over an average of 36 years. Those who had reported being hot-tempered were five times more likely to have had a heart attack by age 55. As Charles Spielberger and Perry London put it, rage “seems to lash back and strike us in the heart muscle.”
Pessimism seems to be similarly toxic. Laura Kubzansky and her colleagues studied 1306 initially healthy men who a decade earlier had scored as optimists, pessimists, or neither. Even after other risk factors such as smoking had been ruled out, pessimists were more than twice as likely as optimists to develop heart disease. Depression, too, can be lethal. The accumulated evidence from 57 studies suggests that “depression substantially increases the risk of death, especially death by unnatural causes and cardiovascular disease”. One study of 7406 women age 67 or older found that among those with no depressive symptoms, 7 percent died within six years, as did 24 percent of those with six or more depressive symptoms. In the years following a heart attack, people with high scores for depression are four times more likely than their low-scoring counterparts to develop further heart problems.
Depression is disheartening.
Recent research suggests that heart disease and depression may both result when chronic stress triggers persistent inflammation. Stress, as we will see, disrupts the body’s disease-fighting immune system, thus enabling the body to focus its energies on fleeing or fighting the threat. Yet stress hormones enhance one immune response, the production of proteins that contribute to the inflammation. Although inflammation helps fight infections, persistent inflammation can produce problems such as asthma or clogged arteries, and even, it now seems, depression.
Stress and Susceptibility to Disease.
Not so long ago, the term psychosomatic described psychologically caused physical symptoms. To laypeople, the term implied that the symptoms were unreal—“merely” psychosomatic. To avoid such connotations and to better describe the genuine physiological effects of psychological states, most experts today refer instead to stressrelated psychophysiological illnesses, such as hypertension and some headaches.
Stress also affects our resistance to disease, and this understanding has led to the burgeoning development of the field of psychoneuroimmunology (PNI). PNI studies how psychological, neural, and endocrine processes affect our immune system (psychoneuro-immunology), and how all these factors influence our health and wellness.
Hundreds of new experiments reveal the nervous and endocrine systems’ influence on the immune system. Your immune system is a complex surveillance system that defends your body by isolating and destroying bacteria, viruses, and other foreign substances. This system includes two types of white blood cells, called lymphocytes. B lymphocytes form in the bone marrow and release antibodies that fight bacterial infections. T lymphocytes form in the thymus and other lymphatic tissue and attack cancer cells, viruses, and foreign substances—even “good” ones, such as transplanted organs. Two other important agents of the immune system are the macrophage (“big eater”), which identifies, pursues, and ingests harmful invaders and worn-out cells, and the natural killer cells (NK cells), which pursue diseased cells (such as those infected by viruses or cancer). Age, nutrition, genetics, body temperature, and stress all influence the immune system’s activity.
Your immune system can err in two directions. Responding too strongly, it may attack the body’s own tissues, causing arthritis or an allergic reaction. Underreacting, it may allow a dormant herpes virus to erupt or cancer cells to multiply. Women are immunologically stronger than men, making them less susceptible to infections (Morell, 1995). But this very strength also makes them more susceptible to selfattacking diseases, such as lupus and multiple sclerosis. Your immune system is not a headless horseman. The brain regulates the secretion of stress hormones, which lessens the disease-fighting lymphocytes. Thus, when animals are physically restrained, given unavoidable electric shocks, or subjected to noise, crowding, cold water, social defeat, or maternal separation, their immune systems become less active. One study monitored immune responses in 43 monkeys over six months. Twenty-one were stressed by being housed with new roommates—three or four new monkeys—each month. (To empathize with the monkeys, recall the stress of leaving home to attend school or summer camp, and imagine having to repeat this experience monthly.) Compared with monkeys left in stable groups, the socially disrupted monkeys experienced weakened immune systems. Stress similarly depresses the immune system of humans.
Consider some striking and consistent results:
• Surgical wounds heal more slowly in stressed animals and humans. In one experiment, dental students received punch wounds (precise small holes punched in the skin). Compared with wounds placed during summer vacation, those placed three days before a major exam healed 40 percent more slowly. In fact, reported Janice Kiecolt-Glaser and her co-researchers, “no student healed as rapidly during this stressful period as during vacation.”
• Compared with the healing of punch wounds in unstressed married couples, either the stress of a 30-minute marital spat or ongoing marital conflict caused punch wounds to take a day or two longer to heal.
• In another experiment, 47 percent of participants living stress-filled lives developed colds after a virus was dropped in their noses, as did only 27 percent of those living relatively free of stress. In follow-up research, the happiest and most relaxed people were likewise markedly less vulnerable to an experimentally delivered cold virus.
• Managing stress may be life-sustaining. The one personality trait shared by 169 centenarians (people over 100) is their ability to manage stress well.
The stress effect on immunity makes physiological sense. It takes energy to fight infections and maintain fevers. Thus, when diseased, our bodies reduce muscular energy output by inactivity and increased sleep. But stress creates a competing energy need. Stress triggers an aroused fight-or-flight response, diverting energy from the disease-fighting immune system to the muscles and brain, rendering us more vulnerable to illness. The bottom line: Stress does not make us sick, but it does alter our immune functioning, making us less able to resist infection and more prone to heart disease.
Stress and AIDS
AIDS has become the world’s fourth leading cause of death and thenumber one killer in Africa. As its name tells us, AIDS is an immune disorder—an acquired immune deficiency syndrome caused by the human immunodeficiency virus (HIV), which is spread by the exchange of bodily fluids, primarily semen and blood. If a disease spread by human contact kills slowly, as does AIDS, it ironically can be lethal to more people: Those who carry the virus have time to spread it, often without realizing they are infected. When the HIV infection manifests itself as AIDS, some years after the initial infection, the person has difficulty fighting off other diseases, such as pneumonia. Worldwide, reports the United Nations, more than 20 million people have died of AIDS. (In the United States, where “only” a half-million of these fatalities have occurred, AIDS has killed more people than did combat in all the twentieth-century wars.) In 2007, worldwide some 2.7 million—half of them women—were infected with HIV, often without their awareness.
So if stress restrains the immune system’s response to infections, could it also exacerbate the course of AIDS? Researchers have found that stress and negative emotions do correlate with (a) a progression from HIV infection to AIDS, and (b) the
speed of decline in those infected. HIV-infected men faced with stressful life circumstances, such as the loss of a partner, exhibit somewhat greater immune suppression and a faster disease progression.
Would efforts to reduce stress help control the disease? Although the benefits are small compared with available drug treatments, the answer appears again to be yes. Educational initiatives, bereavement support groups, cognitive therapy, relaxation training, and exercise programs that reduce distress have all had positive consequences for HIV-positive individuals. Better yet is preventing HIV infection, which is the focus of many educational programs, such as the ABC (abstinence, being faithful, condom use) program used in many countries, with seeming success in Uganda.
Stress and Cancer
Stress and negative emotions have also been linked to cancer’s rate of progression. To explore a possible connection between stress and cancer, experimenters have implanted tumor cells into rodents or given them carcinogens (cancer-producing substances). Those rodents also exposed to uncontrollable stress, such as inescapable shocks, were more prone to cancer. With immune systems weakened by stress, tumors developed sooner and grew larger.
Some investigators have reported that people are at increased risk for cancer within a year after experiencing depression, helplessness, or bereavement. One large Swedish study revealed that people with a history of workplace stress had 5.5 times greater risk of colon cancer than those who reported no such problems, a difference not attributable to differing age, smoking, drinking, or physical characteristics. Other researchers have found no link between stress and human cancer.
Concentration camp survivors and former prisoners of war, for example, have not exhibited elevated cancer rates. One danger in hyping reports on attitudes and cancer is that some patients may then blame themselves for their illness—“If only I had been more expressive, relaxed, and hopeful.” A corollary danger is a “wellness macho” among the healthy, who take credit for their “healthy character” and lay a guilt trip on the ill: “She has cancer? That’s what you get for holding your feelings in and being so nice.” Dying thus becomes the ultimate failure.
Behavioral medicine research provides yet another reminder of one of contemporary psychology’s overriding themes: Mind and body interact; everything psychological is simultaneously physiological. Psychological states are physiological events that influence other parts of our physiological system. Just pausing to think about biting into an orange section—the sweet, tangy juice from the pulpy fruit flooding across your tongue—can trigger salivation. As the Indian sage Santi Parva recognized more than 4000 years ago, “Mental disorders arise from physical causes, and likewise physical disorders arise from mental causes.” There is an interplay between our heads and our health. We are biopsychosocial systems.
Promoting Health. Coping With Stress.
Promoting health begins with implementing strategies that prevent illness and enhance wellness. Traditionally, people have thought about their health only when something goes wrong—visiting a physician for diagnosis and treatment. That, say health psychologists, is like ignoring a car’s maintenance and going to a mechanic only when the car breaks down. Health maintenance includes alleviating stress, preventing illness, and promoting well-being.
Stressors are unavoidable. This fact, coupled with the fact that persistent stress correlates with heart disease, depression, and lowered immunity, gives us a clear message. We need to learn to cope with the stress in our lives. We address some stressors directly, with problem-focused coping. For example, if our impatience leads to a family fight, we may go directly to that family member to work things out. If, despite our best efforts, we cannot get along with that family member, we may also incorporate an emotion-focused coping, such as reaching out to friends to help address our own emotional needs.
When challenged, some people tend to respond more with cool problem-focused coping, others with emotion-focused coping.
We tend to use problem-focused strategies when we feel a sense of control over a situation and think we can change the circumstances or change ourselves. We turn to emotion-focused strategies when we cannot—or believe we cannot—change a situation. We may, for example, seek emotional distance from a damaging relationship or keep busy with active hobbies to avoid thinking about an old addiction. Emotion-focused strategies can be nonadaptive, however, as when students worried about not keeping up with the reading in class go out to party to get it off their mind. Sometimes a problem-focused strategy (catching up with the reading) more effectively reduces stress and promotes long-term health and satisfaction. Several factors affect our ability to cope successfully, including our feelings of personal control, our explanatory style, and our supportive connections.
If two rats receive simultaneous shocks, but one can turn a wheel to stop the shocks, the helpless rat, but not the wheel turner, becomes more susceptible to ulcers and lowered immunity to disease. In humans, too, uncontrollable threats trigger the strongest stress responses. For example, a bacterial infection often combines with uncontrollable stress to produce the most severe ulcers.
To cure the ulcer, kill the bug with antibiotics and control the stomach’s acid secretions with reduced stress. Perceiving a loss of control, we become more vulnerable to ill health. Elderly nursing home residents who have little perceived control over their activities tend to decline faster and die sooner than do those given more control over their activities. Workers given control over their work environment—by being able to adjust office furnishings and control interruptions and distractions—also experience less stress. This helps explain why British civil service workers at the executive grades outlive those at clerical or laboring grades, and why Finnish workers with low job stress are less than half as likely to die of cardiovascular disease (strokes or heart disease) as are those with a demanding job and little control. The more control workers have, the longer they live.
Control may also help explain a well-established link between economic status and longevity. In one study of 843 grave markers in an old graveyard in Glasgow, Scotland, those with the costliest, highest pillars (indicating the most affluence) tended to have lived the longest. Likewise, Scottish regions with the least overcrowding and unemployment have the greatest longevity. There and elsewhere, high economic status predicts a lower risk of heart and respiratory diseases (Sapolsky, 2005). Wealthy predicts healthy among children, too. With higher economic status comes reduced risks of infant mortality, low birth weight, smoking, and violence. Even among other primates, those at the bottom of the social pecking order are more likely than their higher-status companions to become sick when exposed to a coldlike virus. But for those high-status baboons and monkeys who frequently have to physically defend their dominant position, high status also entails stress.
Researchers are debating the explanation for the income-health correlation, because poor health can lower income and because intelligence scores also correlate with both income and health. But this much seems clear: Poverty and diminished control entail physiologically measurable stress, even among children.
Why does perceived loss of control predict health problems? Animal studies show—and human studies confirm—that losing control provokes an outpouring of stress hormones. When rats cannot control shock or when primates or humans feel unable to control their environment, stress hormone levels rise, blood pressure increases, and immune responses drop. Captive animals therefore experience more stress and are more vulnerable to disease than are wild animals (Roberts, 1988). The crowding that occurs in high-density neighborhoods, prisons, and college and university dorms is another source of diminished feelings of control—and of elevated levels of stress hormones and blood pressure.
Optimism and Health
Another influence on our ability to cope with stress is whether our basic outlook is optimistic or pessimistic. Psychologists Michael Scheier and Charles Carver have reported that optimists—people who agree with statements such as, “In uncertain times, I usually expect the best”—perceive more control, cope better with stressful events, and enjoy better health. During the last month of a semester, students previously identified as optimistic report less fatigue and fewer coughs, aches, and pains.
And during the stressful first few weeks of law school, those who are optimistic (“It’s unlikely that I will fail”) enjoy better moods and stronger infection-thwarting immune systems. Optimists also respond to stress with smaller increases in blood pressure, and they recover more quickly from heart bypass surgery.
Consider the consistency and startling magnitude of the optimism and positive emotions factor in several other studies:
• One research team followed 941 Dutch people, ages 65 to 85, for nearly a decade. Among those in the lowest optimism quartile, 57 percent died, as did only 30 percent of the top optimism quartile.
• When Finnish researchers followed 2428 men for up to a decade, the number of deaths among those with a bleak, hopeless outlook was more than double that found among their optimistic counterparts.
• Another study asked 795 Americans ages 64 to 79 years if they were “hopeful about the future.” When the researchers checked up on these folks about 5 years later, 29 percent of those answering no had died—more than double the 11 percent of deaths among those who said yes.
• A now-famous study followed up on 180 Catholic nuns who had written brief autobiographies at about 22 years of age.
Despite living thereafter with similar life-styles and status, those who had expressed happiness, love, and other positive feelings lived an average 7 years longer than their more dour counterparts. By age 80, some 54 percent of those expressing few positive emotions had died, as had only 24 percent of the most positive-spirited.
Those who manage to find humor in life’s daily events also seem to benefit. Among 54,000 adult Norwegians, those scoring in the top quarter on humor appreciation were 35 percent more likely to be alive 7 years later, and the difference was even greater within a cancerpatient subgroup. There is not yet enough consistent evidence to suggest that “laughter is the best medicine”. But some studies suggest that mirthful humor (not hostile sarcasm) may defuse stress and strengthen immune activity. People who laugh a lot (which arouses, massages muscles, and relaxes the body) also have exhibited a lower incidence of heart disease. In one experiment, laughter in response to a hilarious movie clip caused the blood vessels’ inner lining to respond with improved tone and increased blood flow, the opposite of what happened after people viewed a stressful movie clip. Perhaps future research will confirm that, indeed, those who laugh, last.
Social support also matters. That’s what James Coan and his colleagues (2006) discovered when they subjected happily married women to the threat of electric shock to an ankle while lying in an fMRI machine. During the experiment, some of the women held their husband’s hand. Others held the hand of an anonymous person or no hand at all. While awaiting the occasional shocks, the women’s brains were less active in threat-responsive areas if they held their husband’s hand. This soothing benefit was greatest for those reporting the highest-quality marriages.
For most of us, family relationships provide not only our greatest heartaches (even when well-meaning, family intrusions can be stressful) but also our greatest comfort and joy. How can we explain this link between social support and health? Is it because healthy people are more supportive and marriage-prone? Possibly. But people with supportive friends and marriage partners eat better, exercise more, sleep better, and smoke less, and therefore cope with stress more effectively. Supportive friends can also help buffer immediate threats. Humans aren’t the only source of stress-buffering comfort. After stressful events, Medicare patients who have a dog or other companionable pet are less likely to visit their doctor
Having a sense of control, developing more optimistic thinking, and building social support can help us experience less stress and thus improve our health. Moreover, these factors interrelate: People who are upbeat about themselves and their future tend also to enjoy healthpromoting social ties. But sometimes we cannot alleviate stress and simply need to manage our stress. Aerobic exercise, biofeedback, relaxation, meditation, and spirituality may help us gather inner strength and lessen stress effects.