Stress is a word that is used in different ways. Sometimes it refers to an environmental stimulus—a threat or demand from the outside world. This definition lies behind various measures, such as the Social Readjustment Rating Scaled or the Bedford College Life Events and Difficulties Schedule(2) which characterize life experiences and produce standardized measures of their severity. According to this view, experiences have properties—as losses, or challenges, or dilemmas—which can be identified without knowing about the meaning given to them by the person experiencing them.
A second meaning of stress is that it is a bodily state, so that events are only regarded as stressful if they produce changes in the individual. The best-known example of this usage comes from physiology.(3) Stress as a physiological state is also a common lay meaning; when people describe themselves as 'stressed' they are usually referring to a state of tension or autonomic arousal.
A third way to understand stress, which is useful in considering physical illness, is that it arises out of an interaction between environmental demands and the resources available to deal with them. This view is articulated in the transactional model of Lazarus and Folkman. (4) According to the theory, when faced with a new experience individuals assesses its likely impact (the primary appraisal) and assess their resources (the secondary appraisal). Stress arises when this double appraisal identifies a mismatch between demands and resources
Illness as a demand or threat (the primary appraisal)
There are a number of characteristics of an experience that increase the chances of it being appraised as threatening. These include immediacy, ambiguity, uncontrollability, or undesirability. The probability that many people will share an interpretation of a particular episode explains the similarity of people's responses to certain illnesses. The possibility of individual, even idiosyncratic, interpretations can explain sharp differences between people with apparently the same disorder.
A useful way to construe individual appraisals of illness is outlined by Leventhal et al.'(5) in their theory of internal illness representations. The common elements of the illness representation can be identified from a simple self-report questionnaire: (6)
• identity (label and associated symptoms)
• consequences (severity and likely impact)
• time-line (natural history)
• curability or controllability.
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