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Relationships and their impact on stress

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Relationships and their impact on stress

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Caleb Simmons
Being alone or in toxic relationships are detrimental to both physical and mental health. Without a connection, you're more likely to experience damaged immunity, have poor sleep,  high blood pressure, and have an increased risk for developing some diseases. By ensuring you form good, healthy relationships you'll lead a much healthier lifestyle.

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Relationships: the missing piece of the wellbeing puzzle

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Caleb Simmons
"Your brain comes hard-wired with an alarm system for your protection. When your brain perceives a threat, it signals your body to release a burst of hormones that increase your heart rate and raise your blood pressure. This "fight-or-flight" response fuels you to deal with the threat.
Once the threat is gone, your body is meant to return to a normal, relaxed state. Unfortunately, the nonstop complications of modern life mean that some people's alarm systems rarely shut off."

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Stress management: Learn why you feel stress and how to fight it.

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Caleb Simmons
"The term “stress”, as it is currently used was coined by Hans Selye in 1936, who defined it as “the non-specific response of the body to any demand for change.""

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What is Stress?

Stress is not a useful term for scientists because it is such a highly subjective phenomenon that it defies definition. And if you can't define stress, how can you possibly measure it? The term "stress", as it is currently used was coined by Hans Selye in 1936, who defined it as "the non-specific response of the body to any demand for change". Selye had noted in numerous experiments that laboratory animals subjected to acute but different noxious physical and emotional stimuli (blaring light, deafening noise, extremes of heat or cold, perpetual frustration) all exhibited the same pathologic changes of stomach ulcerations, shrinkage of lymphoid tissue and enlargement of the adrenals. He later demonstrated that persistent stress could cause these animals to develop various diseases similar to those seen in humans, such as heart attacks, stroke, kidney disease and rheumatoid arthritis. At the time, it was believed that most diseases were caused by specific but different pathogens. Tuberculosis was due to the tubercle bacillus, anthrax by the anthrax bacillus, syphilis by a spirochete, etc. What Selye proposed was just the opposite, namely that many different insults could cause the same disease, not only in animals, but in humans as well.

Selye's theories attracted considerable attention and stress soon became a popular buzzword that completely ignored Selye's original definition. Some people used stress to refer to an overbearing or bad boss or some other unpleasant situation they were subjected to. For many, stress was their reaction to this in the form of chest pain, heartburn, headache or palpitations. Others used stress to refer to what they perceived as the end result of these repeated responses, such as an ulcer or heart attack. Many scientists complained about this confusion and one physician concluded in a 1951 issue of the British Medical Journal that, "Stress in addition to being itself, was also the cause of itself, and the result of itself."

Unfortunately, Selye was not aware that stress had been used for centuries in physics to explain elasticity, the property of a material that allows it to resume its original size and shape after having been compressed or stretched by an external force. As expressed in Hooke's Law of 1658, the magnitude of an external force, or stress, produces a proportional amount of deformation, or strain, in a malleable metal. This created even more confusion when his research had to be translated into foreign languages. There was no suitable word or phrase that could convey what he meant, since he was really describing strain. In 1946, when he was asked to give an address at the prestigious Collège de France, the academicians responsible for maintaining the purity of the French language struggled with this problem for several days, and subsequently decided that a new word would have to be created. Apparently, the male chauvinists prevailed, and le stress was born, quickly followed by el stress, il stress, lo stress, der stress in other European languages, and similar neologisms in Russian, Japanese, Chinese and Arabic. Stress is one of the very few words you will see preserved in English in these and other languages that do not use the Roman alphabet.

Because it was apparent that most people viewed stress as some unpleasant threat, Selye subsequently had to create a new word, stressor, to distinguish stimulus from response. Stress was generally considered as being synonymous with distress and dictionaries defined it as "physical, mental, or emotional strain or tension" or "a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize." Thus, stress was put in a negative light and its positive effects ignored. However, stress can be helpful and good when it motivates people to accomplish more.

As illustrated to the left, increased stress results in increased productivity - up to a point, after which things go rapidly downhill. However, that point or peak differs for each of us, so you need to be sensitive to the early warning symptoms and signs that suggest a stress overload is starting to push you over the hump. Such signals also differ for each of us and can be so subtle that they are often ignored until it is too late. Not infrequently, others are aware that you may be headed for trouble before you are.

Any definition of stress should therefore also include good stress, or what Selye called eustress. For example, winning a race or election can be just as stressful as losing, or more so. A passionate kiss and contemplating what might follow is stressful, but hardly the same as having a root canal procedure.

Selye struggled unsuccessfully all his life to find a satisfactory definition of stress. In attempting to extrapolate his animal studies to humans so that people would understand what he meant, he redefined stress as "The rate of wear and tear on the body". This is actually a pretty good description of biological aging so it is not surprising that increased stress can accelerate many aspects of the aging process. In his later years, when asked to define stress, he told reporters, "Everyone knows what stress is, but nobody really knows."

As noted, stress is difficult to define because it is so different for each of us. A good example is afforded by observing passengers on a steep roller coaster ride. Some are hunched down in the back seats, eyes shut, jaws clenched and white knuckled with an iron grip on the retaining bar. They can't wait for the ride in the torture chamber to end so they can get back on solid ground and scamper away. But up front are the wide-eyed thrill seekers, yelling and relishing each steep plunge who race to get on the very next ride. And in between you may find a few with an air of nonchalance that borders on boredom. So, was the roller coaster ride stressful?

The roller coaster analogy is useful in explaining why the same stressor can differ so much for each of us. What distinguished the passengers in the back from those up front was the sense of control they had over the event. While neither group had any more or less control their perceptions and expectations were quite different. Many times we create our own stress because of faulty perceptions you can learn to correct. You can teach people to move from the back of the roller coaster to the front, and, as Eleanor Roosevelt noted, nobody can make you feel inferior without your consent. While everyone can't agree on a definition of stress, all of our experimental and clinical research confirms that the sense of having little or no control is always distressful - and that's what stress is all about.

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What is Stress? Stress is not a useful term for scientists because it is such a highly subjective phenomenon that it defies definition. And if you can't define stress, how can you possibly measure it? The term "stress", as it is currently used was coined

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What does stress look like from a more "inside" perspective

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What does stress look like from a more "inside" perspective

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Mary Martinez
A step by step look on the stress response as a chemical reaction within the body.

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Mary Martinez
A more simplified overview of the stress response within the body.

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Understanding the stress response - Harvard Health

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Research suggests that chronic stress is linked to high blood pressure, clogged arteries, anxiety, depression, addictive behaviors, and obesity.…

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Mary Martinez
Acute stress is short-term stress, acute episodic is stress that is short-term stress that is frequently recurrent, and chronic stress is long-term stress that is without reprieve. Chronic stress plagues one's life and wreaks havoc in their life.

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Stress management can be complicated and confusing because there are different types of stress - acute stress, episodic acute stress, and chronic stress - each with its own characteristics, symptoms, duration and treatment approaches. Let's look at each one.

Acute stress is the most common form of stress. It comes from demands and pressures of the recent past and anticipated demands and pressures of the near future. Acute stress is thrilling and exciting in small doses, but too much is exhausting. A fast run down a challenging ski slope, for example, is exhilarating early in the day. That same ski run late in the day is taxing and wearing. Skiing beyond your limits can lead to falls and broken bones. By the same token, overdoing on short-term stress can lead to psychological distress, tension headaches, upset stomach and other symptoms.

Fortunately, acute stress symptoms are recognized by most people. It's a laundry list of what has gone awry in their lives: the auto accident that crumpled the car fender, the loss of an important contract, a deadline they're rushing to meet, their child's occasional problems at school and so on.

Because it is short term, acute stress doesn't have enough time to do the extensive damage associated with long-term stress. Acute stress can crop up in anyone's life, and it is highly treatable and manageable.

There are those, however, who suffer acute stress frequently, whose lives are so disordered that they are studies in chaos and crisis. They're always in a rush, but always late. If something can go wrong, it does. They take on too much, have too many irons in the fire, and can't organize the slew of self-inflicted demands and pressures clamoring for their attention. They seem perpetually in the clutches of acute stress.

It is common for people with acute stress reactions to be over aroused, short-tempered, irritable, anxious and tense. Often, they describe themselves as having "a lot of nervous energy." Always in a hurry, they tend to be abrupt, and sometimes their irritability comes across as hostility. Interpersonal relationships deteriorate rapidly when others respond with real hostility. The workplace becomes a very stressful place for them.

A form of episodic acute stress comes from ceaseless worry. "Worry warts" see disaster around every corner and pessimistically forecast catastrophe in every situation. The world is a dangerous, unrewarding, punitive place where something awful is always about to happen. These "awfulizers" also tend to be over aroused and tense, but are more anxious and depressed than angry and hostile.

The symptoms of episodic acute stress are the symptoms of extended over arousal: persistent tension headaches, migraines, hypertension, chest pain and heart disease. Treating episodic acute stress requires intervention on a number of levels, generally requiring professional help, which may take many months.

Often, lifestyle and personality issues are so ingrained and habitual with these individuals that they see nothing wrong with the way they conduct their lives. They blame their woes on other people and external events. Frequently, they see their lifestyle, their patterns of interacting with others, and their ways of perceiving the world as part and parcel of who and what they are.

Sufferers can be fiercely resistant to change. Only the promise of relief from pain and discomfort of their symptoms can keep them in treatment and on track in their recovery program.

While acute stress can be thrilling and exciting, chronic stress is not. This is the grinding stress that wears people away day after day, year after year. Chronic stress destroys bodies, minds and lives. It wreaks havoc through long-term attrition. It's the stress of poverty, of dysfunctional families, of being trapped in an unhappy marriage or in a despised job or career. It's the stress that the never-ending "troubles" have brought to the people of Northern Ireland, the tensions of the Middle East have brought to the Arab and Jew, and the endless ethnic rivalries that have been brought to the people of Eastern Europe and the former Soviet Union.

Chronic stress comes when a person never sees a way out of a miserable situation. It's the stress of unrelenting demands and pressures for seemingly interminable periods of time. With no hope, the individual gives up searching for solutions.|

Some chronic stresses stem from traumatic, early childhood experiences that become internalized and remain forever painful and present. Some experiences profoundly affect personality. A view of the world, or a belief system, is created that causes unending stress for the individual (e.g., the world is a threatening place, people will find out you are a pretender, you must be perfect at all times). When personality or deep-seated convictions and beliefs must be reformulated, recovery requires active self-examination, often with professional help.

The worst aspect of chronic stress is that people get used to it. They forget it's there. People are immediately aware of acute stress because it is new; they ignore chronic stress because it is old, familiar, and sometimes, almost comfortable.

Chronic stress kills through suicide, violence, heart attack, stroke and, perhaps, even cancer. People wear down to a final, fatal breakdown. Because physical and mental resources are depleted through long-term attrition, the symptoms of chronic stress are difficult to treat and may require extended medical as well as behavioral treatment and stress management.
Source: American Psychological Association

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Stress management can be complicated and confusing because there are different types of stress - acute stress, episodic acute stress, and chronic stress - each with its own characteristics, symptoms, duration and treatment approaches. Let's look at each one. Acute stress is the most common form of stress.

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What can make you more prone to suffer from stress - NLC Library

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What can make you more prone to suffer from stress - NLC Library

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Mary Martinez
"Regression analyses revealed that life satisfaction, self-esteem, optimism, self-efficacy and psychological distress were the most important predictors of stress."

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Author(s): Dalia Saleh, Nathalie Camart, Lucia Romo

University students often face different stressful situations and preoccupations: the first contact with the university, the freedom of schedule organization, the selection of their master's degree, very selective fields, etc The purpose of this study is to evaluate a model of vulnerability to stress in French college students. Stress factors were evaluated by a battery of six scales that was accessible online during three months. A total of 483 students, aged between 18 to 24 years (Mean = 20.23, standard deviation =1.99), was included in the study. The results showed that 72.9%, 86.3% and 79.3% of them were suffering from psychological distress, anxiety and depressive symptoms respectively. More than half the sample was also suffering from low self-esteem (57.6%), little optimism (56.7%), and a low sense of self-efficacy (62.7%). Regression analyses revealed that life satisfaction, self-esteem, optimism, self-efficacy and psychological distress were the most important predictors of stress. These findings allow us to better understand stress-vulnerability factors in students and drive us to substantially consider them in prevention programs.

Source Citation

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Predictors of Stress in College Students

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Author(s): Dalia Saleh, Nathalie Camart, Lucia Romo University students often face different stressful situations and preoccupations: the first contact with the university, the freedom of schedule organization, the selection of their master's degree, very selective fields, etc The purpose of this study is to evaluate a model of vulnerability to stress in French college students.

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Mary Martinez
This scale is commonly used to deduce a person's likeliness to suffer from the ill-effects of too much stress.

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Caleb Simmons
When we speak of change, we're referring to any big transitions in life.

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The Only Thing Constant is Change

Defining Life Transitions

Transition is change. They are life's way of asking us to reexamine our present way of being and force us to develop and grow as individuals. But even when we know that these life transitions are for our own benefit, can they can still be very difficult to deal with emotionally. These transitions can be predictable, such as a move across country or upcoming marriage, or they can be unpredictable, such as the death of a loved one or a sudden loss of a job. Regardless of the event, every transition we experience forces us to make changes to our existing life. We know that change is an inevitable part of life, but that doesn't mean it's always comfortable. This is especially true when the shifts are sudden or unexpected. At these times, we may struggle because our situations don't match our expectations for how we thought our lives would be.

With change comes resistance. A major life transition closes one chapter of our life and opens a new one. It's often a very difficult adjustment as we endure intense feelings of fear and uncertainty. Transitions can be expected or unexpected, welcomed or unwelcomed, chosen or imposed, sudden or gradual. Our natural tendency is to resist change in our routines. We can feel challenged by transitions that take us away from what is familiar. We may feel overwhelmed, disillusioned, or angry. We may blame ourselves for situations that are out of our control.

Examples of Challenging Life Transitions

Marriage or a new relationship

Arrival of a new baby

Parenting an infant, child, or adolescent

Growing up and moving away from home

Adjustment to college or the workplace

Empty nesting

Divorce, separation, or recovery from infidelity

Retirement, job loss, or career changes

Financial gain or loss

Serious illness or disability of self or a loved one

Issues of aging

Death of a loved one

Questioning faith or spirituality

Questioning sexual or gender identity

Adjustment Disorder

A diagnosis of adjustment disorder can occur when a major life stress or change disrupts normal coping mechanisms and makes it difficult or impossible for a person to cope with new circumstances. Symptoms of an Adjustment Disorder begin within three months of a life transition and often include a depressed or anxious mood, changes in daily habits, feelings of overwhelming stress and panic, difficulty enjoying activities, and changes in sleeping or eating. This condition may also lead an individual to engage in reckless or dangerous behavior, avoid family and friends, or even have thoughts of suicide.

Therapy for Change

When life changes prove difficult and lead to stress, anxiety, or depression, a therapist can also help treat those issues and help you explore coping strategies. Because change can cause stress, it can have an effect on one's daily life. A person facing a big change might, for example, experience depression, anxiety, or fatigue, have trouble sleeping, or abuse drugs and alcohol. When people know that they do not cope well with change, speaking with a therapist before any significant changes in life occur may be warranted. In this way, one can prepare for changes and become better able to face them in the future, even without prior knowledge of potential changes.

With every life transition, there can be a sense of grief at the loss you are experiencing. Even when you have been expecting, or even welcoming, a life transition, it's still perfectly normal to feel sadness for what you are leaving behind. It's important to deal with that sense of loss and fear of the unknown before you're ready to embrace your new reality. When your regular support system isn't enough it may be time to talk with a professional, like me. An objective therapist can help you move past self-doubt and fear.

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Transition is change. They are life's way of asking us to reexamine our present way of being and force us to develop and grow as individuals. But even when we know that these life transitions are for our own benefit, can they can still be very difficult to deal with emotionally.

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Why you should learn to deal with change

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Why you should learn to deal with change

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Mary Martinez
"If you can learn to cope with change, you’ll lower your risk for anxiety and depression. Your relationships will flourish, and your body will feel healthier. But if you can’t cope with change, only a minor amount of stress can make you feel overwhelmed by life."

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Psycom.net - Mental Health Treatment Resource Since 1986

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Any life is a life of change. We experience transitions in work and relationships, changes in our physical and mental health, and new events in our local communities and our world. Sometimes we know a change will occur, while other times it comes suddenly and unexpectedly. Maybe it's a disappointment, or maybe it's a wonderful surprise.

Many people spend a great deal of time and energy trying to avoid change, but it will inevitably catch up to them. If you can learn to cope with change, you'll lower your risk for anxiety and depression. Your relationships will flourish, and your body will feel healthier. But if you can't cope with change, only a minor amount of stress can make you feel overwhelmed by life. You might also struggle to set and meet the goals you have for yourself.

Being able to cope with change is sometimes called resilience. Though your environment and genes might influence your level of resilience, the amount isn't set in stone. Practicing different ways of thinking and being in the world can boost your ability to deal with change and help you create a life that is adaptive to new places and unexpected events. Let's take a look at a few healthy practices for increasing your level of resilience and coping with change.
Evaluate Your Level of Control
Sometimes it's all too easy to become fixated on events over which we have no power, or people who might never change their actions or attitude. But rather than focus on blaming others or moving the unmovable, resilient people set their sights on what they can control. To evaluate your level of control over a situation, you can ask yourself, "What can I take responsibility for in this situation?" When you look for opportunities to empower yourself and work towards change that is possible, you're less likely to feel stuck in difficult situations.
Practice Self-Care After a Loss
Often life's transitions involve losses, such as a death, a big move, the loss of a job, or a relationship ending. Even positive transitions, like a graduation or a job change, can make you feel a little sad. During these times of transitions, don't push away any grief you might feel. Acknowledge the loss, and pay attention to what you've learned from the experience. Seek support and camaraderie among friends and family, and consider speaking with a counselor or other mental health professional if you feel you need extra support during the transition.

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Take a Mental Health Quiz Check Your Thought Patterns
In times of change, it's easy for your mind to cut corners. You might see everything in black or white, or you assume the worst will occur. But if you take the time to examine your thought patterns and assess how rational they are, you might find some space to nudge your thinking towards resilience. If you're not sure how to slow down your mind, practicing relaxation techniques, such as mindfulness or deep breathing, can help you feel more in control of your brain and how you evaluate a major change.

You can also generate more positive thoughts if you take the time to remind yourself about transitions and challenges you successfully navigated in the past. Make a list of ways you've been resilient in your life, and consider what traits and actions might be able to see you through the current challenge. By focusing on your strengths instead of your weaknesses, you will feel more empowered to meet what lies ahead.
Be in the Present
While it's important to look to the past to find your strengths, sometimes you can feel too pulled into the future in times of change. When you worry about what the future will bring or what mistakes you might make, you forget to be in the present and observe what's happening around you. To bring yourself back to the present, get in tune with your body. Pay attention to how it responds to stress, and set aside time every day to relax, take some deep breaths, and bring your focus back to the present.
Find Your Priorities
The most resilient people see change as an opportunity rather than a monster to fear. Transitions in life allow you to consider where your priorities lie. How do you really want to spend your time on earth? What's really important to you? Where do you see yourself wasting your time and energy? With a clear sense of your goals and values, you will find your mind and body can be much more resilient when it comes to the stressors of change.

Above all, prioritizing your health in life's transitions means not being afraid to ask for help when you need it. Humans are social creatures by nature, so you weren't built to withstand every sudden event in life without the support of others. Talk to family and friends who are experiencing similar changes, or consider finding a support group in your community. Ask your doctor about how to prioritize your health during change, and don't be afraid to talk to a counselor or other mental health professional about building resilience. You can't avoid change, but you live a life of resilience. You can embrace transition and see challenges as opportunities to thrive.

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The Psychology Of Dealing With Change: How to Become Resilient

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Any life is a life of change. We experience transitions in work and relationships, changes in our physical and mental health, and new events in our local communities and our world. Sometimes we know a change will occur, while other times it comes suddenly and unexpectedly.

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Life changes and their connection to depression - NLC Library

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Life changes and their connection to depression - NLC Library

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Mary Martinez
"The present study demonstrated that amount of life change was associated with more depressive symptoms, whereas a certain amount of excess of positive life changes was related to less depressive symptoms. However, experiencing a large excess of positive life changes did not have any additional beneficial effects, rather the opposite. In other words, more positive life changes relative to negative life changes have the potential to protect against depressive symptoms, yet only when the amount of change is limited."

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Author(s): Elise C Bennik ¹ , Johan Ormel ¹ and Albertine J Oldehinkel ¹

Depression is a highly prevalent disorder, which is expected to rank second in causes of disability worldwide by 2020 (Mathers & Loncar, 2006). Research into depression underscores the role of life changes in its etiology. A substantial body of research has demonstrated that life changes are associated with the onset and course of depressive symptoms (e.g., Brilman & Ormel, 2001; De Graaf et al. 2002; Friis et al. 2002; Kessler, 1997; Ormel & Wohlfarth, 1991; Stroud et al. 2008). It is a challenging task to define the objective stressfulness of life changes, since stress is imperceptible, shows a wide intra-category variance, and can be rated along varying dimensions (Dohrenwend, 2006; Ross & Mirowsky, 1979). Two dimensions that have often been used in prior studies are the amount of change (Holmes & Rahe, 1967), and its unpleasantness or threat (Brown et al. 1973; Ormel & Wohlfarth, 1991; Paykel et al. 1971).

In the late seventies of the last century, several studies compared these two dimensions of stressfulness with regard to the question which one of the two predicted mental health problems best. The results were equivocal. Dohrenwend (1973) and Fontana et al. (1979) found that both the total amount of change and unpleasantness predicted psychological distress, with the former being a better predictor. In contrast, unpleasantness was more strongly correlated with mental health problems than was the amount of change in studies of Gersten et al. (1974), Vinokur and Selzer (1975), Ross and Mirowsky (1979) and Mueller et al. (1977). Since the publication of these studies, the emphasis has been on unpleasant life changes and remarkably little effort has been made to disentangle the effects of unpleasantness and amount of change.

Due to the focus on unpleasantness rather than the total amount of change, research on life changes has been characterized by a preponderance of studies on the influence of negative life changes on depression. Many life changes are, to some degree, both pleasant and unpleasant (Ormel & Wohlfarth, 1991), but for the sake of clarity we will refer to a negative life change when the life change is largely unpleasant and to a positive life change when the life change is largely pleasant. Seligman, initiator of the positive psychology movement (Baumeister et al. 2001), argued for a shift from the negative focus dominating the psychology field towards a more positive focus in 1991. His call increased the interest in beneficial influences of positive stimuli on mental health somewhat, but still few studies have focused on the effects of positive life changes on mental health. The ones that did demonstrated inconsistent findings. Some studies found that positive life changes were associated with increased life satisfaction (Lu, 1999) and remission of depression (Gledhill & Garralda, 2011; Kessler, 1997; Needles & Abramson, 1990; Oldehinkel et al. 2000), as well as with a diminished effect of negative life changes on distress (Reich & Zautra, 1981), depression (Cohen & Hoberman, 1983; Dixon & Reid, 2000; Leenstra et al. 1995) and self-esteem (Cohen et al. 1987). In contrast, other studies revealed no direct association between positive life changes and mental health (Needles & Abramson, 1990; Sarason et al. 1978), or even an association with increased distress (Brown & McGill, 1989; Hirsch et al. 1985) and risk of depression (Overbeek et al., 2010).

Distinguishing between the valence (i.e., the pleasantness or unpleasantness) of life changes and the amount of change could provide an explanation for the inconsistent findings with regard to the effect of positive life changes on depressive symptoms. Assuming that a pleasant experience generally reduces depressive symptoms, whereas the effort required to adjust to (any) change rather tends to increase symptoms (Coddington, 1972), we propose that two opposite forces are acting in the case of positive life changes. Which one of the two dominates will depend on the relative amount of pleasantness and amount of change. In case of a negative life change, both the valence and the change component act in the same direction (i.e., towards more depressive symptoms), which explains why findings regarding negative life changes have been considerably more consistent than those regarding positive life changes. Because negative and positive life changes often co-occur and interact in depressed individuals (Overbeek et al., 2010), the effects of both types of changes should be studied in conjunction, taking into account their overall valence and amount of change (Shahar & Priel, 2002).

We hypothesize that the association of both valence and amount of change with depressive symptoms is not represented by a straight line, but curvilinear. With regard to amount of change, this hypothesis is based on the assumption that amount of change is only related to depressive symptoms above a certain threshold and on a study by Wildman and Johnson (1977), who found a curvilinear relationship between amount of change and mental health. With regard to valence, we expect depressive symptoms to be more strongly related to an excess of unpleasantness (negative valence) than to an excess of pleasantness (positive valence) for two reasons. The first reason is that most adolescents did not have any, or only few, depressive symptoms, resulting in little variation left to benefit from a high amount of positive life changes relative to the amount of negative life changes (ceiling effect). The second reason is that depressive symptom measures cover only the negative part of the continuum ranging from happiness to depression.

It is generally acknowledged that depression is a heterogeneous disorder, which entails different underlying pathologies (Chen et al. 2000; Kendler et al. 1996; Ormel & de Jonge, 2011). Neurovegetative-somatic symptoms (appetite or weight change, sleep problems, psychomotor agitation or retardation, fatigue) and cognitive-affective depressive symptoms (depressed mood, loss of interest, feeling worthless, guilt, and suicidal ideation) have been found to be differentially associated with demographic characteristics, comorbid problems, clinical characteristics of the depression, and personality traits (Lux & Kendler, 2010), as well as with cardiac autonomic and HPA axis function (Bosch et al., 2009). Moreover, Keller et al. (2007) demonstrated that chronic stress was particularly strongly associated with symptoms like fatigue and hypersomnia, while losses (death of loved ones and romantic breakups) were rather marked by anhedonia, appetite loss, and guilt. Hence, although it has, to our knowledge, never been examined directly, it is well conceivable that the relative importance of the valence and amount of life change differs among depressive symptoms.

Valence might be especially associated with cognitive-affective symptoms. Cognitive diathesis-stress theories of depression postulate that individuals with a negative cognitive diathesis tend to make negative inferences about the causes, consequences, and self-implications of a life change (Abramson et al. 1989; Beck, 1987). Most likely, these inferences are based on the valence rather than the amount of life changes. These negative inferences are believed to induce hopelessness and, in turn, other cognitive-affective symptoms (Abramson et al. 1978). Conversely, the attribution of positive life changes to internal, global and stable causes may reduce hopelessness and associated cognitive-affective symptoms (Needles & Abramson, 1990). The amount of life change, on the other hand, might be more strongly associated with neurovegetative-somatic symptoms, because every change requires energy. Frequent or persistent exposure to situations that require energy (i.e., life changes) may take more energy than is easily available and hence lead to lack of energy or disruption of physiological processes such as metabolism and diurnal rhythm. This idea was already expressed in 1936 by Selye, who postulated that organisms have a generalized defense reaction to adapt to challenging stimuli consisting of three phases: alarm phase, resistance and exhaustion. The third phase is only reached when exposure to stressors persists (Selye, 1936). Recent chronic stress research in humans underpins this idea (Armon et al. 2008; Grossi et al. 2003). Thus, neurovegetative-somatic depressive symptoms are hypothesized to be more strongly associated with the amount of life change than with valence.

The goal of the present study was to disentangle the effects of valence and the amount of life change with regard to the development of depressive symptoms. Most studies on the unique influences of valence and amount of change on mental health were conducted back in the late seventies of the last century, after which this topic has been mainly neglected. We gave new impetus to these findings by measuring depressive symptoms instead of global mental health, and by using regression analyses which allowed us to adjust for multiple confounders (including pre-event depressive symptoms) and to model curvilinear effects. In addition to a sum score of depressive symptoms, we examined the effect of two sub dimensions, that is, cognitive-affective and neurovegetative-somatic symptoms. We hypothesized that (1) valence and the amount of life change are independently associated with subsequent depressive symptoms; (2) the association of valence and amount of change with depressive symptoms is curvilinear; and (3) valence is associated most strongly with cognitive-affective symptoms, whereas amount of change is associated most strongly with neurovegetative-somatic symptoms. These hypotheses were examined in a large sample of adolescents ( N = 2230) from the Dutch TRacking Adolescents' Individual Lives Survey (TRAILS). Adolescents are an interesting study target because they often experience changes in many life domains and the incidence of depression rises considerably during this life phase (Kessler et al. 2001). Disentangling valence and the amount of life change may be a fruitful approach to a better understanding of the influence of positive life changes on depression, and to further explore the heterogeneity of depressive symptoms.

Participants and procedure

This study is part of TRAILS, a prospective cohort study of Dutch adolescents. The study was approved by the Dutch Central Committee on Research Involving Human Subjects. Data present in this article are from the second and third wave of TRAILS, which ran respectively from September 2003 to December 2004 and September 2005 to Augustus 2008. The sample selection consisted of two steps. First, 3483 names and addresses of all inhabitants born between October 1, 1989 and September 30, 1990 (first two municipalities) or October 1, 1990 and September 30, 1991 (last three municipalities), were collected at the selected municipalities. Second, primary schools (including schools for special education) within these municipalities were simultaneously approached with the request to participate in TRAILS. TRAILS staff approached eligible children and their parents only when they participated in school. Of the 135 primary schools within the municipalities, 122 (90.4% of the schools accommodating 90.3% of the children) agreed to participate in the study. Seventy-six percent of the approached adolescents (N = 3145) were enrolled in the study ( N = 2230, 50.8% girls, M age = 11.09 years, SD = 0.56). All adolescents and their parents gave written informed consent. Detailed information about sample characteristics, sample selection and analysis of non-response bias has been reported elsewhere (de Winter et al., 2005; Huisman et al., 2008). Of the 2230 baseline participants, 96.4% ( N = 2149, 51.0% girls, M age = 13.65, SD = 0.53) participated in the second wave (T2), which was held two to three years after the first wave (T1). At the third wave (T3), which was held two to three years after wave 2, the response was 81.4% ( N = 1816, 52.3% girls, M age = 16.27, SD = 0.73).

Depressive symptoms were assessed with the Youth Self-Report (YSR), a self-reported evaluation of the child's emotional and behavioral problems in the past 6 months (Achenbach & Rescorla, 2001). The 13 items of the YSR Affective Problems scale (Cronbach's [alpha] = .76, test-retest reliability: r = .79) reflect symptoms of a Major Depressive Episode according to the DSM-IV (Achenbach et al., 2003). Participants were asked to rate the items on a 3-point scale (0 = not true, 1 = sometimes or a bit true, 2 = often or very true). The scale score reflects the sum score of the individual items (T2: M = 3.57, SD = 3.38, T3: M = 3.81, SD = 3.50). A high level of depressive symptoms was defined as a sum score of 7.0 (85 th percentile) or more, which has been established as a good predictor of clinical depressive episodes in adolescents (Aebi et al. 2009). Adolescents with a score below 7.0 were indicated as having low level of depressive symptoms. This cut-off score was also used to define transition groups. For example, adolescents who scored below 7.0 at T2 and above 7.0 at T3, were classified as having moved from low to high levels of depressive symptoms.

Based on our understanding of the constructs measured by the scales and confirmative factor analyses, 12 items (the item "I sleep more than most other children" was omitted from the scales in order to increase internal consistency) of the Affective Problems Scale were divided into two scales, namely neurovegetative-somatic symptoms (less sleep, sleeping problems, overtiredness, loss of energy and eating problems) and cognitive-affective symptoms (anhedonia, depressed mood, crying a lot, feelings of worthlessness, feelings of guilt, self-harm and suicide ideation). More details about the construction of the scales are described in the article of Bosch et al. (2009). Cronbach's alphas for the neurovegetative-somatic symptoms scale were .64 and .67 and for the cognitive-affective symptoms scale .73 and .74 for the T2 data and the T3 data, respectively.

Life changes were measured using the Turning Point Questionnaire (TPQ), which was specifically developed for TRAILS. Adolescents were asked to indicate in which of seven life domains positive or negative changes had occurred in the preceding two years. The domains were romantic relationships, friendships, achievements, family, peer group, school and religion. School was excluded from the analyses because of a low test-retest reliability (Îº = .48), and religion because only very few (< 3%) of the adolescents reported a life change in this domain. Analyses with inclusion of the school domain in the analyses yielded nearly the same results as analyses without changes in the school domain except that the effects of amount of change and valence were slightly larger than without the life change scores in the school domain. An important feature of the TPQ is that it is symmetrical, in that positive and negative life changes are assessed with regard to the same domains. With regard to family, for instance, the two life changes assessed are 'There has been a change in your family for the better' (positive life change) and 'There has been a change in your family for the worse' (negative life change). Please note that the valence and amount of life change scores are not based on the actual number of life changes, but on the number of life domains in which the adolescent experienced a change in the preceding two years.

The TPQ test-retest reliability across a period of two weeks was examined in a sample of 150 adolescents ( M age = 16.57, SD = 0.75, 52.7% boys), who followed pre-university (47.3%) or higher general secondary education (52.7%) at two different schools. The test-retest reliabilities (Cohen's kappa) for the different domains of change ranged from .59 to .78. The test-retest correlation (Spearman rho) of the sum scores for positive and negative life changes were, respectively, .81 ( p < .01) and .78 ( p < .01) (Bennik et al., 2011).

Based on these sum scores we constructed two measures: (1) the amount of change, which refers to the total number of life changes irrespective of valence; and (2) the valence of the life changes, which was calculated as the number of domains with positive life changes minus the number of domains with negative life changes (i.e., the higher the valence, the larger the relative number of positive life changes). We chose a difference score of positive life changes minus negative life changes instead of a ratio score of positive life changes divided by negative life changes because some adolescents experienced zero negative life changes, and it is mathematically not possible to divide a number by zero.

The Turning point questionnaire was only administered at T3, covering the period between T2 and T3. Therefore only life change measures between T2 and T3 were available. Depressive symptoms were measured at T1, T2 and T3, but we only used the data from T2 and T3 since we were interested in the influence of life changes on depressive symptoms at T3, adjusted for the depressive symptoms before the life changes took place (at T2).

All analyses were performed with SPSS 18.0.3. (SPSS Inc., Chicago). Complete data from 1532 adolescents were available, while in 31.3% of the 2230 adolescents information was partly or wholly missing, presumably at random. We used multiple imputation techniques (Fully Conditional Specification and Predictive Mean Matching) to impute missing values in any of the included variables. Since Bodner (2008) recommended using at least as many imputations as the percentage of missing data, the number of imputations was 33. Significance levels (two-tailed) were set at p < .05 for all analysis.

To test the hypothesis that Valence and Amount of change are independently associated with depressive symptoms, we conducted ordinary regression analyses. First, we screened data and examined assumptions for regression analyses. The variance inflation factor (VIF) was calculated to check for multicollinearity. Since all the VIFs were below 1.8, there were no indications of multicollinearity. Assumptions of ordinary regression analyses were not fully met, but additional analyses with robust regression yielded results that corroborated the ones found with ordinary linear regression results. We chose to present the results of the ordinary linear regression analyses in this article because these models provided more relevant information (i.e., proportion explained variances and betas) than robust regression models. The dependent variable was depressive symptoms at T3. The Valence and Amount of change score were entered simultaneously in the model, so that we could assess their unique contribution, adjusted for each other. We also controlled for T2 depressive symptoms, gender, and age. In a second step, quadratic terms of the Valence and Amount of Change scores were included in the model to investigate whether there was a curvilinear pattern in addition to the linear pattern. To prevent multicollinearity, the quadratic variables were centered (original variable minus its mean).

We have also considered incorporation of positive valence, negative valence, and amount of change separately in the models. However, since the total amount of change score is a linear combination (i.e., sumscore) of positive and negative changes, adding the amount of change score to a model with positive and negative life changes is statistically not possible. Hence, the only way to disentangle change and valence in a model with both positive and negative changes is to use difference scores. It is important to note that no information will be lost with our approach, because the separate effects of positive and negative life changes could be derived from the regression coefficients of valence and amount of change (B4 valence = B4 pos. changes - neg. changes; B5 amount of change = B5 pos. changes + neg. changes) . The regression coefficient of the specific effect of positive life changes is B4 valence + B5 amount of change, and the regression coefficient of the specific effect of negative life changes is -B4 valence + B5 amount of change.

We chose to use a difference score for valence and an amount of change score in the analyses, because these variables directly test our hypotheses about valence and change and are easy to interpret without loss of information of the absolute effects of positive and negative life changes. We do not have specific questions or hypotheses about the interaction of valence and amount of change and therefore we left them out the analyses.

As additional analysis to get closer to clinically meaningful findings, we examined whether Valence and Amount of change predicted a transition from low (T2) to high (T3) levels of depressive symptoms, or vice versa. This was tested in two logistic regression analyses; one involving adolescents with low levels of depressive symptoms at T2, with high versus low T3 symptom levels as outcome variable; and the other involving adolescents with high levels of depressive symptoms at T2, with low versus high T3 symptom levels as outcome variable.

Finally, ordinary linear regression analyses with, respectively, neurovegetative-somatic and cognitive-affective symptoms as dependent variables were performed to test whether Valence and Amount of change were differentially associated with different symptom clusters. To examine the unique influence of valence and amount of life change on the different symptom clusters we performed an additional ordinary linear regression analysis with the difference between the cognitive-affective and neurovegetative-somatic symptom scores as dependent variable.

Table 1 shows the proportions of adolescents experiencing positive and negative life changes in each of the five domains. Adolescents reported more positive than negative life changes in most domains, except for family. The over report of positive life changes for the domains romantic relationship and peer group may be due to the development of romantic and adolescent friendship relationships which have not yet ended or not ended in an unpleasant manner (13-16 years). Descriptive statistics of the variables used in this study are listed in Table 2. The Valence score and Amount of change score ranged respectively from -3 to 5 and from 0 to 10. These two life change variables were moderately correlated: the larger the excess of positive life changes, the larger the amount of change score. The correlations with gender and T2 depressive symptoms were very weak (Amount of change) or negligible (Valence).

Proportions and standard deviations of experienced life changes subdivided into different domains and valence

Correlations, means and standard deviations among the study variables

Change in total depressive symptoms

Adjusted for gender, age, T2 depressive symptoms and each other, both Valence and Amount of change were associated with T3 depressive symptoms (see Table 3a). Valence had a negative effect on depressive symptoms which uniquely explained 2% of the variance (R ² change = .020, F = 45.39, p < .001); Amount of change had a positive effect on depressive symptoms at T3 and added 3.5% unique explained variance to the model (R 2 change = .035, F = 80.64, p < .001). All predictors together explained 32% of the variance in T3 depressive symptoms (R ² = .318). There were no indications that Valence predicted T3 depressive symptoms to a greater extent than Amount of change or vice versa (deducted from the overlapping confidence intervals). The effect of Valence was curvilinear, as indicated by a significant quadratic effect (R 2 change = .007, F = 8.76, p < .001 and see Table 3a), which is illustrated in Figure 1: high amounts of unpleasantness had stronger effects on depressive symptoms than high amounts of pleasantness. The graph reached its nadir at about a Valence score of 3, indicating that an excess of more than three positive life change did not have additional beneficial effects anymore, rather the opposite. The regression coefficient of the specific effect of positive life changes is B4 valence + B5 amount of change = (-0.44) + (0.45) = 0.01, and the regression coefficient of the specific effect of negative life changes is -B4 valence + B5 amount of change = -B4 valence + B5 amount of change = - (-0.44) + (0.45) = 0.89 (see Table 3a).

Ordinary multiple regression models predicting respectively T3 depressive symptoms (3a), T3 neurovegetative-somatic symptoms (3b), T3 cognitive-affective symptoms (3c) from valence and amount of change

Curvilinear effect of valence 1 on T3 depressive symptoms. ¹ A negative valence score indicates a higher amount of negative life changes than positive life changes, whereas a positive valence score indicates a higher amount of positive life changes than negative life changes. For example, a score of 3 means that three more positive life changes than negative life changes were reported. [end caption]

Additional transition analyses

Table 4 presents the Odds ratios (OR) and corresponding 95% confidence intervals (CI's) for the transition from low (T2) to high (T3) levels of depressive symptoms and vice versa. The transition from low to high levels of depressive symptoms was significantly predicted by both Valence and Amount of change. Valence decreased the likelihood of the transition from low to high levels of depressive symptoms, while Amount of change increased its likelihood. The associations of Valence and Amount of change with a transition from high to low levels of depressive symptoms was just the other way around and about equally strong. The effects of Valence and Amount of change were linear rather than nonlinear in this model, that is, the quadratic effects were not significant.

Logistic regression models predicting the likelihoods of transition of depressive symptoms

Change in neurovegetative-somatic symptoms and cognitive-affective symptoms

Adjusted for gender, age, T2 neurovegetative-somatic or cognitive-affective symptoms and each other, Valence and Amount of change were associated with both neurovegetative-somatic and cognitive-affective symptoms (see respectively Table 3b and 3c). Valence had a negative effect and Amount of change had a positive effect on the two symptom dimensions. Valence predicted cognitive-affective symptoms better than neurovegetative-somatic symptoms ( t = - 3.21, p = .001), while there was no difference for amount of change.

The aim of the present study was to obtain a better understanding of the influence of positive life changes on depression by decomposing life changes into a valence and an amount of change component. The first hypothesis was that valence and amount of life change are independently associated with depressive symptoms. The results are in accordance with this expectation. The second hypothesis, that valence and amount of life change would demonstrate curvilinear associations with depressive symptoms, was partially supported by our data. We found a curvilinear association between valence and depressive symptoms, but not between amount of life change and depressive symptoms. Finally, we hypothesized that valence would be relatively strongly associated with cognitive-affective symptoms and amount of change with neurovegetative-somatic symptoms. Although all associations were statistically significant, valence was more strongly associated with cognitive-affective than with neurovegetative-somatic symptoms, in accordance with the hypothesis. The effects of amount of life change were about equally strong for both symptom dimensions.

The findings of the current study commensurate with those of Dohrenwend (1973) and Fontana et al. (1979), who notified that both the amount of life change and unpleasantness predict mental health problems. They are in contrast with studies of Gersten et al. (1974), Vinokur and Selzer (1975), Ross and Mirowsky (1979) and Mueller et al. (1977) indicating that unpleasantness is a better predictor of mental health problems than the amount of life change. These inconsistent findings may be caused by the use of different measures of (un)pleasantness. Gersten et al. (1974), Vinokur and Selzer (1975), Ross and Mirowsky (1979) and Mueller et al. (1977) used independent scores of pleasantness and unpleasantness in addition to balance scores (the number of pleasant life changes minus the number of unpleasant life changes or vice versa), whereas Dohrenwend (1973) and Fontana et al. (1979) only used balance scores. The use of balance scores was criticized by Vinokur and Selzer (1975), who pointed out that pleasant life changes are not significantly associated with mental health problems and cause high error variance in the balance score. As outlined in the Introduction of this article, the lack of effects of positive life changes may be due to two opposite life change-related forces: pleasantness versus the adjustment required by changes. By adjusting the effect of pleasantness (valence) for the influence of amount of change and vice versa, we were able to analyze their independent effects on depressive symptoms. Furthermore, by taking into account the total amount of change, two persons with the same valence score but with other absolute numbers of positive and negative life changes would have different predictive values for depressive symptoms, because their scores for amount of change are different.

Although perhaps not immediately evident, our findings are in accordance with previous studies suggesting that the (inverse) effects of positive life changes on depressive symptoms are small (Needles & Abramson, 1990; Sarason et al., 1978). When accounting for amount of change, an excess of positive life changes was associated with fewer depressive symptoms. However, the effects were curvilinear and revealed that these beneficial effects of positive life changes on depressive symptoms were less strong than the detrimental effects of negative life changes. More than three positive life changes relative to negative life changes did not have additional beneficial effects anymore, rather the opposite.

The effect sizes found in our study were small. Our whole model explained 32 percent of the variance of T3 depression, with T2 depression accounting for two third of this explained variance. Gender, valence and amount of change explained the other one third of the variance. Although the proportion explained variance of the quadratic terms is small (0.7 percent) and appears of small clinical relevance, adding the quadratic terms to the model significantly improved the model which has resulted in our conclusion that the effect of valence was rather curvilinear than linear. This proportion is small, because it reflects the unique explained variance of the quadratic effects of valence and amount of change up and above the linear effects of valence and amount of change.

The hypothesis that valence is more strongly associated with cognitive-affective symptoms and amount of life change more strongly with neurovegetative-somatic symptoms, was partially confirmed. Contrary to our hypothesis, the amount of life change was approximately similar associated with both symptom dimensions. Possibly, cognitive-affective symptoms are indirect consequences of neurovegetative-somatic symptoms. In burnout for example, exhaustion is the core symptom, but it is accompanied by cognitive-affective symptoms (Schaufeli & Enzmann, 1998). Since we could not determine the exact time points of the life changes and changes in depressive symptoms in our study, it is impossible to compare direct and indirect effects of valence and amount of life change on symptom clusters.

Our study has several notable strengths. One important asset is the use of a life changes questionnaire that is symmetrical, in that both positive and negative life changes are assessed with regard to the same domains (romantic relationships, friendships, achievements, family and peer group), and that the items assessing positive and negative life changes only differed with regard to the valence of the life changes. In other words, the number of negative life changes and positive life changes assessed were equal in this study, while previous studies were often hampered by an underrepresentation of positive life changes in their life changes measures (Mueller et al., 1977). Another asset is the large sample size compared with most previous studies, which formed an adequate representation of the population of Dutch adolescents (de Winter et al., 2005). Finally, due to the longitudinal design of the TRAILS study, we were able to adjust for pre-event depressive symptoms.

Several limitations require that the results be interpreted with some caution. First, the occurrence of life changes was obtained via self-report rather than interviewer-based measures. Therefore, the relationship between life changes and depressive symptoms might be confounded by the mental health state of the adolescent (Monroe, 2008). This would lead to an overestimation of the size of the positive association between depressive symptoms and negative life changes, and the negative association between depressive symptoms and positive life changes. Because we found that experiencing a high number of positive life changes was associated with more instead of fewer depressive symptoms, we suspect the confounding effect to be limited at the most. A second limitation is the observational nature of the study which does not allow clarifying causal relationships between life changes and depressive symptoms (Kraemer et al., 1997). Third, the life changes measures involved a simple count of the number of domains in which a change occurred, and the changes were not rated with regard to the amount of required readjustment (e.g. Holmes & Rahe, 1967). The questionnaire used did not allow free responses of the participants to describe which changes took place and therefore we did not have specific information about the changes. However, reported correlations between the number of life changes and readjustment ratings are high (Swearingen & Cohen, 1985), and most studies found that a simple sum score of life changes was associated virtually similarly with mental health problems as a life change measure based on readjustment ratings (e.g. Gersten et al., 1974; Vinokur & Selzer, 1975). Since only five domains were measured our life change measures did not cover all domains of life changes, but we do think that we have measured the most important domains. Possibly more important is that the valence and amount of life change scores are not based on the actual number of life changes, but on the number of life domains in which the adolescent experienced a (positive/negative) change. Part of the adolescents may have experienced multiple life changes within a domain, which was not reflected in the scores. The life change scores used in the present study are therefore presumably an underestimation of the actual score. However, it is unlikely that this underestimation resulted in a systematic bias. The questionnaire used was designed to measure important life changes (potential turning points) rather than more minor life changes, because major life changes have been primarily associated with the onset of depression (e.g. Monroe & Harkness, 2005). Furthermore, we think our approach to measure the number of life domains rather than individual changes also has an important benefit: it provides an indication of the (amount of) areas of stability and instability.

Another limitation of the current study is that well-known cognitive vulnerability factors influencing the association between (positive) life changes and depressive symptoms were not incorporated in the analyses, including self-esteem (Cohen et al., 1987), neuroticism (Oldehinkel et al., 2000), social support (Jackson & Warren, 2000), and attributional style (Needles & Abramson, 1990). Therefore, we did not have information about whether the associations of valence and amount of change with depressive symptoms were mediated or moderated by other factors. Individuals with greater cognitive vulnerability may exhibit stronger associations between life changes and depressive symptoms, particularly cognitive-affective symptoms.

It may be interesting for future research to examine whether specific positive life changes are differentially associated with depressive symptoms. The finding that the change component of positive life changes suppressed the beneficial effect of the valence component implies another hypothesis in consequence: positive life changes which require relatively little adjustment have most beneficial effects since they are not overshadowed by the efforts required to adjust to the change. Furthermore, future studies should not only investigate the relationship between life changes and depressive symptoms, but also the relationship between life changes and happiness.

The present study demonstrated that amount of life change was associated with more depressive symptoms, whereas a certain amount of excess of positive life changes was related to less depressive symptoms. However, experiencing a large excess of positive life changes did not have any additional beneficial effects, rather the opposite. In other words, more positive life changes relative to negative life changes have the potential to protect against depressive symptoms, yet only when the amount of change is limited. Furthermore, this study encourages examination of the effects of life changes on specific symptom clusters instead of total numbers of depressive symptoms, which is the current standard.

Competing interests: The authors declare that they have no competing interests.

Authors' contributions: EB reviewed the literature, analysed the data and wrote the drafts of this article. JO and AO contributed to the design of the analysis and interpretation of data and critically reviewed and edited all sections of the article. All authors read and approved the final manuscript.

Acknowledgements: This research is part of the TRacking Adolescents' Individual Lives Survey (TRAILS). TRAILS has been financially supported by various grants from the Netherlands Organization for Scientific Research NWO (Medical Research Council program grant GB-MW 940-38-011; ZonMW Brainpower grant 100-001-004; ZonMw Risk Behavior and Dependence grants 60-60600-98-018 and 60-60600-97-118; ZonMw Culture and Health grant 261-98-710; Social Sciences Council medium-sized investment grants GB-MaGW 480-01-006 and GB-MaGW 480-07-001; Social Sciences Council project grants GB-MaGW 457-03-018, GB-MaGW 452-04-314, and GB-MaGW 452-06-004; NWO large-sized investment grant 175.010.2003.005; NWO Longitudinal Survey and Panel Funding 481-08-013); the Sophia Foundation for Medical Research (projects 301 and 393), the Dutch Ministry of Justice (WODC), the European Science Foundation (EuroSTRESS project FP-006), and the participating universities. Participating centers of TRAILS include various departments of the University Medical Center and University of Groningen, the Erasmus University Medical Center Rotterdam, the University of Utrecht, the Radboud Medical Center Nijmegen, and the Parnassia Bavo group, all in the Netherlands.

Correspondence: Elise C Bennik: e.c.bennik@umcg.nl

Author details: ¹ University of Groningen, University Medical Center Groningen, Department of Psychiatry, Interdisciplinary Center Psychopathology and Emotion Regulation (ICPE), Groningen, The Netherlands.

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doi: 10.1186/2050-7283-1-14

Please note: Some tables, figures or graphics were omitted from this article.

Source Citation

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Life changes and depressive symptoms: the effects of valence and amount of change

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Author(s): Elise C Bennik 1 , Johan Ormel 1 and Albertine J Oldehinkel 1 Depression is a highly prevalent disorder, which is expected to rank second in causes of disability worldwide by 2020 (Mathers & Loncar, 2006). Research into depression underscores the role of life changes in its etiology.

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Caleb Simmons
Common stressors, their impacts on the personal and the professional, symptoms experienced due to stress, plus a few studies.

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Stress Research

"The difficulty in science is often not so much how to make the discovery but rather to know that one has made it." - J.D. Bernal

2017 Stress Statistics

2014 Stress Statistics

Percent of people who regularly experience physical symptoms caused by stress

77 %

Regularly experience psychological symptoms caused by stress

73 %

Feel they are living with extreme stress

33 %

Feel their stress has increased over the past five years

48 %

Cited money and work as the leading cause of their stress

76 %

Reported lying awake at night due to stress

48 %

Stress Impact Statistics

Percent who say stress has a negative impact on their personal and professional life

48 %

Employed adults who say they have difficulty managing work and family responsibilities.

31 %

Percent who cited jobs interfering with their family or personal time as a significant source of stress.

35 %

Perccent who said stress has caused them to fight with people close to them

54 %

Reported being alienated from a friend or family member because of stress

26 %

Annual costs to employers in stress related health care and missed work.

$300 Billion

Percent who say they are "always" or "often" under stress at work

30 %

People who cited physical symptoms experienced the following

People who cited psychological symptoms experienced the following

Irritability or anger

50 %

Feeling as though you could cry

35 %

Cardiac Coherence and Post-traumatic Stress Disorder in Combat Veterans

Jay P. Ginsberg, Ph.D.; Melanie E. Berry, M.S.; Donald A Powell, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010;16 (4):52-60.
PDF version of the complete paper: Cardiac Coherence and PTSD in Combat Veterans
Abstract-PTSD
Background: The need for treatment of posttraumatic stress disorder (PTSD) among combat veterans returning from Afghanistan and Iraq is a growing concern. PTSD has been associated with reduced cardiac coherence (an indicator of heart rate variability [HRV]) and deficits in early-stage information processing (attention and immediate memory) in different studies. However, the co-occurrence of reduced coherence and cognition in combat veterans with PTSD has not been studied before.

Primary Study Objective: A pilot study was undertaken to assess the covariance of coherence and information processing in combat veterans. An additional study goal was an assessment of the effects of HRV biofeedback (HRVB) on coherence and information processing in these veterans.

Methods/Design: A two-group (combat veterans with and without PTSD), a pre-post study of coherence and information processing was employed with baseline psychometric covariates.

Setting: The study was conducted at a VA Medical Center outpatient mental health clinic.

Participants: Five combat veterans from Iraq or Afghanistan with PTSD and five active-duty soldiers with comparable combat exposure who were without PTSD.

Intervention: Participants met with an HRVB professional once weekly for 4 weeks and received visual feedback in HRV patterns while receiving training in resonance frequency breathing and positive emotion induction.

Primary Outcome Measures: Cardiac coherence, word list learning, commissions (false alarms) in go-no go reaction time, digits backward.

Results: Cardiac coherence was achieved in all participants, and the increase in coherence ratio was significant post-HRVB training. Significant improvements in the information processing indicators were achieved. Degree of increase in coherence was the likely mediator of cognitive improvement.

Conclusion: Cardiac coherence is an index of the strength of control of parasympathetic cardiac deceleration in an individual that has cardinal importance for the individual's attention and affect regulation.

The Effect of a Biofeedback-based Stress Management Tool on Physician Stress: A Randomized Controlled Clinical Trial

Jane B. Lemaire, Jean E. Wallace, Adriane M. Lewin, Jill de Grood, Jeffrey P. Schaefer

Open Medicine 2011; 5(4)E154.
PDF version of the complete paper: physician-stress-randomized-controlled-clinical-trial
Abstract- Biofeedback-based Stress Management
Background: Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations.

Objective: To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress.

Design: Randomized controlled trial measuring the efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness.

Setting: Urban tertiary care hospital.

Participants: Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians' lounge and throughout the hospital.

Intervention: Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team.

Main outcome measure: Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200).

Results: During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change -14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change -2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change -8.5, SD 7.6; p < 0.001).

Conclusion: A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.

Coherence Training In Children With Attention-Deficit Hyperactivity Disorder: Cognitive Functions and Behavioral Changes

Anthony Lloyd, Ph.D.; Davide Brett, B.Sc.; Ketith Wesnes, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010; 16 (4):34-42

PDF version of the complete paper: coherence-training-in-children-with-adhd
Abstract-ADHD
Attention-deficit hyperactivity disorder (ADHD) is the most prevalent behavioral diagnosis in children, with an estimated 500 000 children affected in the United Kingdom alone. The need for an appropriate and effective intervention for children with ADHD is a growing concern for educators and childcare agencies. This randomized controlled clinical trial evaluated the impact of the HeartMath self-regulation skills and coherence training program (Institute of HeartMath, Boulder Creek, California) on a population of 38 children with ADHD in academic year groups 6, 7, and 8. Learning of the skills was supported with heart rhythm coherence monitoring and feedback technology designed to facilitate self-induced shifts in cardiac coherence. The cognitive drug research system was used to assess cognitive functioning as the primary outcome measure. Secondary outcome measures assessed teacher and student reposted changes in behavior. Participants demonstrated significant improvements in various aspects of cognitive functioning such as delayed word recall, immediate word recall, word recognition, and episodic secondary memory. Significant improvements in behavior were also found. The results suggest that the intervention offers a physiologically based program to improve cognitive functioning in children with ADHD and improve behaviors that is appropriate to implement in a school environment.

Efficacy and Implementation of HeartMath Instruction in College Readiness Program: Improving Students' Mathematics Performance and Learning

Michael Vislocky, Ph.D. and Ronald P. Leslie, Ph.D.

University of Cincinnati Clermont College, 2005.
PDF version of the Executive Summary: efficacy-and-implementation-of-heartmath-instruction
Abstract-Math Instruction
In 2002, the University of Cincinnati Clermont College (UCCC) and the Greater Cincinnati Tech Prep Consortium (GCTPC) formed a partnership to address the pedagogical needs of high school students in the area of mathematics in order to prepare them for entry into higher education. Over the past four years (2002-2005), HeartMath emotional management training has been offered to Tech Prep students. It is well established that both math courses and math tests can lead to anxiety, and anxiety, in turn, interferes with students' performance in mathematics. On the first day of instruction, students completed the COMPASS Math Placement Test and the post-test was completed on the last day. The math portion was in the form of guided program learning directed at their skill level as determined by their score on the COMPASS pre-test. Instructors were available to answer student questions. In the years 2002-2004, instruction on HeartMath tools and math skills were presented in separate classrooms. In 2005, the two forms of instruction were combined in the 3-hour class. Looking at the average improvement in test points from the COMPASS pre-test and post-test, the following results were obtained: 2002 - 19% average percent increase; 2003 - 15% average percent increase; 2004 - 24% average percent increase; 2005 - 73% average percent increase.

Coherence and Health Care Cost - RCA Actuarial Study: A Cost-Effectiveness Cohort Study

Woody Bedell; Mariette Kaszkin-Bettag, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010;16 (4):26-31.
PDF version of the complete paper: rca-actuarial-study-coherence-and-health-care
Abstract-Health and Medicine
Chronic stress is among the most costly health problems in terms of direct health costs, absenteeism, disability, and performance standards. The Reformed Church in America (RCA) identified stress among its clergy as a major cause of higher-than-average health claims and implemented HeartMath (HM) to help its participants manage stress and increase physiological resilience. The 6-week HM program Revitalize You! was selected for the intervention including the emWave Personal Stress Reliever technology.

From 2006 to 2007, completion of a health risk assessment (HRA) provided eligible clergy with the opportunity to participate in the HM program or a lifestyle management program (LSM). Outcomes for that year were assessed with the Stress and Well-being Survey. Of 313 participants who completed the survey, 149 completed the Revitalize You! The program and 164 completed the LSM. Well-being, stress management, resilience, and emotional vitality were significantly improved in the HM group as compared to the LSM group.

In an analysis of the claims costs data for 2007 and 2008, 144 pastors who had participated in the HM program were compared to 343 non-participants (control group). Adjusted medical costs were reduced by 3.8% for HM participants in comparison with an increase of 9.0% for the control group. For the adjusted pharmacy costs, an increase of 7.9% was found compared with an increase of 13.3% for the control group. Total 2008 savings as a result of the HM program are estimated at $585 per participant, yielding a return on investment of 1.95:1. These findings show that HM stress-reduction and coherence-building techniques can reduce health care costs.
View my collection, "Stress and Cardiovascular Disease" from NCBI View my collection, "Stress and Cancer" from NCBI View my collection, "Stress and Diabetes" from NCBI View my collection, "Post Traumatic Stress Disorder" from NCBI View my collection, "Stress and Aging" from NCBI View my collection, "Stress in Adolenscents" from NCBI View my collection, "Stress and Meditation" from NCBI View my collection, "Stress and Yoga" from NCBI View my collection, "Workplace Stress" from NCBI

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Stress Research "The difficulty in science is often not so much how to make the discovery but rather to know that one has made it." - J.D. Bernal 2017 Stress StatisticsStatistic VerificationSource: American Psychological AssociationResearch Date: 2017Most Common Sources of Stress

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Caleb Simmons
A few techniques you can use to relax are:

Deep breathing

Massage

Meditation

Tai chi

Yoga

Biofeedback

Music and art therapy

Aromatherapy

Hydrotherapy

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Relaxation techniques: Try these steps to reduce stress

Relaxation techniques can reduce stress symptoms and help you enjoy a better quality of life, especially if you have an illness. Explore relaxation techniques you can do by yourself.
By Mayo Clinic Staff
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If you receive care at Mayo Clinic, consider registering for this online class: Introduction to tai chi

Relaxation techniques are a great way to help with stress management. Relaxation isn't only about peace of mind or enjoying a hobby. It's a process that decreases the stress effects on your mind and body. Relaxation techniques can help you cope with everyday stress. And these techniques can help with long-term stress or stress related to various health problems, such as heart disease and pain.

Whether your stress is spiraling out of control or you've already got it tamed, you can benefit from learning relaxation techniques. Learning basic relaxation techniques is easy. Relaxation techniques are often free or low cost, pose little risk, and can be done nearly anywhere.

Explore simple relaxation techniques and get started on de-stressing your life and improving your health and overall well-being.

The benefits of relaxation techniques

When faced with many responsibilities and tasks or the demands of an illness, relaxation techniques may not be a priority in your life. But that means you might miss out on the health benefits of relaxation.

Practicing relaxation techniques can have many benefits, such as:

Slowing heart rate

Lowering blood pressure

Slowing breathing rate

Improving digestion

Controlling blood sugar levels

Reducing activity of stress hormones

Increasing blood flow to major muscles

Reducing muscle tension and chronic pain

Improving focus and mood

Improving sleep quality

Lowering fatigue

Reducing anger and frustration

Boosting confidence to handle problems

To get the most benefit, use relaxation techniques along with other positive coping methods, such as:

Thinking positively

Finding humor

Problem-solving

Managing time and priorities

Exercising regularly

Eating a healthy diet

Getting enough sleep

Spending time outside

Reaching out to supportive family and friends

Types of relaxation techniques

Health care providers such as complementary and integrative health specialists and mental health providers can teach many relaxation techniques. But you can also learn some relaxation techniques on your own.

In general, relaxation techniques involve refocusing your attention on something calming and increasing awareness of your body. It doesn't matter which relaxation technique you choose. What matters is that you try to practice relaxation regularly to reap its benefits.

Types of relaxation techniques include:

Autogenic relaxation. Autogenic means something that comes from within you. In this relaxation technique, you use both visual imagery and body awareness to reduce stress.

You repeat words or suggestions in your mind that may help you relax and reduce muscle tension. For example, you may imagine a peaceful setting. Then you can focus on relaxing your breathing, slowing your heart rate, or feeling different physical sensations, such as relaxing each arm or leg one by one.

Progressive muscle relaxation. In this relaxation technique, you focus on slowly tensing and then relaxing each muscle group.

This can help you focus on the difference between muscle tension and relaxation. You can become more aware of physical sensations.

In one method of progressive muscle relaxation, you start by tensing and relaxing the muscles in your toes and progressively working your way up to your neck and head. This is best done in a quiet area without interruptions. You can also start with your head and neck and work down to your toes. Tense your muscles for about five seconds and then relax for 30 seconds, and repeat.

Visualization. In this relaxation technique, you may form mental images to take a visual journey to a peaceful, calming place or situation.

To relax using visualization, try to include as many senses as you can, such as smell, sight, sound and touch. If you imagine relaxing at the ocean, for instance, think about the smell of salt water, the sound of crashing waves and the warmth of the sun on your body.

You may want to close your eyes, sit in a quiet spot, loosen any tight clothing, and focus on your breathing. Aim to focus on the present and think positive thoughts.

Other relaxation techniques may include:

Relaxation techniques take practice

As you learn relaxation techniques, you can become more aware of muscle tension and other physical sensations of stress. Once you know what the stress response feels like, you can make a conscious effort to practice a relaxation technique the moment you start to feel stress symptoms. This can prevent stress from spiraling out of control and decreasing your quality of life.

Remember that relaxation techniques are skills. As with any skill, your ability to relax improves with practice. Be patient with yourself. Don't let your effort to practice relaxation techniques become yet another stressor.

If one relaxation technique doesn't work for you, try another technique. If none of your efforts at stress reduction seems to work, talk to your health care provider about other options.

Also, keep in mind that some people, especially those with serious mental health issues and a history of abuse, may experience feelings of emotional discomfort during some relaxation techniques. Although this is rare, if you experience emotional discomfort during relaxation techniques, stop what you're doing. Consider talking to your health care provider or mental health provider.

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Show references

1. Complementary, alternative, or integrative health: What's in a name? National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/integrative-health. Accessed Dec. 22, 2021.

2. Relaxation techniques for health. National Center for Complementary and Integrative Health. https://nccih.nih.gov/health/stress/relaxation.htm. Accessed Dec. 22, 2021.

3. Pizzorno JE, et al., eds. Stress management. In: Textbook of Natural Medicine. 5th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Dec. 22, 2021.

4. Seaward BL. Essentials of Managing Stress. 5th ed. Jones & Bartlett Learning; 2021.

5. Seaward BL. Managing Stress: Principles and Strategies for Health and Well-Being. 9th ed. Jones & Bartlett Learning; 2018.

6. AskMayoExpert. Stress management and resiliency (adult). Mayo Clinic; 2021.

See more In-depth

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Relaxation techniques: Try these steps to reduce stress

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Learn how to use relaxation techniques to reduce stress and bring more calm into your life.

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Unconventional therapies for stress - NLC Library

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Unconventional therapies for stress - NLC Library

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Caleb Simmons
There is no "one-size-fits" all treatment for stress. Experiment to find yours. If you're looking for suggestions, this article suggests hypnosis, meditation, prayer, and even dietary supplements. Do your research and most definitely speak with your doctor before ingesting anything.

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Anxiety and stress often involve a web of underlying causes, life issues, and manifestations in day-to-day life. Conditions as multifactorial as these may well benefit from multifactorial treatment approaches.

The "relaxation response"

One of the best ways to relieve stress is to use the normal body process known as the "relaxation response." This physiological process--which is the opposite of the "flight-or-fight" response--is essentially a state of deep rest that changes your physical and emotional response to stress. Due to longstanding cultural attitudes and conventional medicine traditions, this simple, inborn process may be relatively neglected and underused in the U.S.

The relaxation response has many proven beneficial effects. It decreases anxiety--and it lowers blood pressure, heart rate and oxygen consumption. Regular use of practices that produce the relaxation response may also alleviate insomnia, depression, pain and other conditions.

A simple way to elicit the relaxation response Basic meditation is a very simple way to elicit this response. Ideally it is done once or twice daily for 10 to 20 minutes.

* Sit in a relaxed position

* Repeat a word or sound as you breathe.

If your thoughts stray, which is normal, shift your attention back to the word/sound repetition. An essential component of producing the relaxation response is to interrupt the everyday train of thought. On rare occasions, the relaxation response can produce disturbing thoughts or fear of losing control, especially in people with serious psychiatric conditions, but for most it's well tolerated.

A broad array of CAM therapies, known collectively as "mind-body" approaches, may also produce the relaxation response. These include:

In addition to the simple meditation technique described above, there are formal methods, including "mindfulness meditation" and "transcendental meditation" or TM. Classes in these techniques are often available in hospitals, health clubs and community centers.

With this approach, a person learns to create visual images that have relaxing effects. Books and audiotapes are available for instruction.

Focused concentration is used to produce a trancelike or hypnotic state in which the individual is vulnerable to suggestion, for example, to relax. Hypnosis is generally induced by a trained hypnotherapist, but individuals can also learn self hypnosis.

* Music therapy

Relaxation may be produced by creating or listening to music. This may be done independently or by working with a trained music therapist. A detailed review of music therapy and MS will appear in the fall issue of Momentum.

This technique uses machines to monitor bodily functions such as muscle tension or heart rate. During treatment, the individual consciously attempts to alter one of these presumably "involuntary" body processes. Relaxation may be promoted by decreasing heart rate for example. Biofeedback usually requires a trained therapist.

Prayer can be seen as a form of meditation, especially when it involves reciting words, either silently or aloud. Importantly, prayer is one of many components of religious belief and thus may not be effective if done independently of the other aspects of religious belief.

Exercise may produce relaxation through two physiological mechanisms. The repetitive movements of some exercise, like the repetitive language of meditation, interrupt the daily train of thought and induce the relaxation response. Exercise also stimulates the body's production of endorphins and other compounds that have stress-relieving effects.

Conventional and unconventional forms of exercise, such as tai chi and yoga, are available at many community centers and health clubs and can be modified for those with disabilities. All programs should first be discussed with a knowledgeable health-care professional.

Massage is an ancient healing method that may relieve anxiety and produce the relaxation response. Most forms of massage currently used in the U.S. are derived from Swedish massage. Massage is generally well tolerated, but it should be avoided or used with caution by anyone with recent injuries, fever, infection, blood clots (thrombosis), jaundice, cancer, arthritis, or heart disease.

A variety of dietary supplements are claimed to be effective for anxiety. Unfortunately, there is no strong evidence supporting any of them. Worse, some have serious toxicity.

Kava kava is an herbal product that may be effective for anxiety, but it has been associated with more than 60 cases of liver toxicity, some of which resulted in death or the need for a liver transplant. This herb is banned in Europe and Canada, but is still available in the U.S.

Skullcap, another herb, is claimed to have both anxiety-relieving effects and therapeutic effects on MS. There is no good evidence that it does either. Furthermore, it has been associated with four cases of liver toxicity, one of which led to death in a person with mild MS. Kava kava and skullcap should not be used.

Passionflower, valerian and theanine are also claimed to be effective for anxiety, but at this time, there is no convincing evidence that these supplements are effective.

There is no single "one-size-fits-all" treatment plan for anxiety and stress. That doesn't mean nothing can be done, but therapies should be personalized and should take into account individual differences. For those who are interested, CAM approaches, alone or in combination with conventional medications or psychotherapy, may be quite helpful. Before embarking on your strategy, discuss your situation with your healthcare provider.

Did you find this article helpful? Do you want more information on a specific CAM? If yes, which one? editor@nmss.org.

Dr. Allen Bowling is medical director of the Multiple Sclerosis Service, Colorado Neurological Institute (CNI), and clinical associate professor, Department of Neurology, University of Colorado-Denver and Health Sciences Center. More information about CAM and MS may be found in his highly recommended book, Complementary and Alternative Medicine and Multiple Sclerosis (2nd edition, Demos Health) and on his Web site, NeurologyCare.net.

More information and listings of trained therapists are available from the following organizations:

Biofeedback: Association for Applied Psychophysiology and Biofeedback (aapb.org); Biofeedback Certi. cation Institute of America (bcia.org)

Guided imagery: Academy for Guided Imagery (academyforguidedimagery.com)

Hypnosis: American Society of Clinical Hypnosis (asch.net)

Massage: American Massage Therapy Association (amtamassage.org); National Certi. cation Board for Therapeutic Massage and Bodywork (ncbtmb.com)

Meditation: Meditation Society of America (meditationsociety.com)

Music therapy: American Music Therapy Association (musictherapy.org)

Tai chi: American Tai Chi Association (americantaichi.org)

Yoga: American Yoga Association (american yogaassociation.org); International Association of Yoga Therapists (iayt.org).

by Allen C. Bowling, MD, PhD

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Unconventional therapies for stress and anxiety

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Anxiety and stress often involve a web of underlying causes, life issues, and manifestations in day-to-day life. Conditions as multifactorial as these may well benefit from multifactorial treatment approaches. The "relaxation response" One of the best ways to relieve stress is to use the normal body process known as the "relaxation response."

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Caleb Simmons
The suggested stress reducers are as follows:
Exercise for at least 20 minutes a day.
Make a few dietary changes, like eliminating caffeine and alcohol, which is a depressant.
Take a multivitamin daily. Experts also recommend vitamin C and calcium as well.
Take breaks! Even if it's only for a few minutes.
Smile more. At others, or just to yourself, it'll subconsciously make you happier.
Think more pleasant thoughts, even if it's something superficial a couple times a day, like puppies or flowers.
Take a few breaths every now and then. A good exercise is inhaling through the nose for 4 seconds, holding it for 7, and exhaling through the mouth for 8.

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Mary Martinez
As per the article, you should always strive for balance, check in with yourself periodically, and most importantly of all you need to make time to take care of yourself.

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Coping with Change
Making Positive Choices in the Midst of Change
"Five R's" of Dealing With Change-Related Stress
Living Healthy, Working Well Through Change
None of Us Can Stop Change

Coping with Change
Basics
Change can take many forms. It can affect every part of our lives. It occurs in our family, at work, and in our social lives. Some changes involve additions. Births, new friends or relationships, and new possessions are welcome changes. Others involve losses. Death, divorce or illness can be devastating. Some changes are sudden, such as losing your job. Others are more gradual, such as entering middle age.

Change can be good or bad. It depends on the person and the situation. For example, a divorce may be a tragedy or a relief. A promotion is good, right? But if you're unsure of your skills, you may view it as negative. Change may be sought out or it may be forced upon you. It can challenge or stimulate you, or make you feel anxious and threatened. Too little change can make life boring, while too much change can be overwhelming.

Good or bad, change requires an adjustment of some kind. This takes energy. If the demands are too great, it can drain you and create stress. Unmanaged stress can cause physical and emotional problems.

You may not be able to control the change itself. So, the key to coping with change is to get control of your response to it as much as possible. That's when adjusting your attitude toward change can help.

Key Tips

Change is stressful, even when it's positive. But no change at all can be boring. Strive for balance. Too much stress all at once can be unhealthy. Same, too, if it goes on over a long period of time. People who experience a lot of changes in a brief time period are more likely to have an accident or illness.

The Chinese word for change is made up of two symbols. One symbol for is for uncertainty for opportunity. Try to think of change as a mixture of uncertainty and opportunity. Ask yourself what lesson you might learn. What skills you might develop? How might you become stronger as a result of this change?

During times of change, you need to take care of yourself. Get regular exercise. Eat a balanced diet. Get enough sleep.
Specifics
Evaluate your life every few months or so. How many changes you are going through? Being aware will make it easier for you to understand and deal with the stress that may come with change.

Change can cause all sorts of stress-related symptoms, such as:

Headaches

Insomnia

Digestive problems

Muscle tension and backaches

High blood pressure and heart problems

Depression or anxiety

Irritability

Eating too much or too little

Alcohol or drug abuse

Schedule planned changes so they don't happen at once. Are you getting married, buying a new house and coping with an ailing parent? You may want to hold off on job hunting until you've had time to deal to these other changes.

If faced with a sudden change, take time to think about your emotions. Are you happy, sad, scared, angry, excited? After you know what you're feeling, ask yourself these questions:

Is my reaction justified?

Is the level of my reaction justified by the facts?

Am I overreacting?

Am I misinterpreting?

Is there another way to look at this? Is there an opportunity here?

Are there parts of this change that I can control?

Would more information help me cope better with this change?

Learn to relax. Relaxing is one of the best tools for handling stress. Relaxing helps your body unwind. It helps undo the negative effects of stress.

Humor goes a long way in lowering stress. Try to find the humor in situations when possible.

Don't try to weather every change alone. Look for support from family or friends. Humor helps here, too.

FAQs
Only changes that you don't want make problems, right?
No, not really. Any change places demands on you, whether it's one that's wanted, such as a raise, a birth or marriage; or one that's not, such as a job loss, a death or divorce. It's important to be aware of major changes in your life so you can take steps to cope effectively.
Things at work always seem to be changing. How can I cope with changes when I have little or no control over them?
Is it true that you don't have control over the changes? Is there somewhere you can make a suggestion before decisions are made? A meeting, suggestion box or work group? Even if you don't like the change, you may feel better knowing you had some say about them.

Try to view change as a healthy part of life. A company that doesn't change is unlikely to grow. That goes for people, too. Be flexible when change happens. Look for ways to make the change work to your advantage. See it as an opportunity, not a crisis. Sometimes, changing your attitude is the best strategy for coping with change.
I just turned 50. My friends and family threw me a big birthday party, yet I'm really feeling down. I'm already getting mail from the AARP. I'm not ready to be put out to pasture. Everyone thinks I'm happy, but I feel terrible. What's wrong with me?
Sounds like you are stressed about getting older. Turning 50 reminds you of it. You knew it was coming, but it's still something you didn't prepare for. This can be very stressful, yet others may not realize you're going through this.

As you move from stage to stage in your life, you'll face both ups and downs. Don' be surprised to find yourself dealing with stress during most, if not all, of these stages:

Moving from the teen years to early adulthood

Turning 30, 40, 50 . . .

Becoming a parent

Reaching midlife

Becoming a grandparent

Retiring

If you are aware that these are normal phases of life, you can prepare, cope with and reduce stress.

Resources
Books
Charlesworth, Edward A., and Ronald G. Nathan, Stress Management: A Comprehensive Guide to Wellness. Ballantine, 1991.

Davis , Martha, Matthew McKay and Elizabeth Robbins Eshelman, The Relaxation and Stress Reduction Workbook. New Harbinger Publications, 2000.

Making Positive Choices in the Midst of Change

The event + the choices you make = the outcome. Possibly a simplistic equation, but the truth is events don't make us do things. Tornado alerts don't make us run to the basement. It's our choice. In fact, a meteorologist may choose to run outside to get a better look at the twister.
Learn where to take control and where to let go.
Sometimes we try to change something over which we have no control. Other times we don't take a stand. We don't make a choice when we have the ability to. You can be angry that it's raining (there's no controlling the weather) and angry that you're getting wet (your suit is getting ruined!), or you can choose to use an umbrella. Take control and make choices where you can, let go where you can't.
Resist "Victim Thinking."

Victim at sea in a storm proclaims his or her choice, "I'm going to drown."

A Survivor at sea in a storm says, "I don't know how, but somehow I'll survive." The Survivor has hope, but has left his or her fate in the hands of someone else.

A Navigator at sea in a storm says, "I'm not in charge of the sea or the storm. But I am in charge of my boat. I know what I need to do." A Navigator has hope and a plan.

Positive thinking will steer you in the right direction.
Positive self-talk is a great way to sort through feelings and make honest statements to yourself about the change you are going through. It can also help you break through negativity and doubt that can stop you in your track. Positive self-talk can help you gain some control of the change you're going through. The following is an exercise that can help you become your own best navigator through change:

Sometimes I find myself acting like a Victim. So I say to myself, "(your name), why are you acting like a victim?" I respond to myself, "I'm acting like a victim because there's no hope in this situation." I challenge myself, "Not even a possibility that something good can happen here?" "Oh, I suppose there is some chance something good will happen." "Good. You're a Survivor."

Sometimes I find myself acting like a Survivor. I coach myself, "(your name), why are you acting like a survivor?" "I'm acting like a survivor because I will live with it and there isn't one thing I can do about it." I challenge, "You can't think of one thing you can do in this situation?" "Oh, I suppose I can think of one thing I can do." "Great! Now you are acting like a true Navigator!"

By using the simple equation above when faced with change, you'll be in control and well on your way to navigating to calmer waters.

"Five R's" of Dealing With Change-Related Stress

You might not think so at the time, but every change is an opportunity to grow. Change makes us look at who we are. And the direction we are going. The following "Five R?s" can help you move through change. These ideas allow you the time to look your options as well as your opportunities.
Relax
Find ways to relax. Try deep breathing. Try meditating. Take time off from your problems. Don't think about them all the time. Exercise and commit to a healthy lifestyle that includes plenty of rest. And always try to maintain a sense of humor.
Reflect
Reflect on what is happening. Don't try to hide or discount your feelings - both good and bad. But understand the power that negative feelings can have. Negative thoughts and feelings can spread to the people around you. Seek support from others. Don't be critical of how someone else is dealing with change. Use any available resources to help you sort out what you're going through. It is smart to ask for help.
Reassess
Assess your feelings. Separate what you know from what you don't know. Ignore rumors. They only increase stress. Let go of guilt about what could have been done. Create a new vision of yourself and highlight the positives.
Rehearse
Do you need to deal with something stressful? Think about possible questions, how you'd answer them. What you would like to say about what's going on? Rehearsing helps lower stress and anxiety.
Ritualize
Keep your life as normal as possible. Maintain your routine. Keep regular family activities. Seek comfort in the things that are haven't changed in your life. Seeking out the familiar is an instant stress reliever.

How we deal with change determines whether or not we will grow through the experience. What feels like loss now may lead to unexpected benefits in the long run. By practicing the "Five R?s" you can face change feeling Rejuvenated!

Living Healthy, Working Well Through Change

None of us are immune from change. We experience change every day. Some are common, like driving through a detour maze to get to work. Some are life altering, like the loss of a loved one. It's not that we don't expect change in our lives. It's just that it would be nice to have some warning. Here are some of the types of change you might experience:

Relationship changes- marriage, ending of relationship, or the loss of spouse or family member

Workplace changes- company merger, loss of employment, or a job promotion

Quality of life and lifestyle changes- a new baby, adoption, relocation, elderly parents, or illness

Into Our Lives a Little Change Must Fall
We can all expect some changes in our lives. Each of us will handle it in different ways. Some of us are frozen by change. It is difficult to make a decision. Others may feel energized to make positive moves in their lives. Some of us may even be able to see change coming. However you react to change, it's best to weigh your options by seeking out people who can help you make the best decisions.
Change Brings Stress
The very word "change" means to put aside, end, or move on to something new. That alone can cause stress. Change follows a process and understanding the change process is important to lowering stress and moving forward. Keep in mind that everyone deals with change in their own way.
The Process of Change
Stage One - Denial. The first response to change is to deny or minimize it. Some people have a shock-like reaction that lets the person continue on as if nothing has happened. It may look like the person is doing just fine. But it is more likely that the person doesn't want to face the change in his or her life.

Stage Two - Anger. After the reality of the change sinks in, this next stage can bring out anger, anxiety and depression. "Why did this happen to me?" is a common thought. This is the stage where uncertainty, self-doubt and low self-esteem begin to surface. People focus on what the change is doing to them right now. They don't want to look ahead and may be holding themselves back through self-defeating thoughts or acts.

Stage Three - Looking forward. After going though denial and anger, most people begin to look to the future. They will begin to look at other possibilities, new opportunities, and will begin looking for the good that may come out of the change.

Stage Four - Acceptance and new commitment. This is the final stage of the change process. By this stage, people have developed new goals. They have made a shift from anxiety to renewed self-confidence. This is the time people often describe as feeling like a weight has been lifted off their shoulders. The past is not forgotten, but today is here and the future awaits.

There is no timetable when dealing with change. People move through the stages at their own speed. You can't make another person hurry up to be on your timetable.

Some people try to shortcut these stages. They jump from denial to commitment without addressing anger, loss, sadness, and anxiety. It doesn't mean these feelings don't exist. They mistake feeling numb as having gone through the states. But these feelings will surface sooner or later. The person will have to deal with them then.
Healthy Ways of Dealing with Change
Be open to the fact that change happens. It makes dealing with change easier when it does happen. The following are some tips for dealing with changes as they occur.

Recognize that change is a part of life. Life would be boring if things didn't change. Change keeps us fresh, alive.

Anticipate change. Don't become too complacent. Being flexible and open to change will lessen the surprise when it does happen.

Learn to enjoy change. Understand that change is a part of life.

Expect that change will happen over and over -and over again. Life is a series of changes.

None of Us Can Stop Change

We experience change every day. It might be a common annoyance like the streets are closed on your way to work. Or it might be a life changing events like the loss of a loved one. It's not that we don't expect change in our lives. It's just that it would be nice to have some advance warning.

Coping with the stress and sadness that can go along with change is hard. Change is a part of life. Counselors are available to help you deal with changes.
Change happens. It's how we handle it that counts.
In today's world, we expect change to occur. But you might need help dealing with it. Our counselors are available to assist you, your dependents and household members. They can help sort out the change that's going on in your life. A counselor can help develop a plan of what to do next.

Your program has counselors who can listen to your concerns. They can help you to cope with change. A counselor can direct you to other resources in your community. Our counselors can help you with:

Changes in relationships - marriage, end of relationship, or the loss of spouse or family member

Changes at work - merger, loss of job, or a job promotion

Changes in life - a new baby, adoption, moving, elderly parents, or illness

The funny thing is, it doesn't matter if the change is good (a job promotion) or the change is bad (the ending of a relationship). Change still adds stress to your life. If you can't reduce the stress, you might be at risk for depression.
What are the stages of change?
You need to know that you go through stages of change. It will help you to feel more in control. Then you can understand the change and deal with it better. There is a three-step process to dealing with change. The more you know, the quicker you can cope with the change. The three stages of change are:*

Endings. All changes, surprisingly enough, begin with an ending. A job ends, a marriage ends. This is usually difficult to deal with, even when the change is for the better. Stress can occur at this stage as we try to decide what to do.

Neutral Zone. This is the period between an ending and a new beginning. During this period, we experience the most stress as we try to move past our loss to something new.

Beginnings. A new beginning can bring with it stress. We need to adapt to our new job or new relationship. Here, we focus on new thinking and new goals.

Healthy Ways to Deal with Change
Dealing with change can be made easier if we are open to the thought of it. The following are some tips for dealing with changes as they happen:

Manage the Stress From the Change. Change and stress go hand-in-hand. Practice relaxation techniques, meditate, or use other stress-reducing tactics. It will keep stress in check.

Take a More Active Role in Your Life. Be more aware of what's happening around you. Be more aware of what's happening in your life. Then you may notice changes when there is still time to deal with them.

Develop a Plan. Proactively planning steps to handle change will lessen the affect it has on your life. It will help give you more of a feeling of control. Focusing on specific aspects of a change that are in your control makes the change easier to handle.

Practice Coping. Get into the habit of adapting to new things. You can start off small. Take an unfamiliar route to work. Read a book about a subject you know little about. Activities such as these will make it easier for you to cope with change when it occurs.

Learn to Enjoy Change. When you have a positive outlook about change, it makes it easier to handle when it occurs. Don't think about change in a negative way and add stress. Look at change as a way of keeping your life fresh and exciting.

Talk about it. Don't keep feelings of sadness and stress bottled-up inside. Talk to someone you trust and feel comfortable with. Talking about what you're going through can help.

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Coping with Change Making Positive Choices in the Midst of Change "Five R's" of Dealing With Change-Related Stress Living Healthy, Working Well Through Change None of Us Can Stop Change Basics Change can take many forms. It can affect every part of our lives. It occurs in our family, at work, and in our social lives.

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Coping mechanisms in reference to college students' adjustment - NLC Library

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Coping mechanisms in reference to college students' adjustment - NLC Library

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Mary Martinez
Physical activity and practicing mindfulness were associated with lower stress, lower anxiety, lower depression, lower loneliness, and higher self-esteem in this study. Mindfulness in particular was a strong indicator of students' adaptability.

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Author(s): Robert W. Moeller, Martin Seehuus, Jack Simonds, Eleanor Lorton, Terumi Smith Randle, Cecilia Richter, Virginia Peisch

Research has examined the function of stress management techniques, including coping, physical activity, and mindfulness on college students' adjustment. The present study examined the differential contributions of three stress management techniques to students' maladaptation (perceived stress, depression, anxiety, and loneliness) and adaptation (self-esteem). Undergraduate students (<italic>N</italic> = 1185) responded to an online survey. Hierarchical linear regression results indicated that all three stress management techniques - coping, physical activity, and mindfulness - were related to the five outcomes as predicted. Higher levels of disengagement coping strategies were related to higher perceived stress, anxiety, and depression. Components of mindfulness emerged as a strong predictor of adaptation.

Source Citation

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The Differential Role of Coping, Physical Activity, and Mindfulness in College Student Adjustment.

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Author(s): Robert W. Moeller, Martin Seehuus, Jack Simonds, Eleanor Lorton, Terumi Smith Randle, Cecilia Richter, Virginia Peisch Research has examined the function of stress management techniques, including coping, physical activity, and mindfulness on college students' adjustment. The present study examined the differential contributions of three stress management techniques to students' maladaptation (perceived stress, depression, anxiety, and loneliness) and adaptation (self-esteem).

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Stress and its various effects on the different body systems

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Stress and its various effects on the different body systems

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Mary Martinez
Stress can cause tension headaches due to prolonged muscle contractions or even impotence in males from impaired testosterone and sperm production.

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Mary Martinez
Change isn't inherently bad. "Research shows that personality can influence how change impacts our wellbeing. Major life changes can cause stress for people who feel more comfortable in a routine. Alternatively, for those who seek novelty and spontaneity in their lives, change is sometimes more easily welcomed."

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The past 10 days have been uncertain and rather stressful for everyone. One thing is for sure: the majority of us have experienced massive changes during this past week.

Whether current events have impacted your personal or work life directly, or you've been watching all of the events unfold, we can all agree that there are some major changes happening around us.

So how can we deal with change in a healthy way?

THE HUMAN RESPONSE TO CHANGE

Research shows that personality can influence how change impacts our wellbeing. Major life changes can cause stress for people who feel more comfortable in a routine. Alternatively, for those who seek novelty and spontaneity in their lives, change is sometimes more easily welcomed.

It's fair to say that the changes we're currently seeing in the world are impacting us all - even the spontaneous amongst us with typically the biggest of smiles on their faces. When major life changes happen outside of our control, it can be a lot harder to swallow. Because of this, I think it's useful to explain a little bit about what we know about the human response to major life changes and how you can best deal with change. This just might inspire you to look at your situation in a slightly different way.

1) Even positive change can make us feel uneasy. It's okay to feel like this!

If you've been feeling more anxious, uneasy or up in the air lately - that is totally normal. It's interesting to note that the brain tends to deal with all types of major change in the same way. Even seemingly positive life changes, such as having a baby or celebrating a new marriage, can prompt the brain to react with unease and discomfort.

You can take comfort in knowing that it's nature's way of protecting you from the unknown.

2) Managing your stress will make it easier for you to build new habits.

When something is new and unfamiliar, our brain can turn on the stress response which often activates our neural habit pathways, meaning we may be more likely to fall into or be stuck in old habits.

By actively doing things that decrease your stress levels, whether that's exercising or meditating, you will increase your self-control. This calm and collected self-control over your behaviour is important as you set up new routines such as working or exercising in the home, which involves stamping out some of the old habits of what it means to be in your home environment.

3) Uncertainty bias means that we expect the worse in uncertain situations. Recognising this automatic response can help you navigate change healthily.

As humans, we are influenced by hundreds of biases that we aren't even aware of. A bias can be defined as an irrational belief that can unconsciously influence our decision-making process.

During major life changes that cause uncertainty, such as the current situation, Uncertainty bias is likely to be impacting your thinking. This doesn't mean that the current changes are great and that you should expect the best from them. However, by recognising that your brain is likely to be in an automatic state of negativity bias, you may be able to better distance yourself from the negative thoughts and think more rationally and positively about your current situation.

4) Creating IF-THEN rules can help you deal with uncertainty in change.

In circumstances that are out of our control, it's important to plan for barriers we will face in order to maintain our projects, habits and healthy routines. These are called implementation intentions.

Take back some control over your projects, life, wants and needs by planning with implementation intentions, or IF-THEN rules.

For example: 'If my gym closes, then I will sign up to regular online sessions' or 'If my working hours are reduced, then I will work on a craft project I have been meaning to do for 1 hour a day'.

Making these rules specific will really help you out when preparing for and dealing with change. Having a mental representation of what your IF-THEN plan is will not only reduce your anxiety when things change, but it will also help you feel more in control in the meantime.

5) With a long term health condition, strong resilience is something you are likely to have developed already!

Resilience is our ability to mentally or emotionally cope with adversity, to bounce back, adapt or persevere.

Some studies suggest that resilience can be linked to your genes and inherited as a personality trait but it can also be associated with your environment or life experiences. We now know that you can develop your own resilience skills.

Living with a long term inflammatory condition may mean that you are no stranger to uncertainty. You are likely to have experienced the cancellations, disappointments and sudden changes in life that most of the population aren't as equipped to deal with.

If you are feeling overwhelmed by the current situation, remember these resilience skills you already have. The coping skills that have helped you through flares, the strength that means you can forgive your body for making you cancel plans and the grit you've developed to fight for your diagnosis when others didn't understand you.

These resilience skills are going to help you through these current times. Perhaps you can even help those around you, who may not have experienced the uncertainty that living with an inflammatory condition can bring - they may need you now. And you can take refuge in thinking that maybe, after all of this, people will be more understanding of what it means to live with an inflammatory condition.

6) Major life changes can build momentum for positive change.

It's time to build the healthy habits you've always wanted to embed...

Research has shown that major life events, that completely throw our usual lifestyle or routine out the window, can give us the best opportunity for making real, long-term changes in our behaviour.

Although you may feel overwhelmed, this is a blank canvas to re-jig your health behaviours. So if you have been trying to quit smoking, do more yoga, drink more water or anything else...now may actually be a fantastic time to try!
How can you successfully change your behaviour? Here are 3 Quick Tips:

Make a commitment and tell someone to hold you accountable for this.

Swap an old habit with a new one - if your brain can make this link, you are more likely to remember the new behaviour.

Reward yourself for small steps you take, rather than waiting to reward yourself once you have completed your overall goal.

When lots of things change in your life, with the right mindset, you are actually more open to positive change and more likely to be successful. So with a bit of positivity and motivation for change, you can take a hold of this opportunity in a healthy way.

Remember if you are feeling low during current times you can find mental health resources on the Mind Charity website. For up to date information on COVID-19 you can visit the Government webpage.

You can also visit our partner's websites for up to date information on COVD-19 and inflammatory conditions:
Crohn's & Colitis UK National Rheumatoid Arthritis Society
Keep well, safe and happy.

Rachel Moran

Behavioural Scientist Ampersand Health

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The Psychology of Major Life Changes - Ampersand

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The past 10 days have been uncertain and rather stressful for everyone. One thing is for sure: the majority of us have experienced massive changes during this past week. Whether current events have impacted your personal or work life directly, or you've been watching all of the events unfold, we can all agree that there are some major changes happening around us.

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Stress can affect your brain composition, and impact your memory

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Stress can affect your brain composition, and impact your memory

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Mary Martinez
"Here, we summarize the cases that led to the diagnosis of glucocorticoid-induced ‘steroid psychosis’ in human populations and which demonstrated that these stress hormones could thus cross the blood–brain barrier and access the brain where they could influence cognition and mental health. "

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Stress can affect sleep and subsequently academic performance

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Stress can affect sleep and subsequently academic performance

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Mary Martinez
"Evidence suggests the relationship between stress and sleep quality to be bidirectional: 1) high stress levels have negative effects on sleep quality and 2) poor sleep quality  affects subsequent stress levels."

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Your access to the NCBI website at www.ncbi.nlm.nih.gov has been temporarily blocked due to a possible misuse/abuse situation involving your site. This is not an indication of a security issue such as a virus or attack.

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Stress can covertly increase your reluctance to try things

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Stress can covertly increase your reluctance to try things

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Mary Martinez
Basically, a link has been found between avoidance of certain situations and stress. See "approach-avoidance conflict."

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The key to dealing with stress? Science says more stress!

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The key to dealing with stress? Science says more stress!

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Mary Martinez
In 7 of 9 life changes studied, prior stress was shown to reduce the impact of stressful transitions on mental health.

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Mary Martinez
"High perceived efficacy enables individuals to face stressful demands with confidence, feel motivated by physiological arousal, and judge positive events as caused by effort and negative events as due primarily to external circumstances...  In contrast, individuals who are characterized by low perceived efficacy are prone to self-doubts, anxiety arousal, threat appraisals of events and perceptions of coping deficiencies when confronted with difficult situations and demands." (pg. 178-179, ch. 6)

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Caleb Simmons
A few life changes are marriages, divorces, job losses, birth of a child, deaths, and moving.

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Life events are defined as discrete experiences that disrupt an individual's usual activities, causing a substantial change and readjustment. Examples of life events include marriage, divorce, illness or injury, and changing or losing a job. In the literature on stress, life events have been traditionally considered as one type of stressor, along with chronic strains (ongoing stressful circumstances such as living with disability or poverty). Since the pioneering work of Tom Holmes and Richard Rahe in 1967, an enormous body of literature has developed on the topic of life events and illness.

Life events research

Life events research has evolved from early models viewing life changes as inherently stressful and having similar effects on all who experience them to more complex models emphasizing individual differences in both reactions and vulnerability to life events. In addition, there have been a number of conceptual and methodological critiques that have led to more sophisticated models and methods of assessing life events. Recent studies demonstrate that, even with careful attention to methodological issues, life events can have important effects on health and psychological well-being.

Historical issues. Early studies conceptualized life events in terms of the amount of readjustment or change that the events were likely to entail (see Dohrenwend and Dohrenwend; Holmes and Rahe). These studies were based on the assumption that any change in life would be stressful. Particularly influential was the work of Holmes and Rahe, who developed the Social Readjustment Rating Scale (SRRS). The SRRS asked subjects to report the occurrence of life events that had occurred over the previous year, and these events were given life-change unit scores (e.g., 100 for death of a spouse, 28 for an outstanding personal achievement). Total scores were viewed as a measure of life change and as an index of stress. While research with the SRRS did suggest that life events were associated with mental and physical health, limitations to this approach were noted in subsequent work, and conceptual and methodological improvements have been made.

Individual differences in response to life events. Contrary to the assumption that life events have uniform effects that can be measured by life-change units, later studies have shown that the consequences of life events depend on the nature of the events (e.g., whether they are undesirable, unpredictable, or uncontrollable). Growing attention has been paid to subjective meaning of the events to the particular individuals who experience them, rather than the objective occurrence of the events. Since the occurrence of the same event can yield different meanings in each individual, subjective appraisal has been identified as a critical part of the effect life events have on well-being (see Lazarus and Folkman). For example, people generally think that divorce is a stressful experience; however, for some individuals, such as those who have gone through a long-term problematic marriage, divorce can be a resolution of stress and even a relief.

The consequences of life events on physical and psychological well-being are influenced by individual differences in coping resources. When life events occur, individuals' coping resources can buffer the negative consequences of life events and facilitate adjustment. Coping resources may include physical resources (e.g., health and function), psychological resources (e.g., personality traits, values, goals, religious beliefs, self-concept, and self-control), and social resources (social network and social support). One of the most frequently researched psychological resources is mastery, which refers to the extent to when a person feels that he or she has control over his or her life and environment. Individuals with high mastery tend to have a positive perspective on the social environment and believe that they can control or alter their environment. Therefore, those with high mastery are more likely to protect themselves from negative consequences when they face stressful life events.

The impact of social networks and social support has also been widely studied, and there exists a general consensus on their beneficial roles in dealing with stressful life events. It has been found that individuals with persistent deficits in social support experience more stressful life events, higher levels of perceived stress, and greater risk of recurrent depression (see Redinbaugh, MacCallum, and Kiecolt-Glaser). An examination of individuals' personal and social resources is important in understanding individual valances in responding and adapting to stressful life events, and also serves as an important basis for developing effective intervention programs.

Types of life events. Criticisms have been raised concerning the tactic of aggregating total life events to generate an overall score. Many studies on life events have turned the total number of events into a single score by aggregating all life events experienced within a given time frame. This approach treats all events the same, without taking into account the subjectively perceived importance of each event. Since life event inventories cover a variety of events of different importance, equating those events may be insensitive in capturing the significance of different life events, and it may fail to detect the effects of specific events that generate a great deal of stress. Some researchers have suggested the use of a more dimension-specific approach, focusing on specific kinds of events by dividing scales into categories, such as health-related events and loss events.

Retrospective bias in reporting life events. Conventional life event inventories usually ask respondents to read a list of events and report those that occurred to them over a specific time period. The time frames vary from six to eighteen months. Some researchers have raised questions on the accuracy of individuals' memories for life events. In general, people tend to report fewer events for a more distant time period. In addition, a retrospective approach is vulnerable to biasing effects such as selective memory, denial, and over-reporting. For example, depressed people are likely to report more negative events because they tend to focus on the adverse sides of life and to search for events to justify their current moods.

Given this dissatisfaction with the checklist method, researchers have attempted innovative ways to assess life events. Some studies have used combined methods of self-reporting on checklists and interviews. Karen Raphael and colleagues (1991) assessed the occurrence of life events every month for ten months using a checklist, and at the end of the study they did detailed interviews on experience with life events for the studied period. They found that more events were reported on a concurrent monthly basis than were reported on a retrospective interview for the same period. As an alternative to retrospective report over long periods, some researchers have conducted multiple follow-ups for the occurrence of life events, with a very short interval between interviews, in order to detect the onset of events. This approach solves some problems associated with the retrospective report using a checklist method; however, it requires a large sample and longitudinal follow-up.

Life events are not uniform across populations. Some researchers have called into question whether scale items contain relevant and representative life events for target populations. Since scales are rarely generated on the basis of large and well-developed sampling frames, it is hard to judge if the items cover a sufficiently wide range of possible events. More importantly, exposure to life events varies in terms of age, gender, and social roles. For example, retired individuals cannot be promoted, men cannot be pregnant, and unmarried individuals cannot experience marital conflict or divorce. Inclusion of irrelevant items for the target population may result in misclassifying individuals as having fewer numbers of life events.

In response to this concern, a number of life event inventories have been developed for various populations, including the Psychiatric Epidemiological Research Interview (PERI) for general populations; the Life Experiences Survey (LES) for adult age groups; the College Student Life Events Schedule (CSLES) for college students, and the Louisville Older Persons Events Scale (LOPES) for the elderly population.

Confounding of life events and outcomes. Confounding is a particularly important issue in the examination of life events. Many items in life event inventories are closely related to health (e.g., illness, injury, hospitalization), so they can be easily confounded with physical and mental health outcomes. Due to concerns about the confounding of health and life events, some researchers recommend separating health-related life events from non-health-related items. Some studies have selected only healthy elderly individuals in examining the impacts of life events in order to exclude confounding of health variables (see Willis, Thomas, Garry, and Goodwin).

Recent findings on life events and well-being. Numerous studies have examined the consequences of life events on a variety of physical and psychological outcomes. In general populations, life events have been shown to be associated with a variety of physical problems and indicators of psychological distress. However, the magnitude of these associations is often found to be only modest. Researchers have suggested several ways to explain the low associations found in such studies, including methodological issues and individual differences in coping resources.

One fruitful strategy in the study of the effects of life events is longitudinal study of individuals with psychological or physical disorders that tend to have periods of remission and recurrence. For example, it is extremely difficult to demonstrate conclusively that life events provoke the initial onset of depressive disorders, but longitudinal research on individuals with a history of depression provides convincing evidence that life events can lead to recurrence of depressive episodes. Sophisticated longitudinal studies even support the contention that major life events play important roles in onset and recovery from episodes of bipolar disorder and multiple sclerosis disorders that are commonly viewed as entirely biomedical. Research on life events in these clinical populations has also led to increasing recognition that some life events are caused by the disorders studied; for example, loss of a job may be precipitated by early symptoms of a mental disorder.

Finally, life events have been demonstrated to be potent factors affecting physiological processes, in particular the immune and endocrine systems, with implications for health and recovery from illness. For example, studies of individuals undergoing stressful life events ranging from taking final examinations to experiencing bereavement demonstrate a slowing of wound healinga finding with clear implications for practical problems such as recovery from surgery.

Life events in old age

Individuals from various age groups are exposed to different sets of life events. Yet, despite potentially important age differences, relatively little research has focused on life events in later life. Research on life events in old age is of great importance, since identifying prevalent events and managing stress in later life can not only improve our understanding of human development and adaptation, but can also serve as a basis for interventions and social policies.

Age differences in the occurrence of life events. Contrary to the general belief that old age is a stressful period of time, studies have consistently shown that older adults experience fewer life events than do younger adults. However, though the overall number of events that individuals experience may decline with advancing aging, some specific types of life events are more likely to be encountered in later life. Illness and injury, hospitalization, and the death of a spouse or a friend are examples of undesirable life events that are more prevalent in old age. Using a large sample of community-dwelling older adults, Stanley Murrell and colleagues (1984) showed that over half of their sample had experienced hospitalization, either their own or that of significant others, in the past year. Of course, some other types of life events, such as family conflict and problems with jobs, are less prevalent in older adults.

Another reason for the reduction in life events in later life may be found in the composition of measurement scales. Since most life event inventories used in previous studies were originally developed and standardized on relatively young populations, items less relevant to older adults, such as getting married, having children, and changing jobs, are often included. Given the different experiences in the life cycle, some researchers have developed life event inventories for older individuals. Studies employing relevant measures for older individuals have been shown to be more successful in relating life events and measures of well-being. The LOPES is one notable measure specifically designed for older populations. This scale includes fifty-four life events, selected on the basis of a large, stratified sample of older Kentuckians, and a recall period of six months in order to ensure greater accuracy of older adults' recall. It also contains additional useful ratings of subjects such as desirability, the degree of change required, preoccupation, date of occurrence, and novelty of each event.

Age differences when responding to life events. Some events experienced by older individuals are age-normative events that are expected by most people to occur later in the life cycle. When events are anticipated, their adverse impact may be limited because individuals are prepared for them. In the case of planned retirement, older individuals fare much better than do younger persons who involuntarily lose a job. In addition, retirement may even lead to enhanced physical and psychological well-being.

On the other hand, the death of an adult child is a non-normative experience for older individuals. Even though only a small portion of the older population experiences the loss of a child, it can have a devastating influence on physical and emotional well-being of older individuals. The unexpected and untimely nature of such an event interferes with adjustment and adaptation, and can also make older adults feel guilty.

Studies show that older individuals are more likely than younger persons to be affected by the events that occur to people they are close to. Such events have been referred to as network events or nonegocentric events. Examples include adult children's marital or financial problems and illness of family members or friends. With advancing age, individuals pay more attention to the problems of others and become vulnerable to these events.

Researchers have suggested that individuals' prior experiences should be considered to better understand their experiences with life events. This is particularly true for older adults who have had various and rich experiences through the life course. A life-long experience of dealing with stress may provide a context to understand an individual's response to certain events. In many cases, older individuals tend to perceive life events as less troublesome because they are more likely to have relevant experiences to help them cope. Research that focused on older victims of a flood showed that older individuals with prior experience of floods showed less anxiety and distress than younger persons or persons without such experience (see Murrell et al., 1988). Accumulated life experiences may make older individuals more resilient and facilitate their adaptation to change. The experience of seeing others undergo life events may also aid older people in adaptation to life events. For example, the experience of spousal bereavement may be less devastating for older widows compared to younger ones, in part because widowhood of older females is more prevalent and there are many role models in society.

Along with prior experience, current life situations also provide an important context for interpreting individual differences in the impacts of life events. Life events that happen concurrently with other events or under situations of chronic strains may have different meanings than a single event. Older caregivers of dementia patients report more negative events and appraise them as more stressful than controls who are not caregivers (see Reed, Stone, and Neale). In contrast, some researchers have suggested that chronic strains may actually mute the impact of stressful events because minor stressful events pale in comparison to more chronic stressors.

Chronic strains can even change the context and outcomes of major life events. Research suggests that highly strained caregivers show some recovery of functioning after the death of a spouse, while noncaregivers react with increased depression. Since chronic strains and life events interact in a variety of ways, examination of both life events and chronic strains is helpful in understanding individuals' responses to life events.

Positive life events. Most life events research has focused on negative and undesirable life events, and the beneficial effects of positive life events need to receive more attention. Birth of grandchildren, going on a trip out of town, receiving an award or special praise, and starting a new hobby or recreational activity are some of examples of positive events that happen in later life. These positive life events not only have a desirable meaning to older individuals but also moderate the impacts of stressful events. Positive events make individuals focus on good feelings, change views of other events, and provide motivation and resources to overcome stress resulting from negative events. Research on depression in late life has shown that depressed older adults have relatively few pleasant events, and that treatments aimed at increasing pleasant events can reduce depression.

Future directions

With its long history, life events research has progressed a great deal and provided important information from both theoretical and practical perspectives. The study of life events in late life has produced promising results and findings that challenge conventional stereotypes about the vulnerability of older persons. Conceptual sophistication about aging and the life course is evident in the attention that has been paid to the different occurrence of, and reactions to, life events in later life.

However, research on life events and aging has lagged behind that of the broader field in terms of methodology. For example, few studies of life events in older adults have utilized longitudinal assessments and frequent individualized interviews to avoid problems of retrospective recall. While sophisticated methods have been developed and applied to the study of life events in psychiatric and medical disorders in younger people, little is known about how life events may trigger relapse or recurrence of these disorders In the elderly. Studies of older adults should borrow heavily from methods that have been refined in studies of younger persons.

A particular need is for more clinically relevant research on life events and aging, with the goal of promoting an empirically based practice of clinical geropsychology. Evidence to date suggests that older adults respond well to cognitive-behavioral or psychoeducational intervention programs that teach specific skills in coping with life events and chronic strains, and that research on life events provides valuable information for clinicians designing and implementing such intervention programs. However, interventions for bereavement in older adults have shown disappointing results to date, serving an example of an area in which clinicians need better research information to improve clinical practice for older adults.

Yuri Jang William E. Haley

See also Bereavement; Control, Perceived; Geriatric Psychiatry; Social Support; Stress and Coping.

BIBLIOGRAPHY

Aldwin, C. M. "The Elders Life Stress Inventory: Egocentric and Nonegocentric Stress." In Stress and Coping in Later-Life Families. Edited by M. A. P. Stephens, J. H. Crowther, S. E. Hobfoll, and D. L. Tennenbaum. New York: Hemisphere Publishing, 1990. Pages 4969.

Avison, W. R., and Gotlib, Ian H. Stress and Mental Health: Contemporary Issues and Prospects for the Future. New York: Plenum, 1994.

Dohrenwend, B. P., and Dohrenwend, Barbara S. Social Status and Psychological Disorder. New York: John Wiley, 1969.

Lazarus, R. S., and Folkman, S. Stress, Appraisal, and Coping. New York: Springer, 1984.

Neimeyer, R. A. "Searching for the Meaning of Meaning: Grief Therapy and the Process of Reconstruction." Death Studies 24 (2000): 541558.

Pearlin, Leonard I., and Skaff, M. M. "Stressors and Adaptation in Later Life." In Emerging Issues in Mental Health. Edited by M. Gatz. Washington, D.C.: American Psychological Association, 1995. Pages 97123.

Schulz, R.; Beach, S. R.; Lind, B.; Martire, L. M.; Zdaniuk, B.; Hirsch, C.; Jackson, S.; and B., Lynda. "Involvement in Caregiving and Adjustment to Death of a Spouse: Findings from the Caregiver Health Effects Study." Journal of the American Medical Association 285 (2001): 31233129.

Zarit, S. H., and Zarit, J. M. Mental Disorders in Older Adults: Fundamentals to Assessment and Treatment. New York: Guilford Press, 1998.

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life events and stress
life events are defined as discrete experiences that disrupt an individual's usual activities

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causing a substantial change and readjustment. examples of life events include marriage

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and changing or losing a job. in the literature on stress

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life events have been traditionally considered as one type of stressor

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along with chronic strains (ongoing stressful circumstances such as living with disability or poverty).

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LIFE EVENTS AND STRESS Life events are defined as discrete experiences that disrupt an individual's usual activities, causing a substantial change and readjustment. Examples of life events include marriage, divorce, illness or injury, and changing or losing a job.

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Mary Martinez
Individuals with a higher sense of humor were better able to cope with the negative outcome of stressors, such as an exam in the case of this study, as compared to their counterparts with a lower sense of humor.

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Mary Martinez
"Evidence suggests that meditation-based stress-management practices reduce stress and enhance forgiveness among college undergraduates."

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Mary Martinez
This study concluded meditation has a large effect on stress reduction.

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CRD summary

This review concluded that the technique of mindfulness-based stress reduction was able to reduce stress levels in healthy people. The authors advised that further more rigorous research was needed to determine any long-term specific effects. Given limitations in the included studies and conduct of the review, the authors' conclusions should be treated with caution.

Authors' objectives

To assess current evidence for mindfulness-based stress reduction (MBSR) in healthy people

Searching

MEDLINE, Web of Knowledge and The Cochrane Library were searched from 1979 to September 2008 for studies published in English. Search terms were reported. References of retrieved articles were checked for additional references.

Study selection

Eligible studies had to investigate a MBSR intervention, be performed in healthy populations, use validated scales for measurement of stress and provide quantitative data. Studies that combined MBSR and another active treatment were excluded. Controlled studies could have an active or inactive control group. No further restrictions were imposed on study design. Primary outcomes were stress reduction and spirituality enhancement (defined in the paper). Secondary outcomes were rumination, empathy, self-compassion, state anxiety and further psychological changes related to the MBSR programme.

The authors did not state how studies were selected.

MBSR was compared mostly to a waiting list control group. Populations varied and included university staff and students, health care staff or students and pregnant women. Study duration ranged from four to 10 weeks. Where specified, follow-up was of three months duration. Measures of stress varied. Measures of spirituality, where stated, tended to be Index of Core Spirituality (INSPIRIT) or Mindfulness Attention Awareness Scale (MAAS).

Assessment of study quality

The quality of controlled studies was assessed with the Jadad scale (up to a total of 5 points for randomisation, blinding and intention to treat analysis). The quality of cross-sectional studies was assessed using Newcastle-Ottawa scale and considered representativeness, comparison groups, methods of outcome assessment and follow-up (up to 9 points). A score of at least 3 on either scale was considered high quality.

The authors did not state how many reviewers performed validity assessment.

Data extraction

Variables were extracted or calculated from tables in individual studies. Effect sizes expressed as Cohen's d were calculated for each treatment and control group.

The authors did not state how many reviewers were involved in data extraction.

Methods of synthesis

To be eligible for statistical pooling, studies had to provide both pre- and post-test outcome variables or effect size expressed as Cohen's d between post- and pre-test within-group differences. Any studies that did not provide this information were included in the narrative synthesis only, as were data defined as secondary outcome measures.

Effect sizes in MBSR interventions and control groups were compared using t tests weighted for the number of participants with standard deviations imputed where necessary. Statistical analysis was performed on the completers' samples. A sensitivity analysis was conducted on randomised controlled trials (RCTs) only.

Results of the review

Ten trials were included (n=671): seven RCTs; two controlled trials; and one uncontrolled trial. Study quality was generally low; Jadad scores ranged from 0 to 3. Only one of the controlled trials scored 3 and was rated as high quality. One open label uncontrolled trial was evaluated on the Newcastle-Ottawa scale and scored 0. Across the trials, specific issues were related to small sample sizes, self-selection in some of the trials, non randomisation and the difficulty of blinding.

MBSR for the reduction of stress (seven trials): MBSR had a significant positive effect compared to waiting-list treatment (0.743 +/- 0.77 versus -0.208 +/- 0.21, t=21.01, p≤0.001). Analysis restricted to RCTs showed similar results. One trial compared MBSR and active treatment and did not show any statistically significant differences between treatments.

MBSR for the enhancement of spirituality (five trials): MBSR was statistically significantly superior to inactive control (0.824 +/- 0.83 versus -0.043 +/- 0.37, t=9.95, p=< 0.000001). Analysis restricted to RCTs showed similar results. One trial compared MBSR with relaxation training and found no statistically significant differences on the INSPIRIT measure.

Further results from individual studies were reported for the secondary outcomes.

Authors' conclusions

MBSR was able to reduce stress levels in healthy people. Studies were limited in terms of quality and further research was needed to address quality issues and determine any long-term specific effects.

Implications of the review for practice and research

Practice: The authors did not state any implications for practice.

Research: The authors stated that there was a need for rigorous adequately powered RCTs to determine magnitude of effect, any specific effects and possible predictors of response to MBSR. Further studies should focus on long-term effects of MBSR on healthy people and use more representative samples than those found in the current research (based most often on young women Caucasians).

Bibliographic details

Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. Journal of Alternative and Complementary Medicine 2009; 15(5): 593-600. [ PubMed: 19432513 ]

Indexing Status

Subject indexing assigned by NLM

MeSH

Anxiety /therapy; Empathy; Humans; Meditation /methods; Relaxation Therapy; Self Care; Stress, Psychological /therapy

Record Status

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.

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Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis

# data[].attributes.attachment_link.description
This review concluded that the technique of mindfulness-based stress reduction was able to reduce stress levels in healthy people. The authors advised that further more rigorous research was needed to determine any long-term specific effects. Given limitations in the included studies and conduct of the review, the authors' conclusions should be treated with caution.

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Why stress is bad for your brain - NLC Library

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Why stress is bad for your brain - NLC Library

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Mary Martinez
Glucocorticoid hydrocortisone is used to mediate the adverse effects of stress. When produced over a long period of time and in excess, it has been found to be linked to atrophy of the hippocampus in a variety of individuals across the control groups. This damage was even found to be present years after the original stressful event had abated.

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Document controls

Main content

Sustained stress induces overly high concentrations of glucocorticoids (GCs), which have been shown to damage the hippocampus in rodent brains. New studies link hippocampal atrophy in humans to high GC levels due to depression, Cushing's syndrome and combat stress.

Sustained stress can have numerous pathologic effects. Among the molecules that mediate such effects are the adrenal steroid hormones, including the human glucocorticoid (GC) hydrocortisone. Along with epinephrine (adrenaline) and norepinephrine, GCs are essential for surviving acute physical stress (evading a predator, for example) but they may cause adverse effects when secretion is sustained, such as when waiting to hear about a grant renewal (1).

Excessive exposure to GCs has adverse effects in the rodent brain, particularly in the hippocampus, a structure vital to learning and memory and possessing high concentrations of receptors for GCs (2). A few days of stress or GC overexposure "endangers" hippocampal neurons, compromising their ability to survive seizures or ischemia; as the likely underpinning of this, the steroids worsen the poor regulation of glutamate and calcium that occurs during such neurologic insults. Over the course of weeks, excess GC reversibly causes atrophy of hippocampal dendrites, whereas GC overexposure for months can cause permanent loss of hippocampal neurons. Although though a few studies suggest that similar effects occur in the brains of primates (3), there has been virtually no evidence for GC-induced damage in the human. Some new, exciting studies present the first such evidence.

A first example, recently published by Sheline and colleagues at Washington University School of Medicine, concerns major depression (4). Approximately half of depressive patients studied secrete abnormally high amounts of GCs. Although investigators had searched with magnetic resonance imaging (MRI) for hippocampal atrophy in depressive, these studies could not distinguish the hippocampus from neighboring structures or used geriatric depressives with brain-wide atrophy from an array of diseases. The authors of the new study report MRIs with far more resolution than in previous studies and have excluded individuals with neurologic, metabolic, or endocrine diseases. They have found significant reductions in the volume of both hippocampi (12% in the right and 15% in the left) when comparing individuals with a history of depression to age-, education-, gender-, and height-matched controls. No change in overall brain volume was observed. The individuals studied had been depression-free for months or decades and, at the time of the study, had normal GC concentrations. The investigators ruled out several confounding variables: alcohol or substance abuse, electroconvulsive therapy, and current use of antidepressants. Remarkably, there was a significant correlation between the duration of the depression and the extent of atrophy (see figure, top panel).

A similar relation is seen in patients with Cushing's syndrome: GCs are overproduced as a result of a hypothalamic, pituitary, adrenal, or pulmonary tumor, and there is bilateral hippocampal atrophy (5). Unfortunately, for control values the authors of this study had to rely on comparisons with published data from MRI scans. However, as an impressive internal control, among the Cushing-oid individuals, the extent of GC hyperse-creation correlated with the extent of hippo-campal atrophy (which also correlated with the extent of impairment in hippo-campal-dependent cognition) (see figure, middle panel). No atrophy occurred in the caudate nucleus, a brain region with few GC receptors (6).

Additional evidence of the relation between GCs and hippocampal function has emerged from studies of individuals with posttraumatic stress disorder (PTSD). In Vietnam combat veterans with PTSD, Bremner and colleagues found a significant 8% atrophy of the right hippocampus (and near significant atrophy of the left) (7). In a study in Biological Psychiatry (in press), Gurvits, Pitman, and colleagues also examined Vietnam veterans with PTSD and found significant 22 and 26% reductions in volumes of the right and left hippocampi, respectively (8). Finally, in another study, also in press in Biological Psychiatry, Bremner et al. found a 12% atrophy of the left hippocampus in adults with PTSD associated with childhood abuse (with near significant atrophy in the right hippocampus) (9). The studies controlled for age, gender, education, and alcohol abuse - and the Bremner studies - ruled out depression as a confounding variable as well. There is some uncertainty as to the anatomical specificity of the effect. In the studies by Bremner, the results were only presented as absolute hippocampal volume, and there were nearly as large (but nonsignificant) reductions in volumes of the amygdala, caudate nucleus, and temporal lobe. However, the study by Gurvits et al. showed hippocampal atrophy after correction for whole-brain volume, with no atrophy in the amygdala.

It is not clear whether the atrophy is associated with trauma (combat or abuse) or with succumbing to PTSD (which occurs in 5 to 20% of such traumatized individuals). In the Gurvits study, control groups consisted of healthy volunteers (matched for age, education, and other characteristics) and matched veterans with a history of combat exposure but no PTSD. In the combat veterans, both with and without PTSD, longer durations of combat were associated with smaller hippo-campi (see figure, bottom panel). However, because the PFSD patients sustained longer combat exposure than did the controls who had experienced combat but did not have PTSD, it was impossible to dissociate combat from PTSD as a predictor of atrophy. In contrast, in the Bremner combat study (in which there was no non-PTSD combat control group), combat duration did not predict extent of atrophy. Finally, in the childhood abuse study (in which there were no non-PTSD childhood abuse controls), it was not possible to dissociate the PFSD from the trauma.

Each of these studies has some weaknesses, but they are countered by complementary strengths in the other studies.

Are GCs the damaging agents? Depression is accompanied by numerous physiological abnormalities, and it has not been demonstrated that the hippocampal atrophy occurs only among depressives who overproduce GCs. Moreover, among individuals with PTSD, there is no information as to the extent of the GC stress response during the trauma (or what additional physiological changes occur then). Thus, in these cases, it is not clear whether GCs mediate the atrophy. However, as noted, the defining abnormality in Cushing syndrome is GC excess, making it a likely culprit in causing atrophy.

How persistent are the changes? Although the Cushingoid atrophy reverses with correction of the endocrine abnormality (6), in the PTSD and depression studies, the atrophy occurred months to years after the trauma or the last depressive episode, and at a time when patients did not hypersecrete GCs. Thus, these long-standing changes could conceivably represent irreversible neuron loss.

The PTSD and depression studies present a problem of causality. Given the cognitive role of the hippocampus, a smaller hippocampus might be more likely to lead to being assigned frontline combat duty rather than a skilled task at headquarters. Furthermore, given the evidence of depression as a disorder of "learned helplessness," a smaller hippocampus might predispose toward depression (that is, less cognitive capacity to detect efficacious coping responses and thus greater vulnerability to learned helplessness). Finally PTSD individuals, before joining the military, had high rates of learning disorders and delayed developmental landmarks that could reflect cerebral atrophy (10). Thus, a small hippocampus could be a cause, rather than a consequence, of the trauma or stressor in these studies. However, there is no plausible way in which a small hippocampus predisposes one toward the pituitary or adrenal abnormalities of the Cushingoid patients, or toward being a victim of childhood abuse.

Should this literature ultimately show that sustained stress or GC excess can damage the human hippocampus, the implications are considerable. It would then become relevant to question whether the high-dose, GC regimes used to control many autoimmune and inflammatory diseases have neuropathological consequences. (Both therapeutic and experimental administration of GCs to humans results in memory impairment.) In addition, in the rodent the extent of life-time GC exposure can influence the likelihood of "successful" hippocampal and cognitive aging (11); similar issues must be examined concerning our own dramatic differences in cognitive aging.

(1). A. Munck et al., Endocr. Rev. 5, 25 (1984). (2). B. McEwen, Prog. Brain Res. 93, 365 (1992); R. Sapolsky, Semin. Neurosci. 6, 323 (1994) (3). H. Uno et al., J. Neurosci. 9, 1705 (1989); R. Sapolsky et al., ibid. 10, 2897 (1990) A. Magarinos et al., ibid. 16, 3534 (1996). (4). Y. Sheline et al., Proc. Natl. Acad. Sci. U.S.A. 93, 3908 (1996). (5). M. Starkman et al., Biol Psychiatry 32, 756 (1992). (6). M. Starkman, personal communication. (7). J. Bremner et al., Am. J. Psychiatry 152 973 (1995). (8). T. Gurvits et al., Biol Psychiatry, in press. (9). J. Bremner et al., ibid., in press. (10). T. Gurvits et al., J. Neuropsychiatry Clin. Neurosci. 5, 183 (1993). (11). M. J. Meaney et al., Science 239, 766 (1988); A. Issa et al., J. Neurosci. 10, 3247 (1990).

Source Citation

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Sustained stress induces overly high concentrations of glucocorticoids (GCs), which have been shown to damage the hippocampus in rodent brains. New studies link hippocampal atrophy in humans to high GC levels due to depression, Cushing's syndrome and combat stress. Sustained stress can have numerous pathologic effects.

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Mary Martinez
"Overall, listening to music is a functional, inexpensive, and effortless intervention to utilize in various stressful situations. As this intervention has evidently proven to be successful amongst college students, research has sufficiently established the efficacy and benefit of music for diverse populations in varying age groups."

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Document controls

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Music therapy can be an effective treatment that prevents stress from contributing to the etiology of disease. For this study, the participants, college students enrolled in an annual Alternative Nutrition class at California State University, Los Angeles, were instructed to select a song to present during class. After listening to each song selection, participants provided written feedback based on a 9-question survey. Self-perceived stress was measured using a Likert scale from 1 to 10, with 10 being the highest level of stress. Microsoft[R] Excel 2007 Data Analysis, was used to calculate t-Test: Paired Two Sample for Meansat a 5% significance level ([alpha] < 0.05), and Descriptive Statistics to determine standard deviation with a confidence level for mean at 95%. Results across all four years were statistically significant, demonstrating overall stress reduction in the study sample. The authors recognize that the study sample was derived from a population known to be particularly vulnerable to stress. However, beyond the college population, listening to music can benefit anyone subject to the effects of stress.

Keywords: music therapy, college, stress, stress-reduction, relaxation techniques

Time spent in college can be a priceless experience, but it can also be a stressful one. In recent years, the academic circle has noted stress to be an important topic of interest, due to the many stresses of daily life (Agolla & Ongori, 2009). There are a variety of reasons students experience stress, which may include: being away from home for the first time; trying to balance the demands of classes, work, extracurricular activities, and a social life; the pressure to perform well academically. Even though some of these may be perceived as positive changes, any departure from a familiar routine can bring about some degree of stress (Richlin-Klonsky & Hoe, 2003).

Some students may not know how to effectively cope with the demands of college life. As a result, having severe and/or prolonged stress may lead to reduced academic performance. This type of stress can potentially hinder a student's level of contribution and participation in campus life, and increases the likelihood of substance abuse and other destructive behaviors (Ross, Neibling & Hecker, 1999). Coping with unhealthy stress begins with recognizing the signs of building stress levels and the stressors that cause them. While stress can be caused by external events, the events themselves may not necessarily be stressful. In fact, it is the way in which an individual interprets and reacts to a stressor that is responsible for producing stress (Busari, 2012). Consequently, although various methods exist to help college students cope with stress, the appropriate method must be selected for the individual.

According to Romano (1992), the interactions between an individual's perception and reaction to stressors are what result in stress. While many may be unaware of the danger of stress, the American Institute of Stress (2012) claimed stress to be the number one health problem for Americans. While stress itself can be debilitating, its main effect on public health involves increasing risk for diseases such as cancer, diabetes mellitus, and cardiovascular disease. Stress can also lead to depression and its related conditions. Moreover, overall health and wellness is a matter of concern among populations with elevated levels of stress. College students, subject to pressure from many areas, fit into this category.

Music Therapy--Interventions for Health

Music therapy (MT) is defined by the American Music Therapy Association (2011) as the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program. According to the American Music Therapy Association (2011), music therapy is a well-established health program and it is used therapeutically to address an individual's physical, emotional, cognitive, and social needs. Furthermore, a study by Lu and colleagues (2010) defined MT as a form of psychotherapy that is safe, enjoyable, and inexpensive.

The goal and purpose of this study was to examine the role of music as a potentially stress-alleviating therapy among college students. The correlation between music therapy and stress was examined, and research was conducted to investigate the effectiveness of stress reduction via music within an academic population in classroom settings.

What is Stress and how does it function?

Emerging scientific evidence suggests that psychosocial factors--which are the interrelation of social factors, individual thought, and behavior from emotional states, behavior dispositions, and psychosocial stress--can directly influence both physiologic function and health outcomes (Rozanski, Blumenthal, & Kaplan, 1999; Kiecolt-Glaser, 1999; Baum & Posluszny, 1999). Additionally, if adequate coping skills are lacking, a somatic or psychological dysfunction may be expressed in the form of chronic pain and illness, gastrointestinal distress (GI), sleep disturbances, fatigue, high blood pressure,

headaches, or stress emotions, such as anger, anxiety and panic, fright, guilt, shame, sadness, and depression (Yehuda, 2011).

Stress has also been known to affect the immune system through an intricate route of neural and hormonal pathways (Besedovsky & DelRey 1991; Maier & Watkins, 1998). Furthermore, behavior can be affected by stress, manifested by acting impulsively, making poor exercise and nutritional choices, excessive use or abuse of alcohol and/or drugs, and withdrawal from relationships or social situations (MedicineNet, Inc., 2011). Therefore, it can be strongly argued that stress contributes to the etiology of disease.

The main organ responsible for the stress response is the brain, which determines what constitutes as stressful, along with determining the behavioral and physiological responses to specific stressors (McEwen, 2008). McEwen and Stellar (1993) also stated that the brain is the main target of stress and it is structurally and chemically changed by acute and chronic stress.

The chief hormones involved in the stress response are glucocorticoids and catecholamines. Glucocorticoids are steroid hormones produced in the adrenal cortex in response to adrenocorticotropic hormone (ACTH) from the pituitary gland (McEwen, 2008). A specific glucocorticoid, cortisol, is the main stress hormone that becomes elevated during stress. Cortisol manages stressful situations by preparing the body and the fight-or-flight response (Yehuda, 2011). Catecholamines are hormones produced by the adrenal glands, which are released into the blood during times of stress. The key catecholamines are dopamine, norepinephrine, and epinephrine. These hormones increase during the fight-or-flight response as the body requires stored energy, glucose and fat to be immediately available to cells.

Additionally, the immunological system that responds to stress releases stress markers that provide the body with the energy it needs to escape from the real or perceived danger (Yehuda, 2011; American Diabetes Association on Stress, 2011). Understanding the mechanism of stress provides a backdrop for the effectiveness of mind-body therapies (MBT) as a treatment for stress reduction.

Techniques and Therapies for Stress Management

There are various helpful techniques and therapies for individuals who require stress management. Music is known to be an effective therapeutic treatment. Music therapy is a treatment most commonly applied during a form of complementary and alternative medicine (CAM), a practice that involves using the mind to improve health. As defined by the National Center for Complementary and Alternative Medicine (NCCAM) (2008), "mind and body practices focus on interactions among the brain, mind, body, and behavior, with the intent to use the mind to affect physical functioning and promote health" (para. 9). Lu and colleagues (2010) stated that stress in early life can affect the biochemistry of the immune system. Therefore, health can be directly influenced by emotional, mental, social, spiritual, experiential, and behavioral factors with the use of a wide range of healing practices known as mind-body therapies (MBT) to support immune functions as shown in Figure 1.

Research has proven that music therapy can produce ameliorative effects upon immune systems that have been negatively affected by stress. Lu and colleagues (2010) found that stress increased serum corticosterone and interleukin-4 levels in rats. With exposure to music, the stress-induced elevations in these immune system biomarkers became normalized, proving that music therapy can produce a clinical effect (Lu et al., 2010). Decreased levels of immune system reactants are associated with decreased stress and increased relaxation.

It is an unfortunate fact that while relaxation is critical for stress relief; many individuals do not spend an adequate amount of time relaxing. This is common among college students, who are constantly on-the-go or dealing with stressors involving academic concerns. Academic stress has been defined as the product of a combination of academic related demands that exceed the adaptive resources available to an individual (Wilks, 2008). The amount of stress a student may experience is something that should not be taken for granted, which may result in adverse effects to a student's overall adjustment (Hussain, Kumar & Husain, 2008).

The purpose of this study is therefore to investigate the effectiveness of music therapy, and demonstrate how different forms of music influence stress levels before and after a musical selection in a college classroom environment. Specifically, this study aims to investigate how music can affect stress by observing changes in levels of stress among students before and after listening to a music selection. It is hypothesized that music self-selected by the participant will reduce stress levels. The experimental design was a qualitative descriptive study.

Participants consisted of college students attending California State University, Los Angeles, enrolled in an annual Alternative Nutrition class designed to study mind and body medicine, as well as stress management using music therapy and nutritional supplementation. This nutritional science course requires a general nutrition class as an academic prerequisite to qualify as a participant, and to be a student enrolled in an Alternative Nutrition class from the years 2008 to 2012. Participants were separated by cohort for the respective year they were enrolled into this class. All student participants remained anonymous and strictly confidential.

Figure 2. Music therapy survey form

MUSIC THERAPY SURVEY FORM

1. AGE--YRS

2. GENDER--

3. WEIGHT--LBS HEIGHT--FT/INS

4. MAJOR--

5. SUBJECTIVELY, WHAT IS YOUR CURRENT "STRESS LEVEL" (WITH 10 BEING
THE HIGHEST LEVEL)?

CIRCLE ONE: 1 2 3 4 5 6 7 8 9 10

6. DID YOU LIKE THE MUSIC?

CIRCLE ONE: VERY MUCH [1] GOOD [2] SOMEWHAT [3] DISLIKE [4]

7. DID YOU FIND ANY MEANING IN THE SONG?

CIRCLE ONE: HAS MEANING [1] NO MEANING [2] DON'T KNOW [3]

8. DO YOU FEEL HAPPIER AFTER LISTENING TO THE SONG?

CIRCLE ONE: YES [1] NO [2] DON'T KNOW [3]

9. SUBJECTIVELY, WHAT IS YOUR STRESS LEVEL AFTER THE SONG (WITH 10
BEING THE HIGHEST LEVEL)?

CIRCLE ONE: 1 2 3 4 5 6 7 8 9 10

As a required project of this class, participants were to select any song, and present it to their cohort during the class period (3 hours, 50 minutes). All participants were informed of the procedures by the Instructor, and were provided a handout on the procedures of the project. Songs varied in genre, from classical, pop, alternative/rock, to cultural/ethnic music and more.

Participants were asked to listen to each song, and provide written feedback at the end. Feedback was provided with the use of a measurement tool, a 9-question survey, provided by the Instructor. The Music Therapy Survey Form was created and provided by the Instructor. A sample of the survey form is presented in Figure 2. Questions ranged from demographics to the feelings participants had about individual songs. Self-perceived stress was measured using a Likert scale, from 1 to 10, with 10 being the highest level of stress. The two main questions utilized for this experiment were question 5, and question 9, which asked to subjectively choose current stress level before and after listening to each song. It is important to mention, participant data was omitted if a survey was not completed, in which either question 5 or question 9 were not answered or there was no information on means. Next, participants collected completed surveys after presenting their song, and were required to compute question 5 and question 9 for the mean value. To examine individual cohorts, the pre-calculated means for questions 5 and question 9 provided by each participant was collected, and computed to determine the overall mean value. A summary of each cohort is shown in Table 1.

These procedures were also repeated using songs provided by the Instructor. Four songs, chosen by the instructor were: Musical Selection 1 (contemporary Latin jazz); Musical Selection 2 (1970's soul); Musical Selection 3 (1990's pop rock); Musical Selection 4 (1950's pop).Data was collected from partcipants during the years of 2008 to 2012.

Microsoft[R] Excel 2007 Data Analysis, was used to calculate t-Test: Paired Two Sample for Means at a 5% significance level ([alpha] <0.05), and Descriptive Statistics to determine standard deviation with a confidence level for mean at 95%. The first part of the experiment includes a compilation of four years of data collected from participants, starting from 2009 to 2012 for the self-selected song choice. The second part is data collected from song choices made by the Instructor from 2008 to 2012.

For all four years, student cohorts' study results demonstrated a statistically significant overall decrease in stress. Results are shown in Table 1 for the years 2009 to 2012.

The summary shows the results of all four student cohorts. In 2009, the mean before listening to various songs is 4.97, with a standard deviation of 0.43, and after the mean it is 3.88 and a standard deviation of 0.53. In 2010, before the mean is 4.90 and the standard deviation is 0.38, and after the mean is 3.95, with a standard deviation of 0.41. The year 2011 showed another decrease in stress. This cohort had a mean of 6.27 and a standard deviation of 0.40 before. The mean is 4.49, with a standard deviation of 0.61 after various songs being played for 2011. The final year 2012, had a mean of 5.22 and a standard deviation of 0.30 before, and after the mean is 3.94 with a standard deviation of 0.41. Overall, for each cohort, the p-values of most results were highly significant (0.0000 being highly significant), which confirmed a decrease in stress for all songs played during an entire class period.

The results from the second part of the experiment, (Table 2 to Table 5), utilized songs chosen by the Instructor, also demonstrated an overall reduction in stress with the four different songs in all five cohorts. However, there was only one song, Musical Selection 1 for the year 2010 cohort that had no significance in stress reduction. The p-value was 0.27, which is greater than a = 0.05; not statistically significant. However, the decrease of the mean value from 4.27 to a mean of 4 after the song was played indicates there was a small decrease in stress levels.

As it has been emphasized, music can be used to produce health benefits, especially for the study population. There are many potential stressors affecting college students. Pressured with balancing academics and a personal life, many students can fall victim to stress. Listening to music for a short period can alleviate the effects of these stressors.

Research has proven that music may be an effective medium to help college students reduce the effects of negative emotional states (Labbe, Schmidt, Babin, & Pharr, 2007). Results have suggested that listening to at least ten minutes of soothing music has a relaxing effect (Lai, 2004). However, stress-related changes such as those that occur in serum hormone levels, which can affect mood, can be seen in as few as six minutes (Mockel, Rocker, Stork, Vollert, Danne, Eichstadt, & Hochrein, 1994). Thus, music is an easily accessible and efficient therapy to utilize for college students that is also cost-effective. Listening to music does not require a licensed musical therapist, and can be done at the time and location that is convenient to the individual. The only requirement is equipment for playing music, which is already accessible to many students.

In some study participants, listening to music did not produce any effect. Among individual responses, there were some songs that appeared to have caused participant stress levels to increase or have no effect at

all. But as the results show, for the overall study population, self-perceived stress levels were reduced in multiple categories from the pre-selected songs to the songs chosen by the instructor. One possible explanation for this reduction in stress levels is that music therapy utilizes the power of the mind to express emotions, potentially influencing all aspects of health and well-being. As it shows in the results, listening to personally selected music had the most impact on stress levels following each song. It could be that hearing the various types of music provided an emotional response.

There were a few limitations for this music therapy intervention. Because this was a self-administered experiment, the length of the experimental period for listening to all individual songs was limited to only a couple of class meeting days. Due to time constraints, each participant had to introduce and play their songs consecutively with minimal breaks in between, which could have prohibited full focus on each musical selection. Limiting the amount of songs to be played per day to approximately ten or less could provide additional time to respond to each participant's choice of music before reflecting on one's own self-perceived levels of stress; fewer songs played per day may also allow for additional time to prepare for the next song to be played. Conducting a longer study on a single population during the entire length of the academic quarter would demonstrate music's effectiveness over a period of time, and possibly provide a more truthful perception of stress level from participants.

In addition, the effect of music genre was not specifically explored in depth for this intervention. It was mentioned briefly that music genre did not have much influence; however, most studies have demonstrated that soothing, pleasant music, such as classical, has shown to reduce stress levels the most. Further study assessing music genre would provide insight as to which genre is most effective against stress and anxiety or to prove if genre selection makes any difference at all within the same study population. These limiting factors present an opportunity for future studies to be conducted.

Overall, listening to music is a functional, inexpensive, and effortless intervention to utilize in various stressful situations. As this intervention has evidently proven to be successful amongst college students, research has sufficiently established the efficacy and benefit of music for diverse populations in varying age groups. As more people and healthcare professionals become aware and accepting of mind-body therapies and other CAM treatments, music can be widely utilized as a complement to all areas of conventional healthcare.

The Body's Response to Music

The use of music therapy has been closely associated with alleviating stress, anxiety, pain, and a myriad of other physical and/or mental health diseases or disorders. Relieving such health issues is attributable to how the inherent patterns and structures of music in its entirety convey meaning to the brain (Miell, MacDonald, & Hargreaves, 2005). Building upon the basic understanding that the left brain is the thinking side and the right brain is the feeling side, the left part of the brain was found to be more stimulated during cognitive analysis of music or during sad or unharmonious sounds, such as single predicable chords, whereas the right part of the brain is stimulated more with happy and pleasurable sounds (Salimpoor, 2013).

The region of the brain involved with conveying meaning and emotions is the limbic system. It is located deep within the cerebrum, near the auditory cortex where music and sound are processed, and is composed of several brain structures, which include the amygdala, hippocampus, and hypothalamus (Office of Population Affairs, 2012; Lemonick & Bjerklie, 2003). In addition, the limbic system processes the intuitive, creative, and imaginative information that induces the body's psychophysiological responses (Guzzetta, 1989).

Thaut (1990) stated that feelings of reward, pleasure, punishment, and pain also occur in the limbic system. Therefore, listening to music becomes an instant reward, releasing enkephalins and endorphins to change moods, evoke relaxation, and alter pain perception. Understanding the role of the limbic system provides insight as to how relaxation comes about, and where emotions are processed when listening to music. Furthermore, when the mesolimbic system (amygdala, hippocampus) recalls a memory triggered by the sound stimulus, the message is eventually delivered to the forebrain, which then sends neurochemicals throughout the entire body to produce tension or relaxation (Brattico & Pearce, 2010).

According to Bunt (1994), there are three essential elements to music that create its patterns and structures: rhythm, melody, and harmony. Each of these elements is important in producing different responses in the body; both the physiological and psychological responses of a listener can be affected (Chian & Tracy, 1999). Furthermore, music is unique in that it can act as a powerful sensory stimulus, engaging the brain in retraining neural and behavioral functions that can be applied to non-musical context in everyday life, such as therapeutic needs (Yehuda, 2011). Emotional states are developed through music that allows an individual to achieve relaxation.

Music Therapy and Relaxation Response

Music therapy produces a relaxation response, in which Maranto (1993) states music promotes relaxation by physiological and/or psychological entrainment. Entrainment, a principle of physics, occurs where two objects vibrate at similar frequencies causing a mutual sympathetic resonance that vibrate at same frequencies. This concept of entrainment is realized with the direct use of music to generate relaxation (Maranto, 1993). Changes to the body's physiologic processes due to entrainment, are the result of specific musical stimuli, such as rhythms and tempos that act as synchronizers to cause the change (Saperston, 1995). Such responses include release of endorphins, and changes in catecholamine levels, facilitating pain relief as well as lowering blood pressure, heart and respiratory rate, oxygen consumption, and serum lactic acid levels (Guzzetta, 1989; Gardner, 1990; McCaffery & Beebe, 1994; Pert &Chopra, 1999).

the body to slow down and go along with the music's slower beats, producing a relaxation response regardless of genre and duration (Chian, 2009; Lee et al., 2012).

Evidence of a Positive Effect between Choosing a Musical Selection and a Reduction of the Perception of Stress and Anxiety

A 2002 study was performed by physicians Wang, Kulkami, Dolev, and Kain to test music as a method for reducing anxiety in pre-operative patients. The research results indicated a positive effect between music of choice and the reduction of the feeling of stress and anxiety. The pre-operative patients could listen to music of their choice for a time span of 30 minutes. Patients were evaluated at three different times including before, during and after treatment. Blood samples were taken to measure levels of cortisol and catecholamines as bioindicators of stress. Despite the fact that no differences were reported in the hormones released during stress, including epinephrine, norepinephrine and cortisol, patients required decreased levels of propofol to be sedated before the operation. There were no positive effects exhibited between music and stress in all pre-operative patients.

Importance of Music Preference

Music preference also produces a significant effect on its relationship with stress. Various studies have shown the extra benefit of self-selected music by individuals. A study conducted by Lai and Li (2011), examined the association between music and stress while paying close attention to music preferences. Newly employed nurses were able to choose a song from the six pre-selected songs by the study team (Lai & Li, 2011). Participants showed lower perceived stress levels, as well as lower cortisol, heart rate, mean arterial pressure, and higher finger temperatures when listening to music ([less than or equal to] 30 minutes), especially with a song selected by the participants themselves (Lai & Li, 2011). Lowered stress levels were also exhibited among patients undergoing day surgery, especially when patients were able to select music of their choice (Leardi et al., 2007). Therefore, the therapeutic power of music, as evidenced by these clinical trials, may provide an outlet for stress and anxiety relief among populations subject to high amounts of stress, for instance, college students.

Beyond Treatment for Anxiety: Singing as Form of Music Therapy

Previous studies of music therapeutic caregiving involving singing have found that persons with dementia may sing along with the caregiver, interfering with eating. In a 2012 study by Hammar, Williams, Swall, and Engstrom, the caregiver was instructed to use humming as opposed to singing in order to observe its influence upon mealtime situations. The elderly female subject with dementia appeared to eat and drink more during the intervention sessions. She also appeared more focused on the food and the caregiver, and in general appeared to be more alert during the interventions. Furthermore, in the palliative and/or hospice setting, MT has the ability to improve quality of life for dying patients (Halstead & Roscoe, 2002; Hilliard, 2003).

The physical effects produced by music can be observed in plants as well as in humans. A 2004 study by Creath and Schwartz used seed germination as an objective biomarker, to find that musical sound produced a highly statistically significant effect on the number of seeds sprouted compared to the untreated control over all five experiments. Seeds exposed to musical sound sprouted significantly faster than the untreated control. Musical sound had a significant effect compared to noise and an untreated control as a function of time (p<0.03) while there was no significant difference between seeds exposed to noise and an untreated control. Musical sound is defined as being dynamically organized to contain variations, as opposed to noise, which is constant. The noise used in this study had a fixed frequency band that was invariant over long time periods.

Sonic Bloom, a new type of plant fertilizer incorporating music, consists of a sound generator CD and a nutrient spray combining 55 trace minerals, amino acids, and seaweed. The sound generator produces tones in the four to six kilohertz range, the same range as many song birds. Photomicrographs of plant leaf surfaces taken using a scanning electron microscope show that the stomata of plants treated with Sonic Bloom are more numerous, more developed, and better defined than the stomata of untreated plants. Radioactive isotopes were utilized to record an increase in nutrient absorption exceeding 700%. This increase in plant nutrient absorption is relevant to human health, as it produces healthier plants and fruit with higher concentrations of complex sugar chains, which may act as communicators for the body's defense systems (Oliver, 2002).

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School of Kinesiology and Nutrition Science, California State University

Los Angeles Chinatown Senior Citizen Center

School of Kinesiology and Nutrition Science, California State University

School of Kinesiology and Nutrition Science, California State University

School of Kinesiology and Nutrition Science, California State University

School of Kinesiology and Nutrition Science, California State University

Los Angeles Chinatown Senior Citizen Center

School of Kinesiology and Nutrition Science, California State University

Table 1. Summary for Student Song Choices for years 2009-2012

                                   2009               2010
                                 (n = 59)           (n = 44)

                            Before    After    Before    After

Mean                         4.97     3.88      4.90     3.95
Variance                     0.19     0.29      0.14     0.17
Correlation                  0.73      --       0.62      --
df                            58       --        43       --
P(T<=t) two-tail           1.15E-30    --     4.66E-22    --
  ([alpha] < 0.05)
Standard Error               0.06     0.07      0.06     0.06
Standard Deviation           0.43     0.53      0.38     0.41
Confidence Level (95.0%)     0.11     0.14      0.11     0.12

                                   2011               2012
                                 (n = 64)           (n = 56)

                            Before    After    Before    After

Mean                         6.27     4.49      5.22     3.94
Variance                     0.16     0.37      0.09     0.17
Correlation                  0.42      --       0.39      --
df                            63       --        55       --
P(T<=t) two-tail           4.32E-34    --     1.14E-30    --
  ([alpha] < 0.05)
Standard Error               0.05     0.08      0.04     0.05
Standard Deviation           0.40     0.61      0.30     0.41
Confidence Level (95.0%)     0.10     0.15      0.08     0.11

Table 2. Summary for Musical Selection 1

                           2008             2009             2010
                         (n = 48)         (n = 36)         (n = 45)

                     Before   After   Before   After   Before   After

Mean                  5.08    4.21     6.06    4.86     4.27    4.00
Variance              5.18    4.08     4.34    5.44     3.75    3.77
Correlation           0.71     --      0.69     --      0.67     --
df                     47      --       35      --       44      --
P(T<=t) two-tail      0.00     --      0.00     --      0.27     --
  ([alpha] < 0.05)
Standard Error        0.33    0.29     0.35    0.39     0.29    0.29
Standard Deviation    2.28    2.02     2.08    2.33     1.94    1.94
Confidence Level      0.66    0.59     0.70    0.79     0.58    0.58
  (95.0%)

                           2011                2012
                         (n = 61)            (n = 54)

                     Before   After    Before     After

Mean                  6.62    5.23      5.59      4.50
Variance              3.64    4.48      3.60      3.46
Correlation           0.69     --       0.74       --
df                     60      --        53        --
P(T<=t) two-tail      0.00     --     2.724E-07    --
  ([alpha] < 0.05)
Standard Error        0.27    0.32      0.26      0.25
Standard Deviation    1.94    2.27      1.90      1.86
Confidence Level      0.55    0.64      0.52      0.51
  (95.0%)

Table 3. Summary for Musical Selection 2

                           2008                 2009
                         (n = 59)             (n = 54)

                     Before   After     Before     After

Mean                  6.04     4.73      5.11       3.91
Variance              4.46     4.49      4.40       4.95
Correlation           0.30      --       0.75        --
df                     48       --        53         --
P(T<=t) two-tail      0.00      --     5.039E-07     --
  ([alpha] < 0.05)
Standard Error        0.30     0.30      0.29       0.30
Standard Deviation    2.11     2.12      2.10       2.23
Confidence Level      0.61     0.61      0.57       0.61
  (95.0%)

                              2010                 2011
                            (n = 48)             (n = 58)

                      Before     After     Before     After

Mean                   4.88       3.92      6.22       4.72
Variance               4.96       3.23      3.62       4.62
Correlation            0.72        --       0.54        --
df                      47         --        57         --
P(T<=t) two-tail     9.584E-05     --     2.678E-07     --
  ([alpha] < 0.05)
Standard Error         0.31       0.26      0.25       0.28

Standard Deviation     2.23       1.80      1.90       2.15
Confidence Level       0.65       0.52      0.50       0.57
  (95.0%)

                             2012
                           (n = 51)

                      Before     After

Mean                   5.59       4.11
Variance               4.09       3.53
Correlation            0.80        --
df                      50         --
P(T<=t) two-tail     3.515E-11     --
  ([alpha] < 0.05)
Standard Error         0.28       0.26
Standard Deviation     2.02       1.88
Confidence Level       0.57       0.53
  (95.0%)

Table 4. Summary for Musical Selection 3

                           2008                2009
                           (n = 47)            (n = 54)

                     Before   After    Before     After

Mean                  5.47    4.62      6.20      5.06
Variance              4.43    5.89      5.34      4.85
Correlation           0.58     --       0.75       --
df                     46      --        53        --
P(T<=t) two-tail      0.01     --     2.372E-06    --
  ([alpha] < 0.05)
Standard Error        0.31    0.35      0.31      0.30
Standard Deviation    2.10    2.43      2.31      2.20
Confidence Level      0.62    0.71      0.63      0.60

                           2010                2011
                           (n = 46)            (n = 57)

                     Before   After    Before     After

Mean                  4.61    4.07       6.0      4.36
Variance              3.84    5.80      3.50      5.41
Correlation           0.76     --       0.55       --
df                     45      --        56        --
P(T<=t) two-tail      0.02     --     1.047E-07    --
  ([alpha] < 0.05)
Standard Error        0.28    0.35      0.25      0.31
Standard Deviation    1.96    2.41      1.87      2.33
Confidence Level      0.58    0.71      0.50      0.62

                              2012
                              (n = 55)

                      Before     After

Mean                   5.91      4.69
Variance               3.79      3.48
Correlation            0.75       --
df                      54        --
P(T<=t) two-tail     1.471E-08    --
  ([alpha] < 0.05)
Standard Error         0.26      0.25
Standard Deviation     1.95      1.86
Confidence Level       0.53      0.50
  (95.0%)

Table 5. Summary for Musical selection 4

                           2008                2009
                          (n = 45)            (n = 53)

                     Before   After    Before     After

Mean                  6.27    5.04      5.55      4.68
Variance              3.29    5.13      5.02      4.61
Correlation           0.54     --       0.82       --
df                     44      --        52        --
P(T<=t) two-tail      0.00     --     2.006E-05    --
  ([alpha] < 0.05)
Standard Error        0.27    0.34      0.31      0.29
Standard Deviation    1.81    2.27      2.24      2.15
Confidence Level      0.55    0.68      0.62      0.59
  (95.0%)

                           2010                2011
                         (n = 48)            (n = 61)

                     Before   After    Before     After

Mean                  4.96    4.31      6.62      5.23
Variance              5.02    4.94      3.64      4.48
Correlation           0.82     --       0.69       --
df                     47      --        60        --
P(T<=t) two-tail      0.00     --     4.160E-09    --
  ([alpha] < 0.05)
Standard Error        0.32    0.32      0.24      0.27
Standard Deviation    2.24    2.22      1.91      2.12
Confidence Level      0.65    0.65      0.49      0.54
  (95.0%)

                            2012
                          (n = 51)

                      Before     After

Mean                   5.76      4.70
Variance               3.42      4.15
Correlation            0.82       --
df                      50        --
P(T<=t) two-tail     4.362E-08    --
  ([alpha] < 0.05)
Standard Error         0.26      0.29
Standard Deviation     1.85      2.03
Confidence Level       0.52      0.57
  (95.0%)

Source Citation

# data[].attributes.attachment_link.title
Playing music to relieve stress in a college classroom environment

# data[].attributes.attachment_link.description
Music therapy can be an effective treatment that prevents stress from contributing to the etiology of disease. For this study, the participants, college students enrolled in an annual Alternative Nutrition class at California State University, Los Angeles, were instructed to select a song to present during class.

# data[].attributes.body
Caleb Simmons
"Yoga also reduces perceived stress and negative affects in college students thereby improving psychological well-being in them."

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Document controls

Main content

Byline: Mahesh. Tripathi, Sony. Kumari, Tikhe. Ganpat

College students are vulnerable to a critical period in developmental maturation, facing rigorous academic work, and learning how to function independently. Physical activities such as running and bicycling have been shown to improve mood and relieve stress. However, college students often have low levels of physical activity. Yoga is an ancient physical and mental activity that affects mood and stress. However, studies examining the psychophysiological effects of yoga are rare in peer-reviewed journals. The aim of this study is to establish preliminary evidence for the psychophysiological effects of yoga on stress in young-adult college students. The present study suggests that yoga has positive effects on a psychophysiological level that leads to decreased levels of stress in college student. Further research is needed to examine the extent to which different types of yogic practices address the needs of different college subpopulations (e.g., overweight, sedentary, and smokers).

About 40%-50% of college students are physically inactive. Similarly, it was found that college students' physical activity has been seriously neglected as a research topic, there is a lack of multiple-level approaches (i.e., personal, psychosocial, and environmental levels) for examining physical activity behaviors in the college student population and measures of physical activity are subjective and inconsistent which makes comparisons of physical activity patterns among different samples very difficult or impossible.[1] Similarly, the available research indicates that the prevalence of stress is increasing among college students.[2] The previous study reported that yoga reduces menstrual cramps and menstrual distress in female undergraduate students with primary dysmenorrhea.[3] The psychophysiological changes that characterize the efficacy of yoga for better stress management in college students have not been studied adequately.

Participation in physical activity on a regular basis is one of the primary factors in maintaining sound health in modern society. Due to sedentary lifestyle leading many health-related issues, the prevalence of physical inactivity among college students calls for immediate action.[4] Along with aerobics and dance, yoga is one of the most famous physical activity that college girl student would like to prefer as a choice.[5] Physical activity such as yoga is a key element in health promotion. The traditional expressions of yoga as a lifestyle is firmly rooted in and committed to the classic texts (e.g., Yoga Sutra by Patanjali, Hatha Yoga texts like Hatha Yoga Pradeepika, Gheranda Samhita) and embrace the concept of the eight limbs, or aspects, of yoga. In more specific, the eight limbs are of great interest to yogis who seek to adhere to yoga as a philosophical foundation for life, rather than solely a physical practice.[6] Therefore, yoga is essentially an art and science of holistic living; an effective method for improving health in addition to the prevention and management of diseases.[7] Yoga reduces stress through reducing sympathetic activity,[8],[9] and improves the sense of general well-being.[10]

Stress and college student

Stress affects college students' physical, mental, social, and intellectual health. College student will not always possess the necessary stress management skills and coping strategies. Physical activity is one coping strategy that is perhaps underutilized by many college students.[11] Many systematic reviews and different studies on effects on yoga for stress management in college students revealed positive effects of yoga (as a mind-body intervention) on stress reduction in college student.[12],[13],[14]

Physiological effects of yoga in college students

Yoga holds potential as a self-empowering, nonpharmacological method for enhancing stress management, and wellness in college students.[15] It was reported that Pranayama training decreases sympathetic activity, resulting in mental relaxation and decreased autonomic arousal thereby, decreasing force fluctuations during isometric contraction. This was reflected as improvement in hand grip strength and endurance in medical students.[16] In one study aimed at investigating the effect of integrated yoga on autonomic parameters and psychological well-being during both pre- and post-phases of menstrual cycle in healthy young female controls, it was observed that there was a significant alteration of autonomic functions and psychological status in premenstrual phase when compared with postmenstrual phase in young healthy females. In addition, it was revealed that regular practice of yoga has beneficial effects on both phases of menstrual cycle by bringing parasympathetic dominance and psychological well-being probably by balancing neuro-endocrinal axis.[17]

Psychological effects of yoga in college students

It was observed that Suryanamaskara, a yogic practice was effective in leading to relaxation dispositions such as physical relaxation, mental quiet, at ease/peace, rested and refreshed, strength and awareness and joy and reduces sleepiness, somatic stress, worry and negative emotion at a dispositional level.[18] Yogic practices play an important role in enhancing emotional sensitivity,[19] sustained attention,[20] mental performance,[21] and balance personality trait [22] among students, thus paving the way for their academic excellence. Yoga also reduces perceived stress and negative affects in college students thereby improving psychological well-being in them.

Suggested evidence-based yoga therapy protocol for college students

Based on clinical management and psychophysiological effects of yoga in college students, the suggested evidence-based yoga therapy for college students may include following yogic practices:[11],[13],[16],[17],[18],[23],[24]

*Starting Prayer *Kapalbhati Kriya (frontal brain cleansing), Agnisar Kriya (activating the digestive fire) *Hands in and out breathing, hands stretch breathing, ankle stretch breathing *Jogging, forward and backward bending, side bending, twisting *Surya namaskara (salutations to the sun practice) *Tadasan (palm tree pose), Vrikshasana (tree pose), Padahastasan (hand to foot pose), Ardha Chakrasana (half wheel pose), Bhujangasana (cobra pose), Shalabhasana (locust pose) *Quick Relaxation Technique *Nadi Shuddhi Pranayama (psychic network purification), Sheetali Pranayama (cooling breath), Seetkari Pranayama (hissing breath), Bhramari Pranayama (humming bee breath) *Om Meditation *Closing Prayer.

The present review study suggests that yoga has positive effects on psychophysiological level that leads to increased academic performance in college student. Further research on the relationship between yoga practice and college students is warranted to confirm the efficacy of yoga and to include it in the syllabus of the college student.

Financial support and sponsorship

There are no conflicts of interest.

1. Keating XD, Guan J, Pinero JC, Bridges DM. A meta-analysis of college students' physical activity behaviors. J Am Coll Health 2005;54:116-25.

2. Whitehead JR, Corbin CB. Youth fitness testing: The effect of percentile-based evaluative feedback on intrinsic motivation. Res Q Exerc Sport 1991;62:225-31.

3. Berger BG, Owen DR. Mood alteration with yoga and swimming: Aerobic exercise may not be necessary. Percept Mot Skills 1992;75:1331-43.

4. Cruz SY, Fabian C, Pagan I, Rios JL, Gonzalez AM, Betancourt J, et al. Physical activity and its associations with sociodemographic characteristics, dietary patterns, and perceived academic stress in students attending college in Puerto Rico.P R Health Sci J 2013;32:44-50.

5. Chong CS, Tsunaka M, Tsang HW, Chan EP, Cheung WM. Effects of yoga on stress management in healthy adults: A systematic review. Altern Ther Health Med 2011;17:32-8.

6. Malathi A, Damodaran A. Stress due to exams in medical students - Role of yoga. Indian J Physiol Pharmacol 1999;43:218-24.

7. Gopal A, Mondal S, Gandhi A, Arora S, Bhattacharjee J. Effect of integrated yoga practices on immune responses in examination stress - A preliminary study. Int J Yoga 2011;4:26-32.

8. Bhat N, Jain S, Singh A, Wadhwani A, Mansuri R, Bhat S, et al. Prevalence and characteristic of headache in dental professionals: A Questionnaire based survey. J Clin Diagn Res 2016;10:ZC107-10.

9. Yang NY, Kim SD. Effects of a yoga program on menstrual cramps and menstrual distress in undergraduate students with primary dysmenorrhea: A Single-blind, randomized controlled trial. J Altern Complement Med 2016;22:732-8.

10. Satyananda S. Asana Pranayama Mudra Bandha. 4th Revesite edition. Munger, Bihar, India: Yoga Publications Trust; 2008.

11. Kanojia S, Sharma VK, Gandhi A, Kapoor R, Kukreja A, Subramanian SK, et al. Effect of yoga on autonomic functions and psychological status during both phases of menstrual cycle in young healthy females. J Clin Diagn Res 2013;7:2133-9.

12. Thangavel D, Gaur GS, Sharma VK, Bhavanani AB, Rajajeyakumar M, Syam SA, et al. Effect of slow and fast pranayama training on handgrip strength and endurance in healthy volunteers. J Clin Diagn Res 2014;8:BC01-3.

13. Goldstein MR, Lewis GF, Newman R, Brown JM, Bobashev G, Kilpatrick L, et al. Improvements in well-being and vagal tone following a yogic breathing-based life skills workshop in young adults: Two open-trial pilot studies. Int J Yoga 2016;9:20-6.

14. Brems C, Colgan D, Freeman H, Freitas J, Justice L, Shean M, et al. Elements of yogic practice: Perceptions of students in healthcare programs. Int J Yoga 2016;9:121-9.

15. Sengupta P. Health impacts of yoga and pranayama: A State-of-the-art review. Int J Prev Med 2012;3:444-58.

16. Vempati RP, Telles S. Yoga-based guided relaxation reduces sympathetic activity judged from baseline levels. Psychol Rep 2002;90:487-94.

17. Udupa K, Madanmohan, Bhavanani AB, Vijayalakshmi P, Krishnamurthy N. Effect of pranayam training on cardiac function in normal young volunteers. Indian J Physiol Pharmacol 2003;47:27-33.

18. Rocha KK, Ribeiro AM, Rocha KC, Sousa MB, Albuquerque FS, Ribeiro S, et al. Improvement in physiological and psychological parameters after 6 months of yoga practice. Conscious Cogn 2012;21:843-50.

19. Godse AS, Shejwal BR, Godse AA. Effects of suryanamaskar on relaxation among college students with high stress in Pune, India. Int J Yoga 2015;8:15-21.

20. Ganpat TS, Dash S, Ramarao NH. Yoga therapy for promoting emotional sensitivity in university students. J Educ Health Promot 2014;3:45.

21. Sheela, Nagendra HR, Ganpat TS. Efficacy of yoga for sustained attention in university students. Ayu 2013;34:270-2.

22. Ganpat TS, Nagendra HR, Selvi V. Efficacy of yoga for mental performance in university students. Indian J Psychiatry 2013;55:349-52.

23. Tikhe SG, Nagendra HR, Tripathi N. Ancient science of yogic life for academic excellence in university students. Anc Sci Life 2012;31:80-3.

24. West J, Otte C, Geher K, Johnson J, Mohr DC. Effects of hatha yoga and African dance on perceived stress, affect, and salivary cortisol. Ann Behav Med 2004;28:114-8.

Source Citation

# data[].attributes.attachment_link.title
Psychophysiological effects of yoga on stress in college students

# data[].attributes.attachment_link.description
Byline: Mahesh. Tripathi, Sony. Kumari, Tikhe. Ganpat College students are vulnerable to a critical period in developmental maturation, facing rigorous academic work, and learning how to function independently. Physical activities such as running and bicycling have been shown to improve mood and relieve stress. However, college students often have low levels of physical activity.

# data[].attributes.body
Mary Martinez
"Students with higher stress levels had higher scores for emotional eating and uncontrolled eating, and higher frequency of consumption of fast food type ready-to-eat snacks and sandwiches."

# data[].attributes.attachment_link.readable_text
Stress is now considered a global problem, and studying it has gained prominence in the scientific literature because of the multitude of negative effects on human health. (1) Individual biological response to stress is influenced by how individuals experience stressful experiences and varies according to physiological, psychological and environmental features that interact to produce different responses among individuals, (2) such as an increase in appetite, ingestion of alcohol and other substances of abuse. (3)

Evidence suggests that stress alters eating behavior, redirecting food choices to food with greater palatability and energy value, especially those high in sugar and fat. (4,5) The literature also suggests that the effects of stress on food consumption seem to differ according to individual characteristics such as gender. Previous studies have found that stressed women have higher calorie food consumption when compared to less stressed ones, which has not been seen for men. (4,6) Women may react more strongly to stress and/or depressive symptoms in relation to food intake probably because these conditions are associated with the relaxation of social rules involved in food selection. (7)

Chronic stress situations are associated with increased exposure to cortisol, which has effects on the brain reward pathways (BRP). Cortisol increases BRP sensitivity, which can trigger excessive consumption of high palatability foods. (8) Other hormones such as dopamine, leptin and insulin also act at the central level, stimulating the desire for palatable foods. In turn, foods high in fat and sugar generate pleasure and positive emotions, increasing the desire for their consumption and associating the memory of their consumption with the feeling of reward. (9) Thus, the redirection of food choices when facing stressful situations, translated by the tendency to changing food preferences and increased consumption of foods that are usually consumed with caution (such as foods high in sugar), is related to the attempt to use food as a way to relieve this emotional state. (10,11)

In this sense, we have an interlacing of biological and psychological perspectives on the relationship between stress and food consumption. On the one hand, we have physiological responses to the consumption of palatable foods that influence and guide their future use. And on the other, we have hedonic and emotional motivations that guide and influence food consumption and sometimes overlap with biological mechanisms.

Decision-making in relation to food choices is a complex process and there are other factors, as well as emotions such as stress, involved in this action. Among them, the life course stands out, which does not refer simply to the development or progression of the stages of life but considers the socio-cultural environment to which the individual is exposed and the dynamic processes of life that go beyond these stages, including trajectories and transition times that generate changes in the direction of their food choices. (12)

College students are at a time of major transition in life and are particularly prone to emotional imbalances. University entrance can be a stressful experience in view of the major life changes involved in the transition to college and symptoms of stress and depression are common among college students. (13-15) Academic requirements and new social demands, together with the newly won freedom and responsibility for food selection, purchase and preparation can directly affect the eating behavior and generate negative impacts on food choices.

For adequate and specific intervention strategies to be developed, it is important to broaden our understanding of stress interferences on college students' eating habits. This better understanding can support preventive educational activities and also promote health. In this aspect, this study aims to evaluate the association between stress and behavior and food intake for college students.

Study design and research subjects

This is a pilot study, exploratory and cross-sectional developed with graduate students at "Universidade Federal do Triangulo Mineiro" [Brazilian Federal University of the Triangulo Mineiro]. The sample was by convenience (non-probabilistic). Recruiting volunteers was done through disseminating posters in public places at the university and invitations in classrooms. Those interested would be scheduled for data collection, which occurred in two stages: 1) Checking inclusion/exclusion criteria; evaluations: anthropometric, of the symptoms of stress and eating behavior, and guidelines for conducting a food record (FR) of 3 days; 2) Submitting the FR of 3 days. The study was conducted from August 2013 to August 2014.

In total, 80 students were scheduled. Of these, excluding those who did not meet the inclusion criteria and those who did not attend the 1st and/or 2nd stages of the pilot study, 30 students were evaluated, aged 18-30 years. Subjects diagnosed with eating disorders, using appetite suppressants or other medications that alter appetite and those who were performing some kind of treatment with weight loss goal were excluded.

The study was approved by the UFTM Research Ethics Committee (REC) (certificate of filing no. 2373) and all participants signed an Informed Consent Form.

Anthropometric assessment

Body weight (kg) and height (m) were measured in an electronic scale with an accuracy of 0.1 kg and a 0.5-cm graduation for subsequent calculation of body mass index (BMI). All measurements were performed according to previously standardized techniques (16) and by the same professional trained and qualified for this purpose.

To evaluate the stress symptoms, the Perceived Stress Scale (PSS) was used in the version translated to and validated for Portuguese. This scale measures perceived stress, i.e., how individuals perceive situations as stressful. PSS is a general scale and can be used in different age groups as it does not contain questions that are specific to the context. It contains 14 items which were created to check how unpredictable, uncontrollable and overloaded the participants evaluate their lives. Each question has answer options ranging from zero to four (0 = never, 1 = almost never, 2 = sometimes, 3 = often, and 4 = always). The scale total is the sum of the scores of these 14 items and the scores can range from zero (minimum) to 56 (maximum). (17)

For the interpretation of the PSS results, cutoffs are not suggested because it is understood that perceived stress is a continuous variable that must be analyzed as such. (17) Therefore, to evaluate the association between stress, eating behavior and food intake, the calculation of the PSS score tertiles was made and the students were classified into two groups: Lower stress Group: 1st tertile of the PSS score and higher stress Group: 3rd tertile of the PSS score. The classification choice of the participants in tertiles was given in order to get two groups actually distinct and in opposite poles in the level of stress, which is not achieved when the classification is made by the median.

Eating behavior standard evaluation

The eating behavior was assessed by the Three-Factor Eating Questionnaire-21 (TFEQ-21) in its version translated to and validated for Portuguese. (18) The dietary patterns assessed with this questionnaire were: cognitive restraint (CR), emotional eating (EE) and uncontrolled eating (UE).

CR addresses six items and identifies food control in order to reduce weight and/or change body shape. This consists of a mental condition that is adopted by the individual in relation to food with the objective of reducing caloric intake. The EE scale also has six items and measures the propensity to excessive eating in response to likely negative emotional states. As for the UE scale, it has nine items and verifies the tendency to lose food control in the presence of hunger or other stimuli. The total score of each behavior (score 0 to 100 points) was computed by a previously described method. (18)

Just as for the PSS, there are no cutoffs for eating patterns assessed by TFEQ-21. The guidance is that its assessment be made associated with other variables of interest. (18)

Assessment of current food consumption

The current food intake was assessed by the three-day FR, with specific guidelines for the its proper performance. The main advantage of this method lies in the fact that taking note of food must be done at the time of consumption, reducing memory bias. Participants were also advised to maintain their usual dietary intake on the days of recording it. However, it should be highlighted that the simple fact that the participants were aware that their consumption would be evaluated could generate interference on it.

Nutritional analysis of records was done with the help of software Dietpro 5i[R]. Data were calculated regarding the amount of energy (kcal), proteins (g and %), carbohydrates (g and %) and total lipids (g and %) ingested.

Besides the nutrition content analysis, an assessment was also made on the frequency/regularity of consumption of some food groups. Food groups of interest in the study which were considered for this analysis are: (1) Food group high in sugar (chocolate powder mixes, chocolates, candies and junk food in general, cookies and sugary drinks); (2) Food group of fast food type ready-to-eat snacks and sandwiches; and (3) Food group of fruits and vegetables. Obtaining the numerical value corresponding to the consumption frequency/regularity was done by counting the number of times the foods that made up each of these groups were consumed by the participants on the three days evaluated. The main interest of this evaluation was to determine not the amount or size of the serving consumed but the consumption frequency/regularity of these foods to subsequently verify the association between this regularity and stress.

The data normality was checked from the Kolmogorov-Smirnov test. Given that not all variables had a normal type distribution, the use of the non-parametric Mann-Whitney test to compare means between the higher versus lower stress groups and the Spearman's rank correlation coefficient for correlations between variables were standardized. The level of significance adopted was of 5% (p [less than or equal to] 0.05).

Thirty students were evaluated, with average weight and BMI of 60.8 [+ or -] 12.9 kg and 22.7 [+ or -] 4.4 kg/[m.sup.2], respectively. Participants were classified into two groups, according to tertiles of the PSS score (lower stress Group: 1st tertile--15 to 22 points and higher stress Group: 3rd tertile--31 to 40 points) and there were no significant differences in the anthropometric parameters between them (Table 1).

Stress and food consumption

Energy food and macronutrient intake was not different between the higher and lower stress groups (Table 1). As for the analysis of the consumption frequency/regularity, it revealed that the consumption of fast food type ready-to-eat snacks and sandwiches was more frequent for students with higher stress (2.7 [+ or -] 1.8 x 1.0 [+ or -] 1.3, p = 0.03). For the other food groups evaluated, no difference was observed between the groups (Figure 1).

It is also important to note that for the total sample a higher consumption frequency of foods high in sugar compared to the consumption of fruits and vegetables was observed (10.6 [+ or -] 4.3 x 4.1 [+ or -] 2.4, p < 0.001).

Stress and eating behavior

It was observed that students with higher levels of stress had higher scores for the EE and UE eating behaviors. For the CR behavior there was no difference between the groups (Table 1).

For the total sample, a positive and significant correlation was observed between the level of stress and emotional eating behavior (r = 0.37, p = 0.04). A positive correlation was also seen between the scores of cognitive restraint eating behavior and body weight (r = 0.37, p = 0.04) and between the consumption frequency/regularity (number of times the foods were consumed) of foods rich in sugar and total energy consumption (r = 0.38, p = 0.03) and body weight (r = 0.40, p = 0.02).

For the other parameters of food intake, eating behavior and anthropometric assessment evaluated, significant correlations were not observed.

Students with higher levels of perceived stress had higher scores for the eating habits of emotional eating and uncontrolled eating. Furthermore, a positive correlation between stress and emotional eating was also obtained. These findings indicate that in situations of stress, food choices are more determined by emotional factors, associated with the difficulty of controlling the amount ingested. These behaviors can occur as a coping and reversal strategy, albeit temporary, of this negative emotion.

The role that food plays in every individual's life goes beyond the nutritional aspect. When facing stress, we often use food not to meet physiological and nutritional needs but to seek psychological comfort and as a deliberate strategy to change temperament and humor. (19,20) As a rule, in view of stress situations food choices are redirected to higher palatability foods, especially those high in sugar and fat (such as sweets) with a concomitant reduction in the consumption of fresh foods such as fruits and vegetables. Findings in the literature that point to positive associations between the consumption of foods rich in carbohydrates and fats, especially sweets in general, and stress levels are common. (6,7,11,19-22)

Increased consumption of foods high in sugar as an attempt to relieve stress and improve mood may be related to the physiological response resulting from the consumption of such food. Hedonic mechanisms are intimately involved since sugar intake is related to a strong feeling of pleasure. (23) This is because carbohydrates increase the serum levels of serotonin, an important neurotransmitter in the central nervous system that is responsible for feelings of pleasure and is involved in the modulation of various aspects of mood. (9,24,25)

Qualitative food consumption showed a higher frequency of fast food type ready-to-eat snacks and sandwiches for students with higher stress. Liu et al. (20) have also found a higher frequency of consumption of fast food type ready-to-eat snacks and sandwiches for Chinese university with higher stress. Al Ansari et al. (21) have found a positive association between stress levels and the consumption of snacks and fast food for university students in the United Kingdom. These findings corroborate the influence of stress on individual food choices. Foods such as snacks and fast food are highly palatable and the preference for this type of food in view of stressful situations can occur in an attempt to face this negative emotion.

However, for the consumption of foods high in sugar, no differences were found between the groups, which is distinguished from most frequently observed results in the literature, which point to the increase in consumption of foods high in sugar and fat in the presence of stress. (6,7,11,19-22) Such foods are also known as comfort food because they evoke a pleasant and comfortable psychological state. (26) However, it is important to consider that studies with results similar to ours have already been described in the literature. Pollard et al., (27) analyzing college students of both genders before and during the school tests period (a situation of low and high stress, respectively), have found no significant differences in food consumption in view of higher stress situations. Other authors have also found no influence of stress on food consumption, especially when it came to male participants. (4,28,29)

The individuals' attraction for certain foods is the result of the combination of physiological and psychological needs (26) and there are several factors involved in the process of food choices. Decisions about what, how much and when to eat involve complex neural processabilities and are influenced by issues such as food culture, display, variety, availability, individual previous experience, personal factors such as gender, income and age, physiological intake consequences, among others. (30) The absence of stress influence on food consumption observed in some work brings up the importance of not disregarding these other factors role in eating behavior. In the specific case of college students, factors such as ease, convenience and cost are important determinants for food consumption.

Although not highlighted as a general objective of the work, we can not disregard the findings related to students' food intake as a whole. University undergraduate students' dietary pattern is of low quality, in view of the more regular consumption of foods rich in sugars to the detriment of fruit and vegetables. College students are mostly the main responsible ones for caring for their food. Added to this are the busy routine and academic requirements inherent in university life. As a result, food choices seem to displace to food that is easily accessible, has low cost and is of rapid preparation.

The main findings of the study show that students with higher stress levels had higher scores for eating habits of emotional eating and uncontrolled eating and most often the consumption of fast food type ready-to-eat snacks and sandwiches. However, there was no difference in the frequency of consumption of foods high in sugar or quantitative food intake between the groups.

Far from exhausting the discussion on this issue and considering that college students are particularly prone to stress, it is worthwhile to highlight the importance of studies that go deeper in the psychological phenomena involved in the relationship between stress and food intake so that specific food and nutrition education programs can be developed.

DOI: 10.12957/demetra.2016.18592

To the Nutrition Course at "Universidade Federal do Triangulo Mineiro" [Brazilian Federal University of the Triangulo Mineiro], for providing the necessary infrastructure for this work. To FAPEMIG--"Fundacao de Amparo a Pesquisa do Estado de Minas Gerais" [Research Support Foundation of the Brazilian State of Minas Gerais], which has granted a Scientific Initiation scholarship for this work.

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Received: September 14, 2015

Reviewed: October 21, 2015

Accepted: November 10, 2015

Fernanda Rodrigues de Oliveira Penaforte [1,2]

Nayara Cristine Matta [3]

Camila Cremonezi Japur [2,4]

[1] Universidade Federal do Triangulo Mineiro, Departamento de Nutricao, Instituto de Ciencias da Saude. Uberaba-MG, Brasil.

[2] Universidade de Sao Paulo, Faculdade de Medicina de Ribeirao Preto, Curso de Nutricao e Metabolismo, Laboratorio de Praticas e Comportamento Alimentar. Ribeirao Preto-SP, Brasil.

[3] Universidade Federal do Triangulo Mineiro, Curso de Nutricao. Uberaba-MG, Brasil.

[4] Universidade Federal de Uberlandia, Curso de Nutricao. Uberlandia-MG, Brasil.

Fernanda Rodrigues de Oliveira Penaforte

Departamento de Nutricao, Universidade Federal do Triangulo Mineiro Av. Getulio Guarita, 159, sala 321. Uberaba-MG, Brasil. CEP 38025-440

E-mail: fernandapenaforte@yahoo.com.br

Caption: Figure 1. Frequency/regularity (number of times when the food has been consumed) of consumption of foods of the groups: (1) foods high in sugar, (2) fast food type ready-to-eat snacks and sandwiches and (3) fruits and vegetables among groups with higher and lower stress, according to the PSS score tertiles. *: p = 0.03.

Table 1. Anthropometric data of the participants' food consumption and
eating behavior standard, according to PSS score tertiles. Uberaba,
MG, 2014.

                           Lower stress
                               group               Intermediate
Variables                    (n = 11)             group (n = 09)

BMI (kg.[m.sup.-2])      22.9 [+ or -] 4.5       22.0 [+ or -] 2.5
PSS score                35.4 [+ or -] 2.9       25.0 [+ or -] 2.3
Energy                 1608.3 [+ or -] 384.0   1808.0 [+ or -] 478.0
consumption (kcal)
Carbohydrates (g)       206.1 [+ or -] 62.8     240.2 [+ or -] 95.6
Carbohydrates (%)        52.4 [+ or -] 9.7       53.1 [+ or -] 6.0
Proteins (g)             61.9 [+ or -] 19.8      72.9 [+ or -] 17.7
Proteins (%)             15.7 [+ or -] 4.3       16.0 [+ or -] 2.8
Lipids (g)               57.9 [+ or -] 21.4      59.0 [+ or -] 15.5
Lipids (%)               31.6 [+ or -] 7.9       29.6 [+ or -] 5.3
CR behavior (points)     37.2 [+ or -] 17.4      52.5 [+ or -] 19.3
EE behavior (points)     46.0 [+ or -] 28.1      53.1 [+ or -] 24.6
UE behavior (points)     41.7 [+ or -] 14.9      35.4 [+ or -] 19.3

                           Higher stress
                               group
Variables                    (n = 10)          p-value

BMI (kg.[m.sup.-2])      23.5 [+ or -] 6.1       0.71
PSS score                17.9 [+ or -] 2.0     < 0.0001
Energy                 1713.1 [+ or -] 412.7     0.60
consumption (kcal)
Carbohydrates (g)       232.8 [+ or -] 83.4      0.37
Carbohydrates (%)        52.5 [+ or -] 9.4       0.90
Proteins (g)             69.3 [+ or -] 15.5      0.33
Proteins (%)             17.0 [+ or -] 3.3       0.34
Lipids (g)               52.9 [+ or -] 11.4      0.55
Lipids (%)               29.5 [+ or -] 7.0       0.65
CR behavior (points)     45.7 [+ or -] 26.6      0.56
EE behavior (points)     22.8 [+ or -] 17.9      0.05
UE behavior (points)     26.3 [+ or -] 12.3      0.03

Values presented in means [+ or -] SD. CR--cognitive restraint,
EE--emotional eating, UE--uncontrolled eating. Lower stress group: 1st
tertile of the PSS score (15 to 22 points), higher stress Group: 3rd
tertile of the PSS score (31 to 40 points) and intermediate Group: 2nd
tertile of the PSS score (23 to 30 points). The comparisons were
done between the higher stress Group versus the lower stress Group.

# data[].attributes.attachment_link.title
Association between stress and eating behavior in college students

# data[].attributes.attachment_link.description
Stress is now considered a global problem, and studying it has gained prominence in the scientific literature because of the multitude of negative effects on human health. (1) Individual biological response to stress is influenced by how individuals experience stressful experiences and varies according to physiological, psychological and environmental features that interact to produce different responses among individuals, (2) such as an increase in appetite, ingestion of alcohol and other substances of abuse.