Riley O’Neill, MA
Doctoral Candidate, University of Arizona Clinical Psychology Program
2023 SfHP Graduate Student Research in General Health Psychology Awardee
Psychosocial stress is robustly associated with risk for chronic and infectious disease (Cohen et al., 2007; O’Connor et al., 2021). For example, greater chronic stress exposure has been estimated to predict 23% to 60% increases in lifetime risk for coronary heart disease (Gallo et al., 2014; Steptoe & Kivimäki, 2012, 2013). Despite the strength of observed stress-health associations and decades of research aimed at explicating the mechanisms that link stress to health, the core processes of our daily stress experiences remain obscured. These gaps in understanding are reflected in sub-optimal impacts of stress management interventions that have been developed to ameliorate the negative outcomes of several stress-related health conditions (e.g., irritable bowel syndrome, chronic pain syndrome) (Anheyer et al., 2017; Horn et al., 2023; Nagele et al., 2014; Schakel et al., 2019).
Many investigators have posited that the challenges with accurately elucidating stress-health processes are driven by a lack of ecologically valid models of daily stress experiences (Biggs et al., 2017; Monroe & Kelley, 1995; Obbarius et al., 2021). Contemporary theorists have pushed back against foundational stress-health theories that viewed stress as a discrete experience and have developed more ecologically valid “process” models that may better characterize stress effects throughout daily life. For example, the Generalized Unsafety Theory of Stress (GUTS) (Brosschot et al., 2018) and Social Safety Theory (SST) (Slavich, 2020) posit that stress may be predominantly experienced through ongoing safety-related awareness and contextual monitoring. In contrast to classic theories focused on exposure-response comparisons, these contemporary theories describe a “persistent activity model” wherein humans are constantly evaluating their environments for cues as to whether they are safely connected to others and able to access protective resources. In these modern frameworks, awareness of safety signals is the key determinant of real-world stress responses.
Importantly, both theories explicitly state that humans are in a constant state of contextual safety evaluation or “vigilance.” It is this vigilance that is hypothesized to influence a cascade of behavioral, physiological, and psychological reactions. To understand how active contextual monitoring may be a key biobehavioral process through which stress “gets under the skin,” we can look to empirical support for vigilance-reactivity associations and to the growing emphasis on attention-bias modification within psychosocial interventions for health. In two early studies conducted using an adapted signal detection paradigm and pre-task monitoring of a competitor, Gump and Matthews (1998) and Smith and colleagues (2000) demonstrated that vigilance of social stimuli was associated with the types of heightened vascular reactivity patterns that have been extensively linked to cardiovascular disease risk (Chida & Steptoe, 2010; Kamarck et al., 2018). More recently, O’Neill and colleagues (in press) found that experimental tasks inciting more vigilance behavior evoked significantly greater cardiovascular reactivity sustained throughout a 30-minute task period and less post-task recovery towards baseline physiological functioning than comparable tasks with less vigilance demand.
This small body of early empirical support demonstrates active monitoring of one’s environment for safety or threat is associated with physiological reactivity patterns that are believed to link stress to health risks. Furthermore, many psychosocial interventions for health include elements focused on modifying attentional bias to stimuli to reduce individuals’ vigilance of threatening sensations. Each of the leading empirically supported psychotherapeutic treatments for insomnia, chronic pain syndromes, and disorders of gut-brain-interaction provide interventions for decreasing patients’ persistent monitoring of physical sensations and overall arousal (Altena et al., 2023; Kinsinger, 2017; Majeed et al., 2019). For example, a recent randomized control trial examining pain reprocessing therapy (PRT) for chronic back pain, a psychotherapeutic intervention aiming to reduce chronic pain patients’ symptom vigilance and appraisal of physical sensations as threatening, demonstrated significant reductions in self-reported pain among PRT patients compared to placebo or usual care patients immediately post-treatment and at 1-year follow-up (Ashar et al., 2022).
Despite evidence from early empirical work and leading psychosocial interventions for stress-related health conditions, vigilance remains under addressed by health psychology researchers and practitioners. To better address the impacts of psychosocial stress on physical wellbeing, we should conceptualize stress as a continuous process of awareness of cues regarding threats and safety. For mechanistic investigators, this conceptual shift may include incorporating contextual determinants (e.g., geo-coded crime risk, residential area deprivation index scores, proximity to sociocultural enclaves) and direct assessments of vigilant behavior (e.g., Social Vigilance Questionnaire; Ruiz et al., 2017) into examinations of stress experiences and associated health impacts. Relatedly, this early evidence for vigilance’s core role within daily stress processes provides support for incorporating promotion of safety awareness, versus solely focusing on stress reduction, into psychosocial interventions aimed at buffering stress’s impacts on physical wellbeing. As the health psychology field looks towards the future of stress-health research and intervention, we can expect to see persistent activation models of stress and vigilant behavior at the center of our upcoming work.
References
Altena, E., Ellis, J., Camart, N., Guichard, K., & Bastien, C. (2023). Mechanisms of cognitive behavioural therapy for insomnia. Journal of Sleep Research, 32(6), e13860. https://doi.org/10.1111/jsr.13860
Anheyer, D., Haller, H., Barth, J., Lauche, R., Dobos, G., & Cramer, H. (2017). Mindfulness-based stress reduction for treating low back pain. Annals of Internal Medicine, 166(11), 799–807. https://doi.org/10.7326/M16-1997
Ashar, Y. K., Gordon, A., Schubiner, H., Uipi, C., Knight, K., Anderson, Z., Carlisle, J., Polisky, L., Geuter, S., Flood, T. F., Kragel, P. A., Dimidjian, S., Lumley, M. A., & Wager, T. D. (2022). Effect of pain reprocessing therapy vs placebo and usual care for patients with chronic back pain: A randomized clinical trial. JAMA Psychiatry, 79(1), 13–23. https://doi.org/10.1001/jamapsychiatry.2021.2669
Biggs, A., Brough, P., & Drummond, S. (2017). Lazarus and Folkman’s psychological stress and coping theory. In The Handbook of Stress and Health (pp. 349–364). John Wiley & Sons, Ltd. https://doi.org/10.1002/9781118993811.ch21
Brosschot, J. F., Verkuil, B., & Thayer, J. F. (2018). Generalized Unsafety Theory of Stress: Unsafe Environments and Conditions, and the Default Stress Response. International Journal of Environmental Research and Public Health, 15(3), E464. https://doi.org/10.3390/ijerph15030464
Chida, Y., & Steptoe, A. (2010). Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: A meta-analysis of prospective evidence. Hypertension (Dallas, Tex.: 1979), 55(4), 1026–1032. https://doi.org/10.1161/HYPERTENSIONAHA.109.146621
Cohen, S., Janicki-Deverts, D., & Miller, G. E. (2007). Psychological stress and disease. JAMA, 298(14), 1685–1687. https://doi.org/10.1001/jama.298.14.1685
Gallo, L. C., Roesch, S. C., Fortmann, A. L., Carnethon, M. R., Penedo, F. J., Perreira, K., Birnbaum-Weitzman, O., Wassertheil-Smoller, S., Castañeda, S. F., Talavera, G. A., Sotres-Alvarez, D., Daviglus, M. L., Schneiderman, N., & Isasi, C. R. (2014). Associations of chronic stress burden, perceived stress, and traumatic stress with cardiovascular disease prevalence and risk factors in the HCHS/SOL Sociocultural Ancillary Study. Psychosomatic Medicine, 76(6), 468–475. https://doi.org/10.1097/PSY.0000000000000069
Gump, B. B., & Matthews, K. A. (1998). Vigilance and cardiovascular reactivity to subsequent stressors in men: A preliminary study. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 17(1), 93–96. https://doi.org/10.1037//0278-6133.17.1.93
Horn, A., Stangl, S., Parisi, S., Bauer, N., Roll, J., Löffler, C., Gágyor, I., Haas, K., Heuschmann, P. U., Langhorst, J., & Keil, T. (2023). Systematic review with meta-analysis: Stress-management interventions for patients with irritable bowel syndrome. Stress and Health, 39(4), 694–707. https://doi.org/10.1002/smi.3226
Kamarck, T. W., Li, X., Wright, A. G. C., Muldoon, M. F., & Manuck, S. B. (2018). Ambulatory Blood Pressure Reactivity as a Moderator in the Association Between Daily Life Psychosocial Stress and Carotid Artery Atherosclerosis. Psychosomatic Medicine, 80(8), 774–782. https://doi.org/10.1097/PSY.0000000000000627
Kinsinger, S. W. (2017). Cognitive-behavioral therapy for patients with irritable bowel syndrome: Current insights. Psychology Research and Behavior Management, 10, 231–237. https://doi.org/10.2147/PRBM.S120817
Majeed, M. H., Ali, A. A., & Sudak, D. M. (2019). Psychotherapeutic interventions for chronic pain: Evidence, rationale, and advantages. The International Journal of Psychiatry in Medicine, 54(2), 140–149. https://doi.org/10.1177/0091217418791447
Monroe, S. M., & Kelley, J. M. (1995). Measurement of stress appraisal. In Measuring stress: A Guide for Health and Social Scientists (pp. 122–147). Oxford University Press.
Nagele, E., Jeitler, K., Horvath, K., Semlitsch, T., Posch, N., Herrmann, K. H., Grouven, U., Hermanns, T., Hemkens, L. G., & Siebenhofer, A. (2014). Clinical effectiveness of stress-reduction techniques in patients with hypertension: Systematic review and meta-analysis. Journal of Hypertension, 32(10), 1936. https://doi.org/10.1097/HJH.0000000000000298
Obbarius, N., Fischer, F., Liegl, G., Obbarius, A., & Rose, M. (2021). A modified version of the transactional stress concept according to Lazarus and Folkman was confirmed in a psychosomatic inpatient sample. Frontiers in Psychology, 12. https://www.frontiersin.org/articles/10.3389/fpsyg.2021.584333
O’Connor, D. B., Thayer, J. F., & Vedhara, K. (2021). Stress and health: A review of psychobiological processes. Annual Review of Psychology, 72(1), 663–688. https://doi.org/10.1146/annurev-psych-062520-122331
O’Neill, R. M., Kern, K. J., Friedman, S. E., Sbarra, D. A., Hamann, H. A., & Ruiz, J. M. (In press). Examining impacts of situational stress on cardiovascular physiology during a vigilance task. Biopsychosocial Science and Medicine, 10.1097/PSY.0000000000001374. https://doi.org/10.1097/PSY.0000000000001374
Ruiz, J. M., Taylor, D. J., Uchino, B. N., Smith, T. W., Allison, M., Ahn, C., Johnson, J. J., & Smyth, J. M. (2017). Evaluating the longitudinal risk of social vigilance on atherosclerosis: Study protocol for the North Texas Heart Study. BMJ Open, 7(8), e017345. https://doi.org/10.1136/bmjopen-2017-017345
Schakel, L., Veldhuijzen, D. S., Crompvoets, P. I., Bosch, J. A., Cohen, S., van Middendorp, H., Joosten, S. A., Ottenhoff, T. H. M., Visser, L. G., & Evers, A. W. M. (2019). Effectiveness of stress-reducing interventions on the response to challenges to the immune system: A meta-analytic review. Psychotherapy and Psychosomatics, 88(5), 274–286. https://doi.org/10.1159/000501645
Slavich, G. M. (2020). Social safety theory: A biologically based evolutionary perspective on life stress, health, and behavior. Annual Review of Clinical Psychology, 16, 265–295. https://doi.org/10.1146/annurev-clinpsy-032816-045159
Smith, T. W., Ruiz, J. M., & Uchino, B. N. (2000). Vigilance, active coping, and cardiovascular reactivity during social interaction in young men. Health Psychology: Official Journal of the Division of Health Psychology, American Psychological Association, 19(4), 382–392. https://doi.org/10.1037//0278-6133.19.4.382
Steptoe, A., & Kivimäki, M. (2012). Stress and cardiovascular disease. Nature Reviews Cardiology, 9(6), 360–370. https://doi.org/10.1038/nrcardio.2012.45
Steptoe, A., & Kivimäki, M. (2013). Stress and cardiovascular disease: An update on current knowledge. Annual Review of Public Health, 34(Volume 34, 2013), 337–354. https://doi.org/10.1146/annurev-publhealth-031912-114452
