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Assessing the Effects of Stress on Physical Symptoms

William E. Whitehead

Stress researchers, in attempting to circumvent methodological problems in correlation studies, have


resorted to analytical techniques that increase the likelihood of a Type II error. For instance, studies
suggesting that stress plays no role in irritable bowel syndrome are at variance with a large body of clinical
experience and may be in error. Several measurement issues are discussed, but the most significant concerns
the way investigators deal with individual differences in chronic levels of stress and symptoms. J. Suls and
colleagues, in this issue, recommend correcting for these individual differences before estimating the
relationship between stress and symptoms, but this is illogical because most stressors are chronic—they are
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

related to the social and economic circumstances in which people live. A more important confound, not
This document is copyrighted by the American Psychological Association or one of its allied publishers.

considered by most investigators, is the contribution of somatization to stress assessment and symptom
reports.

Key words: stress, irritable bowel syndrome, somatization, life event scale,
hassles and uplifts, Type II error, time series

The stress hypothesis refers to the proposition that events happen- hypothesis for irritable bowel syndrome). However, I begin by
ing to people contribute significantly to the development of physical commenting briefly on other conceptual and methodological issues
or psychological disorders (Hinkle, 1973; Holmes &Rahe, 1967).It enumerated above.
would be difficult to overestimate the influence that this hypothesis
has had on contemporary psychology. It stimulated the development Is Stress a Stimulus or a Response?
of a number of psychological treatment techniques (collectively
called stress-management training), and it is the most common All models of stress treat it as an interaction between external
reason given to patients to persuade them to accept referral to a events and characteristics of the person. It is recognized that some
psychologist for treatment. events, such as being criminally assaulted, distress almost every one
Despite its popularity, however, the stress hypothesis has been but that individuals differ in how much they react to even the most
difficult to definitively prove because of both conceptual and meth- traumatic events. For relatively mild events, such as telephoning a
odological problems. Among the conceptual issues are (a) confusion stranger, individual differences in reactivity are particularly pro-
overwhether stress should be thoughtof as astimulus or as aresponse nounced. Stress researchers differ in the emphasis that they give to
and (b) a failure to distinguish between specific and nonspecific the stimulus variables versus the person variables, and this has led to
reactions to environmental events (e.g., is ablood pressure increase two very different traditions in the assessment of stress.
in response to immersing one's hand in ice water a stress response or In an effort to make stress research more objective and scientific,
a reflex?). Methodological problems with the evaluation of the stress Holmes and Rahe (1967) defined stressors as external events requir-
hypothesis include (a) confounding of dependent and independent ing adaptation by the individual, and they proposed to measure stress
variables, (b) unreliability of retrospective reports, (c) selecting the by counting the number of stressful events—events that had previ-
proper time scale for looking at the relationship between stress and ously been shown to cause distress in most people—to which the
physical symptoms, and (d) dealing with individual differences in individual had been exposed. This measurement approach has come
the chronic level of stress and bowel symptoms. to be called life event scaling. The important characteristics of the
The article by Suls, Wan, and Blanchard (1994) provides a model of stress that underlies life event scaling are (a) the events are
thoughtful analysis of several of these methodological problems and conceived as happening to subjects rather than being consequences
provides new analytical techniques for dealing with them. It is also of their personality or behavior, (b) the events are stressful to (i. e.,
a good example of the shift in contemporary stress research away require behavioral adaptation by) most people, and (c) the events are
from a focus on the effects of stress on aggregated symptom reports thought to be uninfluenced by the health outcomes that they are
and toward a focus on specific disorders or constellations of symp- intended to predict.
toms. I comment on the approach recommended by Suls et al. and on An alternative approach to stress measurement is the Hassles and
the conclusions they draw with regard to the role of stress in the Uplift Scale (DeLongis, Coyne, Dakof, Folkman, & Lazarus, 1982).
irritable bowel syndrome because I believe their approach may have This is based on a quite different model of stress, which proposes that
led them to a Type II error (i.e., to prematurely dismiss the stress it is not the events themselves, but the subject's cognitive appraisal
of the demands of the situation in relation to his or her goals and
abilities to cope that contributes to the development of illness.
This editorial was supported by Grants KO5 MH00133 and RO1 DK31369. Because DeLongis and colleagues view the cognitive appraisal as
Correspondence concerning this article should be addressed to William E. more important than the stimulus, they measure stress in terms of the
Whitehead, Division of Digestive Diseases, CB#7 80 Burnett-Womack Build- amount of distress or "hassle" occasioned by daily events. The
ing, University of North Carolina, Chapel Hill, North Carolina 27599-7080. criticism of this point of view is that the degree of distress associated
Health Psychology. 1994, Vol. 13. No. 2,99-102
Copyright 1994 by the American Psychological Association. Inc.. and the Division of Health Psychology/0278-6133/94/$3.00

99
100 WILLIAM E. WHTTEHEAD

with everyday events is so importantly influenced by personality 2. It is easier to investigate the physiological and psychological
characteristics or psychological traits that it may not be possible to mechanisms by which stressful external events influence symptoms.
measure stress (the reaction) independently of these personality Investigators have shown that psychological stress increases smooth
traits. For a debate on this issue, seeB. S. Dohrenwend, Dohrenwend, muscle tonein the distal bowel (Kollmannsperger, Musial, Mueller,
Dodson, and Shrout (1984); Lazarus, DeLongis, Folkman, and & Crowell, in press), increases motility in the colon (Fukudo &
Gruen (1985); and B. P. Dohrenwend and Shrout (1985). Suzuki, 1987;Welgan,Meshkinpour,&Beeler, 1988) but not in the
Both the proponents of life event scaling and the supporters of the esophagus (Soffer, Scalabrini, Pope, & Wingate, 1988), and changes
hassles approach agree that external events can only contribute to whole gut transit time by speeding it up in diarrhea-predominant
illness by means of physiological or psychological arousal. This patients and by slowing it down in constipation-predominant pa-
would appear to argue in favor of the hassles approach (or of tients (Cann, Read, Brown, Hobson, & Holdsworth, 1983).
alternative measures of distress). However, the distinction between 3. The differential effects of specific classes of stressors can be
these two conceptual approaches does have important practical investigated. Thomas Almy (1951) suggested many years ago that
consequences. Whether dealing with an individual patient or inves- the emotions of anger and helplessness had different effects on the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

tigating the etiology and course of a disorder such as irritable bowel motility of the distal colon, and this was supported by Welgan and
This document is copyrighted by the American Psychological Association or one of its allied publishers.

syndrome, we want to know whether the patient is showing anormal colleagues (Welgan et al., 1988). Other studies suggest that trau-
response to abnormal circumstances or an abnormal response to matic events during childhood, including loss of a parent through
normal circumstances. If the former, we would invest more effort in death or marital dissolution (Hislop, 1979; Lowman, Drossman,
modifying the environment (e.g., foster home placement or marital Cramer, & McKee, 1987) and sexual abuse (Drossman etal., 1990),
separation), but if the latter, we would place more emphasis on may be specifically associated with functional gastrointestinal disor-
teaching coping and stress-management techniques. ders.
Some investigators (Paykel, 1983; Sarason, Johnson, & Siegel,
1978; Whitehead, Crowell, Robinson, Heller, & Schuster, 1992) Methodological Problems Related to the Use
have dealt with this dilemma by using a life events scale first but then of Correlational Study Designs
asking the subject to rate the amount of distress occasioned by each
event and using these distress ratings as weighting factors. It is then Stress researchers have shown a strong preference for correla-
possible to look separately at the number of stressful life events and tional study designs despite the limitations of this approach, some of
at the distress occasioned by those events. An alternative is to use which are summarized below. The principal reason for preferring
both a life events scale and a distress scale. In either case, it is useful correlational designs over experiments is that itis unethical, and also
to administer a personality test and to examine the extent to which impractical, to expose subjects to the kinds of events that they report
variance in the stress measure is explained by neuroticism or nega- as occurring and as affecting their health status; laboratory stressors
tive affectivity. are a pale imitation of life, and psychophysiological reactions to
them often habituate rapidly. Investigating the effects of disasters
that have affected large groups also has limitations: It is costly to
Specific Versus Nonspecific Effects of Stressors
keep a research team prepared to get to the site of a disaster quickly,
pending litigation may compromise the openness of subjects to
In his pioneering work on stress, Hans Selye (1956) distinguished inquiry, and no baseline data is available. However, some traumas
between specific reactions to the noxious events he presented to his are predictable (e.g., elective surgery or complications of diabetes
experimental animals (e.g., infection, cold exposure, and blood loss) mellitus) and could provide a good alternative to correlational
and the nonspecific response that he found to be common to all studies.
noxious events and that he described as the general adaptation Confounding of dependent and independent variables. Some of
syndrome. However, when this concept was adopted by psycholo- the items on life event scales may be a consequence of illness instead
gists to account for the psychophysiological effects of psychological of (or in addition to) being acause of illness. Examples are financial
stressors, the distinction between specific and nonspecific reactions worries andjob loss. Paykel (1983) recommended asking subjects to
was largely ignored. Most studies in the last 25 years have used identify whether stressful life events were consequences of specific
measures of stress that sum together all types of stressful events and illnesses and then eliminating those items from the analysis.
have looked at the relationship of such stress measures to aggregate Unreliability of retrospective reports. Jenkins, Hurst, and Rose
measures of illness or physical symptoms (e.g., Holmes & Rahe, (1979) showed that recall for stressful life events occurring more
1967). This continues to occur even though, as Suls et al. (1994) point than 3 months previously was so inaccurate as to be useless. The
out, different experimental stressors have different effects on some effects of poorrecall were compounded by the tendency for subjects
of the outcome measures of interest. to search for explanations for their physical symptoms and to fall
A salutary shift in stress research, which is exemplified by the back on the popular belief that stress could be the cause. The solution
work of Suls et al. in this issue, is the investigation of stress effects to this problem was to ask for recall only for the previous 3 months
on a specific disorder or constellation of symptoms. There are (e.g., Whitehead et al., 1992). Craig and Brown (1984) recom-
several advantages to this approach: mended use of an intensive interview—sometimes supplemented by
1. One can compare patients to healthy controls, to learn whether an examination of the subject's personal documents—to increase the
the patients show a greater reactivity to stressful events. In irritable accuracy of recall, but a better solution, which is illustrated by the
bowel syndrome, patients do show greater reactivity than controls in Suls et al. (1994) article and by other studies (Grant, Yager,
symptom reports (Whitehead et al., 1992) as well as physiological Sweetwood, & Olshen, 1982), is to measure both stress and symp-
reactivity (Whitehead, Engel, & Schuster, 1980). toms prospec lively.
ASSESSING THE EFFECTS OF STRESS ON PHYSICAL SYMPTOMS 101

Selecting the proper time scale. Depue and Monroe (1986) pointed bowel symptoms with somatization partialed out was .17 (p < .01),
out the problems that could arise when one failed to distinguish which was modest but statistically significant. The range of the
chronic illness from acute symptoms or, in general, when one failed partial correlation for the four 3-month intervals examined was. 11
to take the natural history of a disorder into account. The duration of to .25. The median partial correlation between stress in one 3-month
somatic symptoms may last from minutes (e.g., abdominal pain or interval and bowel symptoms in the next 3-month interval, with
postprandial diarrhea) to weeks (e.g., constipation). Moreover, the somatization partialed out, was .16 (p < .01). Thus, somatization
symptoms of disorders such as irritable bowel syndrome and inflam- does contribute significantly to individual differences in chronic
matory bowel disease are often organized into "bouts" or "flare- levels of stress and chronic levels of bowel symptoms, but the
ups," which last from a few days to a few months. The duration of correlation between stress and bowel symptoms, whether measured
stressful events also varies greatly. When using any of the time- concurrently or by lagged correlations, remains significant when
series techniques recommended by Suls et al. (1994), itis important adjusted for somatization.
to remember that the correlation between a f as t event and a slow one Likelihoodofa Type II error. Even if one accepts the assumptions
is bound to be lower than the correlation between events of similar of Suls et al. (1994) that the chronicity of stress and symptoms is a
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

duration. Because not enough is known about the natural history of problem that has to be dealt with statistically, their approach appears
This document is copyrighted by the American Psychological Association or one of its allied publishers.

irritable bowel syndrome to select the best units of time for observa- to be too conservative. On logical grounds, one can easily demon-
tions, the approach taken by Suls and colleagues of analyzing the strate that when two highly correlated predictor variables, which are
time series in successively smaller units of time has much to also highly correlated with the outcome variable, are entered into a
recommend it. multiple regression analysis, the first predictor variable to be entered
Dealing with individual differences in chronic levels of stress and will appear to be a robust predictor, whereas the second predictor
symptom reports. Individuals who score high on stress scales at one variable will appear to make weak, probably statistically nonsignifi-
point in time tend to be the same people who score high at another cant, contributions to the outcome variable, because its inclusion
time, and similarly, individuals who score high on physical symptom does not add to the predictive power. This kind of outcome should not
scales at one time tend to score high at a later time also. This is a be interpreted to mean that the second predictor variable is unrelated
robust phenomenon: In a study in which we measured stressful life to the outcome variable; it can only be interpreted to mean that under
events and bowel symptoms in four successive 3-month periods the circumstances, one cannot prove that the predictor variable
(Whitehead et al., 1992), the median correlation between stress entered second is related to the outcome variable. The regression
scores in consecutive 3-month intervals was .42, and the median analysis provides ahigh level of protection against aType I statistical
correlation between bowel symptom scores in successive 3-month error, but at the cost of a high likelihood of a Type II error (i.e.,
intervals was .70. These autocorrelations were greater than the missing a real relationship between stress and illness). (Alternative
median correlation between stress and bowel symptoms for the same statistical methods are available, which allow one to estimate the
3-month period (r =.25) or the lagged correlation between stress in relative contribution of each predictor variable independent of order
one 3-month interval and bowel symptoms in the next 3-month effects, but these are seldom used.)
interval (r=. 26). Several published observations suggest, contrary to what one
How should these autocorrelations be interpreted? Depue and would infer from the analysis of Suls et al. (1994), that there is (or at
Monroe (1986) drew attention to part of the problem, thechronicity least that there may be) a relationship between stress and bowel
of physical symptoms, and viewed it as a contaminant that had to be symptoms in irritable bowel syndrome: (a) Most investigators find
dealt with by extracting any variance attributable to the persistence that patients with irritable bowel syndrome score higher than control
of physical symptoms before examining the stress—physical symp- subjects, who do not have irritable bowel syndrome, on stressful life
tom correlation. Suls et al. (1994) made the same assumption, and event scales, even after correcting for neuroticism (Mendeloff,
they recommended extraction of both the variance associated with Monk, Seigel, & Lilienfeld, 1964; Whitehead et al., 1992). (b)
symptom persistence and the variance associated with the persis- Eighty-five percent of people with irritable bowel syndrome report
tence of high levels of stress. However, these individual differences that stressful events trigger exacerbations of their symptoms
in the chronic level of stress and of physical symptoms are exactly (Drossman, Sandier, McKee, & Lovitz, 1982), and more than half
what one would expect on the basis of the stress hypothesis: Because report that a major stress preceded the onset of their first bowel
many stressors are chronic and are associated with the social and symptoms (Hislop, 1971). (c) Stress-management training in the
economic circumstances in which people live, it is reasonable that form of cognitive behavior therapy (Blanchard et al., 1992) or in the
some subjects should have consistently high levels of stress. Itis also form of brief psychotherapy designed to teach more effective ways
reasonable that those subjects should be the ones who have chronic of coping (Guthrie, Creed, Dawson, &Tomenson, 1991) appears to
or recurring physical symptoms. significantly benefit patients with irritable bowel syndrome.
It is possible, however, that individual differences in chronic Under most circumstances, there is very little cost associated with
levels of stress and chronic levels of physical symptoms could reflect a Type II error. In evaluating new treatments, for example, it is less
nothing more than somatization (i.e., a tendency to endorse many costly to reject a marginally effective new treatment than it is to
symptoms). To test this, we reexamined our data on stress and bowel approve or endorse a worthless treatment. However, much harm
symptoms by adjusting for the number and severity of symptoms could be done by prematurely rejecting the stress hypothesis for
reported on the Moos (1985) Menstrual Distress Questionnaire as irritable bowel syndrome or other psychophysiological disorders
occurring during the follicular phase of the menstrual cycle; because because this hypothesis is sodeeply entrenched: Itis widely believed
this is a time when the menstrual-related symptoms on the Moos by clinicians, patients, and the general public; it is supported by
scale should be minimal, we interpreted these scores as measures of many clinical data; and it is the theoretical basis for effective
somatization. The median partial correlation between stress and treatment. Perhaps the conclusions of Suls et al. (1994) and of our
102 WILLIAM E. WHITEHEAD

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bowel syndrome. Medical Journal of Australia, 1, 372-374.
Holmes, T. H., & Rahe, R. H. (1967). The social readjustment rating scale.
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