A Clinical Guide to theTreatment of the

Human Stress ResponseSecond Edition

The Plenum Series on Stress and CopingSeries Editor:

Donald Meichenbaum, University of Waterloo, Waterloo, Ontario, Canada

Current Volumes in the Series:

BEYOND TRAUMACultural and Societal DynamicsEdited by Rolf J. Kleber, Charles R. Figley, and Berthold P. R. Gersons

A CLINICAL GUIDE TO THE TREATMENT OF THE HUMAN STRESSRESPONSESecond EditionGeorge S. Everly, Jr. and Jeffrey M. Lating

CREATING A COMPREHENSIVE TRAUMA CENTERChoices and ChallengesMary Beth Williams and Lasse A. Nurmi

ETHNICITY, IMMIGRATION, AND PSYCHOPATHOLOGYEdited by Ihsan Al-Issa and Michel Tousignant

INTERNATIONAL HANDBOOK OF HUMAN RESPONSE TO TRAUMAEdited by Arieh Y. Shalev, Rachel Yehuda, and Alexander C. McFarlane

INTERNATIONAL HANDBOOK OF MULTIGENERATIONAL LEGACIES OFTRAUMAEdited by Yael Danieli

THE MENTAL HEALTH CONSEQUENCES OF TORTUREEdited by Ellen Gerrity, Terence M. Keane, and Farris Tuma

PSYCHOTRAUMATOLOGYKey Papers and Core Concepts in Post-Traumatic StressEdited by George S. Everly, Jr. and Jeffrey M. Lating

STRESS, CULTURE, AND COMMUNITYThe Psychology and Philosophy of StressStevan E. Hobfoll

TRAUMA, WAR, AND VIOLENCEPublic Mental Health in Socio-Cultural ContextEdited by Joop de Jong

TRAUMATIC STRESSFrom Theory to PracticeEdited by John R. Freedy and Stevan E. Hobfoll

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A Clinical Guide to theTreatment of the

Human Stress ResponseSecond Edition

George S. Everly, Jr.Loyola College in Maryland and

The Johns Hopkins UniversityBaltimore, Maryland

and

Jeffrey M. LatingLoyola College in Maryland

Baltimore, Maryland

KLUWER ACADEMIC PUBLISHERSNEW YORK, BOSTON, DORDRECHT, LONDON, MOSCOW

eBook ISBN: 0-306-47800-5Print ISBN: 0-306-46620-1

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New York

To Marideth Rose Everly and to George S. Everly, Sr.,both of whom have taught me some of the most important

lessons in life that I have ever learnedGSE

To Austin and Jenna, I am so grateful for the immense love,joy, and balance you have brought to my life.

JML

Preface to the Second Edition

Over a decade has passed since the first edition of this critically acclaimedvolume was published. Much is new, but much has remained the same. Thereader will find that the primary efferent biological mechanisms of the stressresponse are largely the same as described in 1989. This underscores the bril-liance of Selye, Cannon, Mason, Gellhorn, and Levi as they sought to eluci-date the anatomical and physiological constituents of human stress. Newinformation has been generated regarding the microanatomy, biochemistry,and genetic aspects of the human stress response. Furthermore, the anatomyand physiology of posttraumatic stress has been more thoroughly elucidated.The important role of cognitive processes in the determination of subse-quent stress arousal remains underscored and has been empirically validatedby subsequent research (Smith, Everly, & Johns, 1992, 1993). The “rediscov-ery” of the importance of positive psychology and optimism is consistentwith our earlier etiological emphasis upon the cognitive–affective domain inthe overall phenomenology of human stress.

But there have been even more dramatic changes in the field ofhuman stress since our first edition was published. Since then, we have dis-covered that the stress response can affect virtually every cell in the humanbody, not only by virtue of direct neural, neuroendocrine, and endocrinemechanisms, but also by the more recent realization that psychologicalprocesses, through stress response mechanisms, can dramatically affect thehuman immune system, and as a result, one’s vulnerability to autoimmuneand communicable diseases. We have included a special chapter on theimmune system to update and emphasize this important phenomenon.

Since the first edition was published, interest in posttraumatic stresshas dramatically increased. School shootings, mass disasters, “airline rage,”“road rage,” violence in the workplace, and of course terrorism in the wakeof September 11, have emerged as important stress-related issues. To

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viii PREFACE TO THE SECOND EDITION

respond to this interest, we have not only revised and expanded our chap-ter on posttraumatic stress, but we have also included a new chapter on cri-sis intervention as an empirically validated intervention for the mitigationof dysfunctional and disabling posttraumatic stress reactions.

Numerous clinical innovations have emerged since the first editionwas published. Interventions such as Eye Movement Desensitization andReprocessing (EMDR), Critical Incident Stress Debriefing (CISD), CrisisManagement Briefings in response to mass disasters and terrorism, andCritical Incident Stress Management (CISM) have generated interest andprogrammatic utilization. Therefore, we have included a special section oninnovations in clinical practice.

Since the first edition was published, a new interest in spirituality andreligion as stress management tools has emerged. Spirituality, religion, andfaith appear to exert generally positive effects upon health. In response, wehave included a new chapter on these topics.

Dramatically new information has emerged in the area of dietaryfactors and stress. Dietary sympathomimetics, antioxidants, and cholesterolare all topics addressed in a new chapter on diet and stress.

Since the first edition was published, psychopharmacological inter-vention in the human stress response has significantly changed. The adventof selective serotonergic reuptake inhibitors (SSRIs) and increased utiliza-tion of anticonvulsant medications has expanded the basic pharmacopeiafor the treatment of human stress.

Finally, new perspectives and research have emerged relevant to topics inour original edition, necessitating an updated presentation of those topics.

We believe that these additions, along with our efforts to update pre-viously addressed topics, will make this textbook useful to students, prac-titioners, and faculty in the fields of psychology, psychiatry, medicine,nursing, social work, public health, business administration, and even pub-lic safety and emergency services. We hope that these updates will onceagain make this volume the standard textbook for the understanding andtreatment of the human stress response.

GEORGE S. EVERLY, JR.JEFFREY M. LATING

Acknowledgments

George S. Everly, Jr. wishes to thank the following individuals for their con-tributions, either direct or indirect, to the creation of this second edition:Theodore Millon, Ph.D., D.Sc., for his continued mentorship, BertramBrown, M.D., M.P.H., for his support and guidance in international affairs,Jeffrey T. Mitchell, Ph.D., for his friendship and support over the lastdecade, but most of all, he thanks his family.

Jeffrey M. Lating wishes to thank Wayne Campbell, M.D., for hisexpertise and early review of the chapter on psychoneuroimmunology, andStephen Bono, Ph.D. for his guidance, friendship, and support. Thanksalso to Amos Zeichner, Ph.D., Don Wilmes, Ph.D., Lee McCabe, Ph.D.and Jennifer Haythornthwaite, Ph.D. for their continued mentorship. Hewould also like to thank his wife, Kathy Niager, Ph.D., whose patience andtolerance enables him to stay focused on his work.

Finally, both authors would like to thank Melvin Gravitz, Ph.D.,Roger Page, Ph.D., Jason Noel, Pharm.D., Judy Curtis, Pharm.D. andKristy Kelly, B.A. for their scholarly contributions. They are also indebtedto Kristy Kelly, Jan Warrington, Psy.D., Thomas Winston Thorpe, DorisManner, Nina Morrison, Phyllis Grupp, Kristy Burroughs, Mike D’Imperio,and Joanne Newbert for their editorial and production assistance in thedevelopment of the text, Dan Vaught and Steve Beck for their artistic con-tributions, and Eliot Werner, Sharon Panulla, Herman Makler, and DonaldMeichenbaum, Ph.D., for their useful suggestions.

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Contents

I: THE NATURE OF HUMAN STRESS

1. The Concept of Stress 3

367

Stress, Behavior, and HealthDefining StressTen Key Concepts in the Study of StressPlan of the Book

2. The Anatomy and Physiology of theHuman Stress Response

Neurological FoundationsNeural TransmissionBasic Neuroanatomy

A Systems Model of the Human Stress ResponseStressor EventsCognitive-Affective DomainNeurological Triggering MechanismsThe Stress ResponseThe Stress Response: A SummaryTarget-Organ Activation

CopingSummary

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3. The Link from Stress Arousal to Disease

Selye’s “General Adaptation Syndrome”Lachman’s ModelSternbach’s ModelKraus and Raab’s “Hypokinetic Disease” ModelSchwartz’s “Disregulation” ModelConflict Theory of Psychosomatic DiseaseEverly and Benson’s “Disorders of Arousal” ModelSummary

4. Stress-Related Disease: A Review

Gastrointestinal DisordersGastrointestinal PhysiologyPeptic UlcersUlcerative ColitisIrritable Bowel SyndromeEsophageal Reflux

Cardiovascular DisordersCardiovascular PhysiologyEssential HypertensionVasospastic PhenomenaMyocardial Ischemia and Coronary Artery Disease

Respiratory DisordersAllergyBronchial AsthmaHyperventilation

Musculoskeletal DisordersSkin DisordersPsychological Manifestations of the Stress ResponseSummary

5. Psychoneuroimmunology

Immune SystemInnate ImmunityAcquired ImmunityCell-Mediated ProcessesHumoral Responses

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CONTENTS xiii

Integrated Relationship between the Central Nervous Systemand the Immune System

Animal Lesion StudiesConditioning Studies (Animals)Conditioning Studies (Human)

Immune System to Central Nervous SystemThe Stress Response and the Immune System: A Soluble LinkStress and Immune Functioning: Animal StudiesStress and Immune Functioning: Human Studies

Summary

6. Measurement of the Human Stress Response

Stressor ScalesCognitive-Affective Correlate ScalesNeurological Triggering MechanismsMeasuring the Physiology of the Stress Response

Assessment of the Neural AxesElectrodermal MeasuresElectromyographic MeasurementCardiovascular MeasurementAssessment of the Neuroendocrine AxisAssessment of the Endocrine Axes

Assessment of Target-Organ EffectsPhysical DiagnosisPsychological Diagnosis

The Assessment of CopingLaw of Initial ValuesSummary

II: THE TREATMENT OF THEHUMAN STRESS RESPONSE

7. Personologic Diathesis and Human Stress

Historical FoundationsThe Principle of Personologic PrimacyPersonologic Psychotherapy and Stress-Related Disorders

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Millon’s Personality Theory and StressSummary

8. Control and the Human Stress Response

A Definition of ControlTheories of Control

Learned HelplessnessIllusions of Control

Self-EfficacyControl and IllnessControl and AgingControl and RecoveryControl and PsychotherapySummary

9. Psychotherapy: A Cognitive Perspective

Cognitive PrimacyCognitive-Based Psychotherapy

Ellis’s ModelBeck’s Cognitive Therapy ModelMeichenbaum’s Stress Inoculation TrainingPositive Psychology

Summary

10. A Neurophysiological Rationale for the Use of the RelaxationResponse: Neurological Desensitization

Disorders of ArousalPsychiatric Disorders of ArousalSomatic Disorders of ArousalThe Neurological Foundations of Limbic Hypersensitivity

and the Disorders of ArousalErgotropic TuningNeurological Reverberation and ChargingNeuromuscular Set-Point Theory

Models of Neuronal PlasticityThe Relaxation Response

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CONTENTS xv

The Physiology of the Relaxation ResponseSelecting a Relaxation TechniqueClinical Precautions and Undesirable Side Effects

Loss of Reality ContactDrug ReactionsPanic StatesPremature Freeing of Repressed IdeationExcessive Trophotropic States

Summary

11. Meditation

History of MeditationTypes of MeditationMechanisms of ActionTherapeutic HallmarksResearch on the Clinical Applications and Effects of MeditationHow to Implement Meditation

PreparationComponentsExample Protocol

Summary

12. Voluntary Control of Respiration Patterns

HistoryBasic Patterns of BreathingMechanisms of ActionClinical ResearchHow to Implement

Breathing Exercise 1Breathing Exercise 2Breathing Exercise 3

Summary

13. Neuromuscular Relaxation

HistoryMechanisms of Action

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Research on Clinical Applications and EffectsHow to Implement a Physically Active Form of

Neuromuscular Relaxation: PreparationHow to Implement Neuromuscular Relaxation: Procedure

The Sequential Steps to Follow for Each Muscle Being RelaxedExample Protocol

Summary

14. Hypnosis in the Management of Stress Reactions

Historical PerspectivesHypnosis, Stress, and Mind—Body InteractionTheories of HypnosisHypnosis and StressSummary

15. Biofeedback in the Treatment of the Stress Response

HistoryBiofeedback Modalities

Electromyographic (EMG) BiofeedbackTemperature BiofeedbackElectroencephalographic (EEG) BiofeedbackElectrodermal (EDR) Biofeedback

PrecautionsRole of the Therapist and Other FactorsThe Past and Future of BiofeedbackSummary

16. Physical Exercise and the Human Stress Response

History of Therapeutic ExerciseMechanisms of ActionResearch Supporting Therapeutic Exercise for StressExercise GuidelinesExercise for Stress ManagementAdditional Caveats about Physical ExerciseSummary

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CONTENTS xvii

17. The Pharmacological Management of Stress Reactions

PharmacologyBenzodiazepinesAntidepressantsBuspirone

Miscellaneous AgentsBeta-Adrenergic Blocking AgentsAntihistaminesBarbiturates and Nonbarbiturate Sedative-HypnoticsAntipsychotic Medications

Summary

III. SPECIAL TOPICS IN THE TREATMENT OF THEHUMAN STRESS RESPONSE

18. Religion, Spirituality, and Stress

Mechanisms of ActionResearch

Emotional HealthPhysical Health

Incorporating Spiritual and Religious Beliefs intoPractice and Therapy

Summary

19. Nutrition and Stress

Energy-Yielding NutrientsCarbohydratesFatsProteins

Energy Sources and StressSerotonin, Stress, and EatingAntioxidantsPsychoneuronutritional MedicineSummary

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20. Posttraumatic Stress Disorder

The Prevalence of Trauma as a Public Health ProblemDiagnostic SymptomatologyA Two-Factor Theory of Posttraumatic Stress

Neurological HypersensitivityPsychological Hypersensitivity

The Psychological Profile of Posttraumatic Stress DisorderTreatment of Posttraumatic Stress Disorder

PsychopharmacotherapyPsychotherapyNeurocognitive Strategic Therapy for Posttraumatic StressEye Movement Desensitization and Reprocessing (EMDR)

Summary

21. Management of Acute Distress through a ComprehensiveModel of Crisis Intervention for Mass Disasters and Terrorism

Mass Disasters and TerrorismThe Battlefield of the MindBasic Terms: On the Nature of a Psychological Crisis and

Crisis InterventionCritical Incident Stress Management (CISM)Research Findings and the Effectiveness of Crisis InterventionSummary

22. Hans Selye and the Birth of the Stress Concept

23. Summation and Conclusions

A Treatment ModelA Treatment ProtocolA Word about Treatment AdherenceSummary

APPENDIXES: SPECIAL CONSIDERATIONS INCLINICAL PRACTICE

A. Self-Report Relaxation Training Form

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B. Physically Passive Neuromuscular Relaxation

C. Stress-Inducing Sympathomimetic Chemicals

D. Vascular Headaches and Vasoactive Substances

E. The Etiology of Panic Attacks: Nonpsychological Factors

F. Biochemical Bases of Arousal

G. Professional Journals for Stress Research

H. How Do You Cope with Stress?: A Self-ReportChecklist Designed for Health Education Purposes

I. Crisis Management Briefing (CMB): Large-Group CrisisIntervention in Response to Terrorism, Disasters,and Violence

J. Critical Incident Stress Debriefing (CISD):Small-Group Crisis Intervention

K. Herbal Stimulants

L. Herbs with Putative Antianxiety Properties

References

About the Authors

Index

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