Reactivity to Stress: When Does a History of Medical

Adversity Foster Resilience Versus Vulnerability?1

Daphne B. Bugental,2 David Beaulieu, Erin Fowler,
Eileen OBrien, and Laura Cayan
Young adults with (or without) a history of medical or physical disorders (MPDs)
were exposed to repeated laboratory stress. The effects of MPD status on habituation (as measured by changing levels of cortisol) were found to be moderated by the
extent to which respondents reported attachment feelings in their relationships (as
measured by the Social Provisions Scale). Students in the MPD group who reported
attachment feelings showed (a) cortisol increases during their first exposure to a
laboratory stressor; and (b) cortisol decreases during a second exposure to the same
stressor 1 week later. No equivalent benefit was found for students who lacked this
medical history. Findings suggest the extent to which medical adversityunder the
right interpersonal circumstancespromotes resilience.
jasp_622

1385..1399

Across disciplines, there has been an emerging interest in the differential

processes that foster vulnerability versus resilience or thriving in the face of
early adversity. As an example of resiliencethriving, we focused on young
adults ability to habituate easily to a repeated stressor. It was expected that
habituation would be greatest for those individuals who had experienced the
combination of medical adversity and high levels of social support.
Research concerned with the long-term effects of medical adversity has
followed two central directions. Some researchers have focused on the longterm costs of disabling medical conditions. Others have focused on the protective factors that buffer against such outcomes. Some researchers have
gone so far as to suggest that long-term benefits (i.e., thriving) may follow in
response to adversity (e.g., Carver, 1998; OLeary & Ickovics, 1995). The
study of thriving in response to illness or other challenging life experiences
has been described as a paradigm shift in the field of health psychology
(Ickovics & Park, 1998).

1
This research was supported by awards from NIMH (RO1 MH 051773) and the National
Science Foundation (BNS 9021221) to the first author, and the Elizabeth Munsterberg Koppitz
Child Psychology Graduate Fellowship to the second author. The authors thank Shanta
Kokotay, who assisted as experimenter.
2
Correspondence concerning this article should be addressed to Daphne Bugental, Department of Psychology, University of California, Santa Barbara, CA 93106. E-mail: bugental@
psych.ucsb.edu

1385
Journal of Applied Social Psychology, 2010, 40, 6, pp. 13851399.
2010 Copyright the Authors
Journal compilation 2010 Wiley Periodicals, Inc.

1386 BUGENTAL ET AL.

Negative Outcomes
The medical model of disability has focused on prevention and cure of
medically disabling conditionsoften accompanied by the view that continued medical problems involve loss and devastation, and solutions only
involve prevention and cure (as noted by Wright, 1983). Some types of
negative outcomes have, indeed, been reported to be reliably associated with
medical adversity or disability. For example, depressive symptoms and
adverse health behaviors (e.g., smoking) are significantly higher among
persons with disabilities than within the general population (U.S. Department of Health and Human Services, 2006). Students with disabilities have
been found to be more likely to use mental health services than students
without disabilities (Huebner, Thomas, & Berven, 1999). In addition, selfreported stress is elevated for individuals who experience medical adversity
(Turner & Noh, 1988) or who have experienced medical or physical problems
on a chronic basis (Eiser, 1990).

Positive Outcomes
Countering this negative outlook, individuals who have experienced
major medical problems early in life have sometimes been found to show
exceptional levels of resilience and coping ability (e.g., Barnum, Snyder,
Rapoff, Mani, & Thompson, 1998). The possibility of thriving in the face of
early adversity is consistent with emerging interest in positive psychology.
For example, a special issue of the Journal of Social Issues (Ickovics & Park,
1998) included a series of papers that presented a variety of perspectives on
the notion of thriving.
Relevant to the outcomes of concern here, Epel, McEwen, and Ickovics
(1998) focused on the positive interpretation of life events as a predictor of
physiological habituation to a repeated stressor. In addition, Carver (1998)
discussed the possibility that decreased reactivity to stress may occur among
individuals who either (a) hold positive expectations (e.g., optimism); or (b)
have secure perceptions of the availability of social support.
More recently, the Journal of Positive Psychology published a special
issue focused on the origins of positive emotions (Frederickson, 2006). Relevant to the argument offered here, Moskowitz and Epel (2006) examined
the association between finding benefit in adversity (as measured by the
Posttraumatic Growth Inventory, or PTGI) and adaptive physiological
responses. More adaptive daily cortisol slopes were found for those who
had high scores on the PTGI, combined with high levels of daily positive
emotion.

REACTIVITY TO STRESS

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What Predicts the Polarized Outcomes That Follow Adversity?

Focusing on the seeming polarity of outcomes that follow from early
adversity, Rutter (2002) commented that stress experiences make individuals
either more resistant or more vulnerable to later psychosocial hazards
(p. 10). Rutter went on to note that little research has been conducted to
explore the processes that yield later problems or later resilience. McEwen
(2002), coming from a biosocial perspective, argued for a polarized pattern
of physiological response to stress: allostatic load versus allostasis. When
individuals face repeated, unrelieved stress, they may become less able to
accommodate to later stress (i.e., allsotatic load). In contrast, the experience of
stress followed by recovery may lead to a strengthening of the adaptive
functioning of the bodys stress response systems, which, in turn, enhances
ones ability to accommodate to later stress (a process referred to as allostasis).
A key factor that may influence the differential outcomes described for
those who have experienced medical adversity is the availability and quality
of social support. At the most general level, those who have high perceived
social supportor who are in the presence of a supportive friend (as reviewed
by Uchino, Cacioppo, & Kiecolt-Glaser, 1996)are less likely to show cardiovascular reactivity in response to a stress induction. However, still needed
is a systematic comparison of the differential impact of social support on
individuals with and without a history of medical adversity.
Although social support typically provides benefits, it appears to be most
beneficial when the nature of the support offered matches the need of the
recipient (e.g., Horowitz et al., 2001). This finding is consistent with the
earlier proposal of Cutrona and Russell (1987) that the specific type of
support that is beneficial may depend on the current needs of the recipient. At
a more general level, social support produces more benefit for those who are
experiencing high stress than for those who are experiencing lower stress
(Cohen & Wills, 1985).
The Present Study
Within the present paper, we give consideration to the effects of medical
adversity on the individuals capacity to habituate to stress, as moderated by
the extent and types of perceived social support. We expect that individuals
who have experienced medical adversity will vary widely in their reactions to
stress. Individuals with this history who also have experienced poor-quality
social support systems are predicted to demonstrate low levels of habituation,
whereas individuals exposed to early medical adversity and high-quality
support systems are predicted to demonstrate high levels of habituation
(consistent with resiliencethriving).

1388 BUGENTAL ET AL.

Although reduced stress is generally found to follow from the presence of
perceived social support, little is known about the unique functioning of such
processes among those who have experienced medical adversity. Our expectation is that high perceived social support provides a unique advantage (in
facilitating the ability to accommodate to stress) among individuals who have
experienced this history.

Method
Participants
The study sample included 100 undergraduates (30 male, 70 female). For
5 participants, at least one cortisol sample was unusable, thus reducing
the sample size in some analyses. Participants mean age was 20.0 years
(SD = 4.5). Within this sample, 25 students were from underrepresented
minorities (10 Latino, 3 African American, 5 Asian American, 2 Native
American, and 5 Other). In addition, 65 participants were currently attending a university, while 35 were attending a community college. The students
were either freshmen or sophomores. The mean education of participants
mothers was 15.1 years (SD = 3.1).
Recruitment efforts focused on identifying individuals who had experienced medical adversity (i.e., either an illness or injury that would lead them
to be characterized as permanently or temporarily disabled). Ads were posted
on bulletin boards in the two schools, including ads posted in offices that
provide services to disabled students. Each recruit was asked to bring along
another student, matched in gender, approximate age, and academic interests, but restricted to individuals who had experienced only typical medical
problems.

Design Overview
Research participants were all exposed to a repeated, two-part laboratory
challenge (a public-speaking task and a mental arithmetic task). The publicspeaking task involved either a personally relevant topic or a generic topic3
(with counterbalanced order of assignment to one of the two topics). Central
grouping variables included (a) presence or absence of a medical problem or
injury that was relatively severe; (b) gender; and (c) level (and type) of social
support. The central dependent variable involved changing levels of cortisol.
3

No significant main or interactive effects were obtained as a result of story topic.

REACTIVITY TO STRESS

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Laboratory Challenges
All participants were exposed to an adaptation of the Trier Social Stress
Test (Kirschbaum, Pirke, & Hellhammer, 1993). A more moderate version
of this stress test was employed here in order to maximize the effects
of individual differences (the full Trier Test is designed to create peak
stress experiences for as many people as possible, despite individual
differences).
Public-speaking challenge. Participants were given a repeated laboratory
challenge that involved a 3-min public speaking task (making a tape recording that would be heard by others). Half of the participants were asked to
describe a generic event (i.e., difficulties associated with starting college life),
while the other half were asked to describe a personally relevant event that
was a source of distress.
Mental arithmetic challenge. Participants were given a mental arithmetic
challenge that involved counting backward by 7 from a higher number. The
task continued for 1 min.

Measures
Medical history. Although participants were differentially recruited
based on the presence or absence of a history of severe medical disorders, all
participants were also asked to provide a description of the medical problems
they had experienced. The medical conditions reported were rated for their
severity on a 7-point scale ranging from 1 (low severity) to 7 (high severity).
Ratings were made by three judges who were currently providing services to
families experiencing medical problems. Interrater reliability in rating the
severity of problems was acceptable (Cronbachs a = .76).
More severe conditions included medical problems such as spina bifida or
cancer. Less severe conditions included medical problems such as bronchial
disorders or allergies. Supporting the success of our selection methods, the
medical severity ratings for participants with a history of medical or physical
disorders (MPD; M = 5.14, SD = 1.01) and participants lacking this history
(non-MPD; M = 2.22, SD = 1.65) were significantly different, t(135) = 12.49,
p < .001.
Demographic measures. Relevant demographic measures were also
obtained. These include student age, ethnicity, gender, and maternal
education.
Social Provisions Scale (SPS; Cutrona & Russell, 1987). The SPS is a
well-known instrument that measures perceived social support. It is a 24-item
measure of satisfaction with existing sources of social support. The scale

1390 BUGENTAL ET AL.

assesses perceived support in six areas: (a) guidance; (b) reliable alliance;
(c) reassurance of worth; (d) opportunity for nurturance; (e) attachment
feelings; and (f) social integration. Coefficient alphas on the subscales ranged
from .65 to .76.
Cortisol. Cortisol measures were taken at baseline and 20 min following
the conclusion of the two-part experimental challenge. The same procedures
were followed on an initial visit (original exposure to challenge) and a
second visit 1 week later (repeated exposure to challenge). There were two
kinds of dependent variables: (a) prepost difference scores (on each visit);
and (b) habituation scores (computed by subtracting the second difference
score from the initial difference score).
Participants were scheduled to visit the lab from mid to late afternoon.
Although we were unable to maintain the exact start time for all participants
because of limitations in their availability (thus causing potential problems
for variability in diurnal rhythms), for each specific participant, the time of
day was exactly the same for both visits.
Saliva samples were taken by asking participants to spit into a plastic cup
marked for the desired quantity (a minimum of 1 ml). Saliva production was
facilitated by asking participants to chew on a 2-inch plastic straw in
advance. All participants were asked to avoid eating for 2 hr prior to their
visits. In addition, data from participants were excluded if they were currently sick.
The saliva samples were pipetted into cryogenic vials, and stored at -20
degrees C. Prior to assay, samples were thawed and centrifuged at 1500 rpm
for 30 min to separate mucins. Cortisol was measured by utilizing a commercially available enzyme immunoassay (EIA) kit (Behavioral Endocrinology
Lab, University Park, PA). Samples were assayed in duplicates that were
averaged for use in analyses. Samples from the same participants were run in
the same assay. Assay sensitivity was .01 mg/dl. The average intra- and
inter-assay coefficients of variation were 5% and 13%, respectively. Cortisol
readings were examined for outliers, and all values exceeding 3 SD were
excluded.

Procedure
Selection variables (i.e., presence or absence of a history of severe medical
problems; academic level; gender) were measured as part of the recruitment
and selection process. Demographic variables were measured at the start of
the first visit to the lab. Social support was measured at the end of the second
visit. Cortisol levels (during both visits) were taken prior to and following the
experimental induction.

REACTIVITY TO STRESS

1391

Results
Regression analyses were employed to test the effects of medical history
(i.e., presence or absence of a severe MPD), gender, and social support on
habituation. It was anticipated that the presence of social support would
serve as a stronger moderator of the habituation levels shown by the MPD
group than the non-MPD group. The effects of different types of support
were measured on an exploratory basis. Type of story and school were
included as covariates in all analyses (maternal education and ethnicity
showed no significant or trend-level relationship to habituation, and were not
included). The main and interaction effects of gender were also tested.
Dichotomous measures were included as dummy variables. The dependent
variable was habituation, which was defined as the extent to which increases
in cortisol levels in the second visit were less than those in the first visit.
As shown in Table 1 and Figure 1, a significant interaction was found
between group status and total social support. It can be seen that high social
Table 1
Medical Adversity and Overall Social Support as Predictors of Habitation
Variable
Step 1
Type of story
School
Step 2
Medical adversity
Overall social support
Gender
Step 3
Medical Adversity Support
Medical Adversity Gender
Support Gender
Step 4
Medical Adversity Support Gender

SE (B)

Beta

R2D
.00

.01
.00

.03
.03

.05
-.01

.01
.05
.04

.03
.04
.03

.05
.16
.12

.16
.07
.08

.08
.07
.07

.29*
.18
.18

.09

.16

.10

.03

.06

.00

Note. High scores on type of story reflect the use of personally relevant stories, while
low scores reflect the use of generic stories. High scores on school reflect the use of
university students, while low scores reflect the use of community college students.
*p < .05.

1392 BUGENTAL ET AL.

Figure 1. Levels of habituation following a laboratory stressor as a function of history of

medical adversity and current level of total social support. Regression lines are plotted for
participants whose level of support was 1 SD above and 1 SD below the mean. Habituation
scores reflect the extent to which cortisol increases were higher in the first exposure to the stressor
than the second exposure (units in mg/dl).

support was more beneficial (in terms of enhanced habituation) for participants with a history of medical adversity than for those lacking this history.
Within this grouping, higher levels of support were associated with particularly high levels of habituation, whereas low levels of support were associated
with particularly low levels. No significant effects were found for gender or
covariates. Follow-up analyses conducted separately for the two groupings
(MPD vs. non-MPD) reveal a significant effect for total support for the MPD
grouping (b = .39, p = .02), but not the MPD grouping (b = -.02, ns). In
addition, a follow-up analysis reveals no main or interactive effect as a result
of the severity of the medical condition reported by those in the MPD group.
Additional analyses were conducted separately for the six different subscales of the SPS (Cutrona & Russell, 1987). The interaction between group
status (MPD vs. non-MPD) and support only reached significance for attachment feelings (b = .34, p = .02) and guidance (b = .37, p = .02). No significant
effects were found for gender or covariates. The pattern of interaction
shown for attachment feelings and guidance are shown in Figures 2 and 3.
Follow-up analyses conducted separately for the two groupings reveal a main
effect of attachment feelings (b = .41, p = .01) and guidance (b = .34, p = .03)
for the MPD group. The effects of either support variable did not approach
significance for the non-MPD group.
A main effect on habituation was found for only one type of support; that
is, reassurance of worth (b = .24, p = .03). Both MPD and non-MPD participants showed higher levels of habituation when they reported that others
provided them reassurance of their worth.

REACTIVITY TO STRESS

1393

Figure 2. Levels of habituation following a laboratory stressor as a function of history of

medical adversity and current feelings of attachment to others. Regression lines are plotted for
participants whose feelings of attachment to others were 1 SD above and 1 SD below the mean.
Habituation scores reflect the extent to which cortisol increases were higher in the first exposure
to the stressor than the second exposure (units in mg/dl).

Figure 3. Levels of habituation following a laboratory stressor as a function of history of

medical adversity and current level of guidance from others. Regression lines are plotted for
participants whose level of guidance was 1 SD above and 1 SD below the mean. Habituation
scores reflect the extent to which cortisol increases were higher in the first exposure to the stressor
than the second exposure (units in mg/dl).

In order to unpack the bases of the interaction findings for habituation

(with either attachment feelings or guidance as moderators of the effects of
MPD grouping), follow-up analyses were conducted separately for Visits 1
and 2. In each analysis, change in cortisol level was included as the outcome
measure, and baseline cortisol levels (as well as all other covariates listed
earlier) were entered as covariates at Step 1. Main effects of MPD, disability,

1394 BUGENTAL ET AL.

Figure 4. Changes in cortisol level following the first presentation laboratory stressor as a
function of history of medical adversity and current feelings of attachment to others. Regression
lines are plotted for participants whose feelings of attachment to others were 1 SD above and 1
SD below the mean.

and support were entered at Step 2. Two-way interactions were entered at

Step 3, and the three-way interaction was entered at Step 3.
On both visits, a significant interaction was obtained between MPD
grouping and level of attachment feelings (Visit 1, b = .32, p = .05; Visit 2,
b = -.28, p = .04). As shown in Figures 4 and 5, the direction of effects was
opposite in the two visits. On the first visit, the higher the level of attachment
feelings, the greater were the increases shown in cortisol levels in the MPD
group. On the second visit, the higher the level of attachment feelings, the
greater were the decreases in cortisol levels in the MPD group. The observed
reversal reveals that participants with MPDs and high attachment feelings
were the grouping most likely to reveal a stress reaction during Visit 1 and
were also the most likely to show a habituation response during Visit 2.
An equivalent analysis was conducted to explore the differential effects
of guidance as a moderating variable during the two visits. Although a
significant interaction was found between MPD status and guidance at Visit
1 (b = .33, p = .04), no significant findings (or trends) were found at Visit 2.
Follow-up analyses conducted separately for MPD groupings reveal no significant effects. Correspondingly, guidance was not found to reveal a pattern
for any participant grouping that reflected increased stress at Visit 1 and
decreased stress at Visit 2 (i.e., the pattern expected for habituation).
An additional regression analysis was conducted to explore the differential effects of reassurance of worth on changes in cortisol levels at the two
visits. At Visit 1, reassurance of worth was predictive of increasing cortisol
levels (b = .17, p = .04). At Visit 2, reassurance of worth was predictive of

REACTIVITY TO STRESS

1395

Figure 5. Changes in cortisol level following the second presentation laboratory stressor as a
function of history of medical adversity and current feelings of attachment to others. Regression
lines are plotted for participants whose feelings of attachment to others were 1 SD above and 1
SD below the mean.

decreasing cortisol levels as a trend (b = -.15, p = .09). These findings support

the interpretation that high reassurance of worth is quite generally predictive
of relatively high levels of habituation.

Discussion
Young adults who had experienced a history of early medical adversity
were found to differ in their habituation to a repeated laboratory stressor as
a result of their reported social support. Participants with a history of
medical adversity showed particularly high habituation to a repeated stressor
if their support patterns were seen as fostering feelings of attachment; that is,
emotional closeness that provides a sense of security. In contrast, no significant buffering effects of support were shown by participants who lacked this
medical history. The unique advantages provided by attachment support for
MPD participants were equivalent for males and females. Thus, it appears
that those who have experienced a high level of medical adversity may show
exceptional benefits as a result of the provision of attachment, and the
associated feelings of closeness and emotional security.
It may be that a difficult medical history, when appropriately buffered,
serves to produce what may be thought of as stress immunization. In this
case, a difficult and presumably stressful medical historyfor those who are
buffered by relationships that provide feelings of attachmentmay lead to
an enhanced ability to cope with future stress. Consistent with this interpre-

1396 BUGENTAL ET AL.

tation, Drageset and Lindstrom (2005) found that women who were told that
they might have a serious medical condition (breast cancer) were more likely
to demonstrate effective coping if they reported high attachment support (as
measured by the SPS). It has also been suggested in the developmental
literature that children who experience early adversity show benefits at older
ages, but only when they have a supportive, nurturing home environment
(Bugental, 2003; Gunnar, 2000; Nelson, 2000).
Findings with respect to the role of social support were consistent with
past research in the field of close relations. As noted earlier, the benefits of
support are generally greater among those who are experiencing the highest
level of stress (Cohen & Wills, 1985). This represents a variant of the general
finding that support is most effective when there is a match between the needs
of the recipient and the nature of the support offered (e.g., Horowitz et al.,
2001).
Indeed, evidence was provided here for thriving. That is, the responses
shown by MPD participants with high attachment support were more consistent with adaptive coping than those shown by participants who lacked a
history of medical adversity (regardless of their levels of social support). On
the first exposure to the stressor, they showed increasing levels of cortisol;
however, on the second visit, they demonstrated decreasing cortisol levels.
This response pattern suggests that they were more likely to respond to stress
initially than were other participants. However, at the same time, they
showed decreasing cortisol levels on the second visit; a pattern that suggests
their ability to engage initially with a source of stress, but then to habituate
fully to a recurrence of that event. This pattern of response may be thought
of as responding to the stressor as a challenge. Individuals with this same
medical historybut lacking attachment supportresponded in a similar
fashion to the stressor on both visits.
These combined findings qualify the notion suggested by Rutter (2002)
that individuals who experience adversity may be more resistant to later
stress, whereas those who do not experience adversity may show sensitization. The evidence reported here qualifies the expected advantage for early
adversity, and suggests that adversity may only predict later advantages in
managing stress among those who have received high attachment support.
No evidence was found for sensitization, however.
In future work, it will be important to determine the source of perceived
support within the attachment support category. That is, it will be useful to
know if the support involves parents, professionals, friends, or romantic
partners. It would also be useful to determine the long-term variations that
follow from attachment early in life.
The only exception to the specificity of the advantage of social support
(for those with a history of medical adversity) involved the general effects of

REACTIVITY TO STRESS

1397

reassurance of worth. This particular pattern of support was useful for both
MPD and non-MPD groupings. Thus, it appears that reassurance of worth
by supportive others predicts a very general advantage in the ability to
habituate to repeated stress. This finding is consistent with the observation of
Cutrona, Cole, Colangelo, Assouline, and Russell (1994) that college students academic success (after controlling for academic aptitude) is predicted
by the reassurance of worth they receive from their parents.

Study Limitations
Several limitations can be identified within the present study, most of
which can be corrected with expansion of the measures and population
studied here. First, it could be argued that the resilience or thriving evidenced
by those with a problematic medical history may be unique to the relatively
advantaged portion of the population studied (i.e., college students).
Although not completely addressing this concern, no evidence was found
here to suggest that demographic variables influenced the outcomes
obtained. However, future research is needed within less advantaged populations. Additionally, the sample included more women than men. Thus,
further evidence is needed for males.
Second, no systematic analysis was possible of differences in habituation shown for specific MPDs because of the wide range of reported disorders. However, no significant effects were found as a result of the severity
of the reported disorder. It is more probable that the effects observed
followed from the indirect effects of the presence or absence of a history
of medical adversity, rather than as a direct effect of specific medical
conditions.
Third, the time of day was not completely uniform because of scheduling
difficulties (i.e., students were limited in their availability). Although variability was minimal (all participants were measured in the mid to late afternoon), findings for cortisol levels (subject to circadian rhythms) may have
been limited by these variations.
A qualification should be added regarding the meaning of perceived social
support. Although the SPS (Cutrona & Russell, 1987) provides a measure of
the perceived availability of social support, it is important to recognize that
this construct may also be thought of as a stable individual difference in
expectancies, as well as an environmental provision (Sarason, Sarason, &
Shearin, 1986). As a result, it will be important in future research to determine the extent to which actual manifestations of social support provide
unique (or enhanced) benefits for recipients who have a history of medical
adversity.

1398

BUGENTAL ET AL.

Implications
The reported findings reveal the limitations in research that focuses exclusively on the negative outcomes of early adversity. A history of early medical
adversity, when accompanied by high perceived attachment support, may
serve not only to allow resilience, but also to foster an increased capacity to
habituate to stress. That is, individuals with this history manifest habituation
responses that are even more adaptive than those shown by individuals
lacking this history: a pattern consistent with thriving.

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