Module 4 - Stress
• Causes/sources of stress
• Physiology of stress and effects on health. The GAS Model
(Selye). Causes of stress: lack of control (e.g., Geer and Maisel,
1972), work (e.g., Johansson, 1978), life events (Holmes and
Rahe, 1967), personality (e.g., Friedman and Rosenman, 1974),
daily hassles (e.g., Lazarus, 1981).
• Measures of stress
• Physiological measures: recording devices and sample tests
(e.g. Geer and Maisel, 1972; Johansson, 1978); self report
questionnaires (Holmes and Rahe 1967, Friedman and
Rosenman, 1974, Lazarus, 1981).
• Management of stress
• Medical techniques (e.g. chemical). Psychological techniques:
biofeedback (e.g. Budzynski et al., 1973) and imagery (e.g.
Bridge, 1988). Preventing stress (e.g. Meichenbaum, 1985).
Define, in your own words what is meant
by the term ‘stress’ / ‘measuring stress’ /
Stress can be defined as is a process by which we appraise
and cope with internal and / or environmental threats and
challenges. When short-lived or taken as a challenge, stressors
may have positive effects. However, if stress is threatening or
prolonged, it can be harmful.
Measuring stress refers to a variety of methods and
techniques to assess the type, levels and qualities of stress
experienced by patients. These methods can be self-reports,
physiological tests or even behavioural observations.
Managing stress is defined as the various techniques used
by medical practitioners to help patients reduce or eliminate the
stress they experience. These techniques can include medicines,
physical methods such as massages or even psychological methods
such as counselling or even hypnosis.
Any event or circumstance that causes stress is called
Stressor as such does not cause stress but our perception
of that event, the meaning we attach to it and the way we
react to it leads to symptoms or diseases of stress.
Two main categories (types) of stress:
Acute & Chronic
Acute - Acute stress is the reaction to an immediate threat,
commonly known as the fight or flight response. The threat can be
any situation that is experienced, even subconsciously or falsely, as
Common acute stressors include:
Chronic Frequently, however, modern life poses on-going
stressful situations that are not short-lived and the urge to act
(to fight or to flee) must be suppressed. Stress, then, becomes
Common chronic stressors include:
• on-going highly pressured work,
• long-term relationship problems,
• Persistent financial worries.
THE GENERAL ADAPTATION SYNDROME
Coping with stress
and resistance to
-ences of stress (such
as illness) occur
when coping is
Significant Life Changes
The death of a loved one, a divorce, a loss of job,
or a promotion may leave individuals vulnerable
How was the SRRS devised?
• In 1967, psychologists Thomas H. Holmes &
Richard H. Rahe conducted a study on life
events & their impact on stress
• Sample: 394 (179 M & 215 F)
• Whites = 363 Negro = 19
• Lower class = 71 Middle class = 323
• Age: < 30 years = 206
• Age: > 60 years = 51
• Rate 43 life events
• Marriage given 500 – arbitrary number
• Rate other life events in relation to
adjustment needed as compared to marriage
Life Events Score
Death of spouse 100
Marital separation from mate 65
Detention in jail, other institution 63
Death of a close family member 63
Major personal injury or illness 53
Fired from work 47
Marital reconciliation 45
Major change in the health or
behavior of a family member 44
Sexual difficulties 39
Gaining a new family member 39
(e.g., through birth, adoption, oldster
Major business re-adjustment 39
(e.g., merger, reorganization,
Major change in financial status 38
Death of close friend 37
Change to different line of work 36
Major change in the number of
arguments with spouse 35
Taking out a mortgage or loan for a
major purchase 31
Foreclosure on a mortgage or loan30
Major change in responsibilities at
Less than 150 life change units = 30% chance of
developing a stress-related illness
150 - 299 life change units = 50% chance of
Over 300 life change units = 80% chance of
Other studies by Holmes & Rahe
• Aim: To find out if scores on the Holmes &
Rahe Social Readjustment Rating Scale
correlated with the subsequent onset of
Sample & Tasks
• 2500 male American sailors were given the SRRS
to assess how many life events they had
experienced in the last 6 months.
• The total score on the SRRS (the life changing
score) was recorded for each participant.
• Over the following six-month tour of duty,
detailed records were kept of each sailor’s health
• The recorded Life Change Scores were correlated
with the sailors’ illness scores.
• There was a positive correlation of +0.118
between Life Change Scores and illness scores.
• Although the correlation was small, it did
demonstrate a meaningful relationship
between LCUs and health (as LCU scores
increased, so did the frequency of illness)
• The researchers concluded that as the LCUs
were positively correlated with illness scores,
experiencing life events increases the chances
of stress related illness.
• However, the correlation was not perfect,
therefore life events cannot be the only factor
contributing to illness.
• The majority of research conducted by Holmes and
Rahe was androcentric. Tested the SRRS on males,
therefore it may not be suitable for women.
• Ccriteria within the SRRS outdated & only relevant
to society in 1967. Therefore it can be suggested
that the research is historically bound & cannot be
applied to today's society.
• The relationships found between the SRRS &
health is only correlational, we cannot infer that
stress causes health problems but merely that the
two are associated. It may be that illness leads to
physical life problems.
• The SRRS does not distinguish between positive
and negative life changes therefore it may lack
internal validity as it is not a true measure of life
events and stress.
• The SRRS fails to consider that some individuals
may find aspects more or less stressful than
others. This scale assumes that life events are the
same for everyone, for instance Christmas is
more stressful for some than others.
• Questionnaires are self-report measures and the
SRRS is an unreliable assessment of life events
as people may not recall life events accurately.
Richard Lazarus and his colleagues have
suggested that the petty annoyances, frustrations,
and unpleasant surprises we experience every day
reduce psychological well being.
These may add up to more grief
worsening already present illnesses.
Daily hassles scale
Rush hour traffic, long lines, job stress, burnout
are most significant sources of stress and can
Daily Hassles and Uplifts
Daily hassles are relatively minor events arising
out of day-to-day living such as losing your
house keys and missing the college bus.
Uplifts are positive everyday events
Daily Hassles and Uplifts Scale
• Devised by Lazarus et al (1981)
• Questionnaire of 117 items.
• Each item is a daily event.
• Participants asked to complete questionnaire individually at
end of their day.
• The items rated as an uplift and a daily hassle on a scale of 0-3
– (0= not applicable
– 1= Somewhat
– 2= Quite a bit
– 3 = a great deal).
• The total daily hassles score and uplifts score are used as an
indicator of stress.
• Support from research now largely accepted that Daily Hassle sand
Uplifts are better predictors of later health/ill health than life events.
• For example, Flett et al (1995) found that major life-changing events
may differ from daily hassles in the extent to which a person would
seek social support.
• 320 students read a scenario describing an individual who had
experienced either a life event or daily hassle. They then rated the
support of support that person would receive and would seek from
others. Those who had experienced a life event were rated as needing
and receiving more social support.
• One reason why daily hassles are such a negative influence on later
health is that we don’t receive adequate social support to deal with
Research with rats and humans has indicated
that absence of control over stressors is a
predictor of health problems.
Key study: Geer and Maisel (1972)
– To see if perceived control or actual control can
reduce stress reactions to aversive stimuli (photos of
– Laboratory experiment.
• 60 psychology undergraduates from New York
• Independent design as participants were
randomly assigned to one of three conditions.
• Each participant was seated in a sound-shielded room and
wired up to galvanic skin response (GSR) and heart-rate
– Group 1 were given actual control over how long they
saw each photograph for.
– Group 2 were yoked to the actual control group,
warned how long the photos would be shown for and
that a noise would precede them.
– Group 3 were also yoked to actual control group, but
were told that that from time to time they would see
photographs and hear tones.
• A Beckman Model RB polygraph was used to
collect psycho-physiological data.
• The data was converted from a voltmeter to a
• Each recording was performed in a sound and
electrically-shielded room to ensure no audio
or visual input from the projector would
interfere with the data collection.
Procedure (cont. 2)
• The heart monitors were attached in standard
positions, and the GSR electrodes were placed
between the palm and forearm of the
participants’ non-preferred arm e.g. left arm
for right-handed people.
• The predictability group (Group 2) were most
stressed by the tone as they knew what was
coming, but did not have control over the
• The control group (Group 1) were less stressed
by the photograph than the predictability
group and no-control group (Groups 1 and 2)
as they had control.
• It is likely that having the control to terminate
aversive stimuli reduces the stressful impact of
• Personality is thought to comprise several:
– feelings as perceived by others
Key study: Friedman and Rosenman (1974)
• To investigate links between the Type A
behaviour pattern & cardiovascular (heart)
• Using structured interviews, 3200 Californian men,
aged between 39 and 59, were categorised as either
Type A, Type X (balanced between Type A and Type B)
or Type B (the opposite of Type A i.e. more relaxed).
• They categorised these behaviours as a direct response
when the participants were constantly interrupted in
• This sample was followed for up to eight and a half
years to assess their lifestyle and health outcomes.
Type A a term used for competitive, hard-driving,
impatient, verbally aggressive, and anger-prone people.
Type B easygoing, relaxed people (Friedman and
Type A are more likely to develop
coronary heart disease.
Personality Types and Health
The Type A Personality
• Friedman and Rosenman (1959) described the
Type A personality as having six distinct
– Competitive drive
– Desire to achieve poorly defined goals
– Need for recognition
– Sense of time urgency and impatience
– Persistent mental and physical activity
– High level of mental and physical alertness
• 257 men in the sample developed CHD, of
which 70% were from the Type A group.
• This difference in the incidence of CHD
between two groups was independent of
lifestyle factors such as smoking & obesity that
are known to increase the chances of heart
• The Type A behaviour pattern increases
vulnerability to heart disease.
• Behaviour modification programmes to
reduce Type A behaviour should result in a
reduced risk of heart disease.
• Although aspects of lifestyle were controlled
for, there may have been other variables that
could have affected vulnerability to heart
disease, such as elements of hardiness.
• This was not an experimental study, so cause
and effect cannot be assumed; other studies
have failed to show a relationship between
Type A behaviour and heart disease.
The Hardy Personality
• Kobasa (1979) describes hardiness as involving the three
C’s: a sense of control, commitment, and challenge
• In contrast to the other personality types, hardiness is
characterized by resilience to stress and illness, and a
positive coping response
• Research indicates hardiness has a buffering effect by
moderating the stress and illness link, but results are mixed
and the effect appears to be greater for men
Personality Types and Health
The Hardy Personality
• Individual differences in cognitive appraisal seem to play a
role in hardiness, with nonhardy persons more prone to
• Methodological issues regarding hardiness concern the
predictive utility of the control and commitment
• Content items assessing hardiness also tap negative affect
which empirically inflates the link between hardiness and
Personality Types and Health
• Bandura (1997) described self-efficacy as the
belief in one’s capability to perform a behaviour
• Bandura listed three components of self-
efficacy that describe this belief:
– Magnitude: difficulty levels of the tasks
– Strength: how strong you are to handle these
– Generality: can you apply these skills to other tasks
Personality Traits and Health
• Bandura asserted that beliefs about one’s ability contribute
to an overall sense of self-efficacy, but self-efficacy can also
exist in specific domains
• Endler, Speer, Johnson, and Flett (2002) found that high self-
efficacy is associated with low anxiety
• Bandura (1986) stated that perceived self-efficacy is a
determinant of stress-related illness with higher levels of
self-efficacy associated with adaptive coping styles
Personality Traits and Health
• Researchers have also found that high levels
of general self-efficacy are associated with
high self-esteem and optimism, and low
anxiety and depression
• Schwartz (1999) cautioned that effective
coping results from having high-self-efficacy
across all four phases of goal-setting, action,
Personality Traits and Health
Key study : Johansson (1978)
• To investigate whether work place stressors,
such as repetitiveness, machine-regulated
pace of work & high levels of responsibility,
increase stress related physiological arousal &
stress related illness.
• High risk group of 14 ‘finishers’ in a Swedish sawmill. Their job
was to finish off the wood at the last stage of processing
timber. The work was:
• Machine paced, Isolated, very repetitive, yet highly skilled &
finishers’ productivity determined wage rate for the entire
• Low-risk group of 10 cleaners, whose work was more
varied, self paced, allowed more socialising with other workers
• Levels of stress hormones (adrenaline and noradrenaline) in the
urine were measured on work days & rest days.
• Records were kept of stress related illness and absenteeism.
Findings & Conclusions
• Finishers secreted more stress hormone on work days
than rest days and more than the control group
• Finishers had higher rates of stress related illness than
the low risk group
• A combination of workplace stressors- especially
repetitiveness, machine pacing of work & high levels of
responsibility- lead to chronic (long term) physiological
arousal. This in turn leads to stress related illness and
• Name: One problem with research into
workplace stress is that it fails to control
• Explain: Research into workplace often fail to
control important variables like personality type.
It may be the case that persons with type A
behaviour are attracted to demanding and
stressful jobs. (Diet) Food and drink, too.
• Apply: Therefore it may be that personality type
leads to health problems not low job control. Diet
may affect illnesses.
• Name: A second problem with research into workplace
stress is that it fails to consider individual differences
in the response to stress.
• Explain: In Eastern Europe, the link between low job
control & stress related illness is apparent. However,
not everybody who is in a stressful job is experiencing
• Apply: This means that the findings of western
research do not consider the individual coping styles &
social support networks in responses to stress.
• Study was done in Sweden – positive /
• Study was done in a sawmill, not a school or
an office – positive / negative?
• Samples of urine taken daily???
Describe what psychologists have found out
about stress / measuring stress ...
How would you do it?
• Your patient is an 18 years old boy who is being physically
abused by his father and he has begun to rebel against
• Your patient is an elderly woman who has broken her hip
when she slipped on the tiles in her kitchen. She used to
be independent and now she is relying on one of her
daughters for everything, including cooking and bathing.
• Your patient is a principal secretary with a heavy
workload and she is experiencing severe headaches.
Use self-reports ???
1. Holmes & Rahe Self-Report Scale
2. Lazarus’ and Folkman’s Daily
Hassles and Uplifts Scale (DHUS)
Use objective methods ???
• Physiological measures?
• Johansson (1978) – urine sample for
adrenaline & noradrenaline
• Geer and Maisel (1972) – heart monitors,
polygraph & GSR (Galvanic Skin Response)
• Benzodiazepine; antianxiety drugs such as
Librium and Valium. Reduces the activity of the
neurotransmitter serotonin. Inhibitory effect
on the brain increasing muscle relaxation and a
• Beta-blockers such as Inderal. Reduces activity
in the sympathetic nervous system, effective
against raised heart rate and blood pressure.
• Long-term use of benzodiazepines can lead to physical and
psychological dependency, therefore should only be used for
• All drugs have side-effects. Benzodiazepines can cause
drowsiness and adversely affect memory (Green 2000).
• Drugs treat the symptoms of stress not the causes. Most
stresses are psychological, therefore physical measures do not
address the real cause of the problem.
• Biofeedback is a technique in which an
electromechanical device monitors status of a person’s
physiological processes, e.g., heart rate, blood pressure
or muscle tension, & immediately reports info. back to
him / her.
• Person then gains voluntary control over these processes
through operant conditioning. Feedback from device
becomes the reinforcement / reward: “I can control my
Key study: Budzynski et al. (1970)
• To see whether biofeedback is an effective
method of reducing tension headaches.
• Experimental method, with patients being trained
in a laboratory.
• 18 participants who replied to an advertisement
in a local paper in Colorado, USA.
• N=18 divided into 3 groups of 6 part. each
• Independent design.
• The participants were randomly allocated to one
of three groups.
• For 2 weeks patients kept a record of their
• Groups A and B were given 16 sessions of
training, with 2 sessions each week for 8 weeks.
– Group A were taught relaxation and told the ‘clicks’
of the biofeedback machine would reflect their
muscle tension, with slower clicks indicating less
– Group B were told to concentrate on the varying
clicks. They were given pseudo-feedback.
– Group C were given no training but were told they
would begin training in two months.
• Muscle tension of Group A was significantly
different from Group B by end of training, &
after 3 mths, Group A’s tension was significantly
lower than Group B’s.
• Group A’s reported headaches dropped
significantly from their baseline, whereas the
other didn’t, & was also significantly less than
Group B’s and Group C’s reported headaches.
• Drug usage in Group A decreased, more than in Group
• Group A reported fewer headaches than Group B.
• Follow up for Group A
• After 18 months, when 4r out of the 6 participants
• 3 reported very low headache activity, and 1 reported
• Biofeedback is an effective way at training
patients to relax and reduce their tension
headaches, so can be seen as an effective
method of stress management.
• Relaxation training is also more effective than
just being monitored, but is better when used
together with biofeedback.
Limitations of biofeedback techniques
• It is claimed that biofeedback techniques can
have significant positive effects in the reduction
of generalised anxiety disorders (GADs). The use
of this technique & related efforts to reduce
heart rate in sufferers of anxiety disorders has
had only limited success.
• Biofeedback may be no more effective than
muscle relaxation in the absence of biofeedback.
This is a critical issue as biofeedback can be
expensive as a technique
Biofeedback with children
• Virginia Attanasio, et al. (1985) gave 3 reasons
why biofeedback is particularly suitable for use
• 1. Children treat biofeedback as a game, and
are therefore interested and motivated in the
• 2. Children are less sceptical about their ability
to succeed in biofeedback training.
• 3. Children are more likely to practise their
training at home, as they are instructed to do.
• 1. Children have shorter attention spans,
particularly when below the age of 8.
• 2. Children may perform disruptive behaviours
such as disturbing the electrodes or by
interrupting by talking about other unrelated
• 3. Children are more likely to practise their
training at home, as they are instructed to do.
Imagery (Bridge et al, 1988)
– To see whether stress could be alleviated in patients
being treated for early breast cancer.
– Controlled randomised trial lasting six weeks.
– Outpatient radiotherapy department in a teaching
– 154 women with breast cancer stage I or II after first
session of six week course of radiotherapy, of whom
15 dropped out before end of study.
• Patients saw one of two researchers once a week
for six weeks.
• Controls were encouraged to talk about
• Relaxation group was taught concentration on
individual muscle groups
• Relaxation and imagery group was also taught to
imagine peaceful scene of own choice to enhance
relaxation. Relaxation and relaxation plus imagery
groups were given tape recording repeating
instructions and told to practise at least 15 minutes
Measurements and main results
• Initial scores for profile of mood states and Leeds
general scales for depression and anxiety same in
• At 6 weeks total mood disturbance score was
significantly less in the intervention groups,
women in the combined intervention group
being more relaxed than those receiving
relaxation training only;
• Mood in the control group was worse.
• Women aged 55 and over benefited most.
Stress - inoculation (Meichenbaum)
• Preparing people for stress. Just like an injection to prevent a
disease. Meichenbaum and Cameron (1983)
• 1. Conceptualisation - identify and express feelings and fears.
– Educated about stress. Client encouraged to relive stressful situations,
analysing what was stressful about them & how they attempted to deal
• 2. Skill acquisition and rehearsal
– E.g., how to relax, desensitisation, emotional discharge, turning to others &
cognitive redefinition. Specific skills might be taught, e.g., parenting
techniques, communication skills, time management or study skills.
• 3. Application and follow through.
– The trainer guides the patient through progressively more threatening
situations so that the patient can apply their newly acquired skills. The
techniques become reinforced and this makes the practises self sustaining.
Key study: Meichenbaum (1972)
• To compare SIT with standard behavioural
systematic desensitisation & a control group
on a waiting list.
• A field experiment where students were
assessed before & after treatment using self-
report & grade averages.
• 21 students aged from 17 to 25 who responded
to an advert for treatment of test anxiety.
• Matched pairs design with random allocation to
either the SIT therapy group, the waiting list
control group or the standard systematic
• Matched groups on gender and anxiety levels.
• Each participant was tested using a test anxiety
questionnaire and allocated to their group.
• SIT group
– Participants received 8 therapy sessions.
– Given ‘insight’ approach to help them identify
their thoughts before tests.
– Given some positive statements to say &
relaxation techniques to use in test situations.
• Systematic desensitisation group
– 8 therapy sessions with progressive relaxation training,
which they were encouraged to practise at home.
• Control group
– were told they were on a waiting list and that they
would receive therapy in the future.
• Performance on the tests improved in the SIT
group compared with the other two groups.
• The significant difference was between the
two therapy groups and the control group.
• Participants in the SIT group showed more
reported improvement in their anxiety levels,
although both therapy groups showed overall
improvement compared to the control group.
• SIT is a more effective way of reducing anxiety
in students who are anxiety prone in test
• It is more effective than behavioural
techniques such as systematic desensitisation
as it adds a cognitive component to the
• Think about this:
• Would the results be the same if the sample were men
and testicular cancer, teenagers taking final
• Ecologically valid
• Support from other research: Zeigler et al (1982) found
cross-country runners found stress inoculation useful in
reducing stress and in improving running performance.
• Valid measures, but used self-reports
• Meichenbaum's model focuses on both nature of stress
problem (enabling clients to more realistically appraise their
life) & ways of coping with stress giving clients more
understanding of the strengths and limitations of specific
• Combination of cognitive strategies & behavioural techniques =
potentially effective way of managing stress.
• Despite this potential, few controlled studies have confirmed
• Has been effective in a variety of stressful situations, ranging
from anxiety about mathematics in college students, managing
hypertension in all age groups and stress management in
general. It has been successfully combined with other
treatment methods to alleviate stress.
Example of support for SIT
• Kiselica et al. (1994) used a combination of stress
inoculation, progressive muscle relaxation,
cognitive restructuring & assertiveness training to
significantly reduce trait anxiety & stress related
symptoms among adolescents.
• These results, however, did not extend to their
improving academic performance, suggesting
that other factors may also be involved here.
Interventions cannot necessarily rule out the
possibility of placebo or expectancy effects