Published on January 28, 2008
Slide1: by Professor of Psychiatry – Faculty of Medicine Head of the Psychiatric Department – University Hospital University of Coimbra - Portugal Stress: Stress In everyday life it is impossible for the human being to avoid stress inducing situations. Stress is not always harmful. What is harmful for the human being is: A rather monotonous life, without stimuli that fulfill it or Having a life with a high number of disturbing and repetitive demands which cannot be adequately dealt with. Stress: Stress In intermediate situations stress is useful because it is a source of impulse which lead the individual to make decisions and solve problems, helping him improve his performance, skills and creativity. In this sense, stress brings some flavour to life and may become an incentive of professional and personal fulfillment. Stress: Stress Excessive stress becomes harmful because it may : evoke strong negative emotions; lead to the development or worsening of a physical and/or psychic illness; have a negative influence on family, working and social life; cause a higher number of labour and road accidents, harm the decision-making processes and have repercussions on aspects of an economical nature. Stress: Stress The stress inducing events may be of 3 types: Fatalities coming from outside: e. g., the sudden death of a relative. Causes coming from within, determined by the behaviour and attitudes of the individual which generate serious situations. Sometimes, a mixed causality, in which an individual, due to the way he(she) is, is unable to avoid disturbing situations facing him(her). Stress: Stress Types of stress Harmful Beneficial Centered on the event Promotes personal development Is limited to a given situation which is successfully overcome Centered on the individual Long term disturbance to the individual’s stability Mixed Coping strategies: Coping strategies A person in stress can develop any one of 3 kinds of strategies : problem-centered, emotion-centered, and centered on obtaining social support. There are individuals who are predisposed to use a given type of strategy instead of others. Any one of them can be used concomitantly. These strategies can be adequate or inadequate. Vulnerability to stress: Vulnerability to stress And now we must ask: What does vulnerability mean? Are some persons more vulnerable to stress than others? What does vulnerability mean?: What does vulnerability mean? For Beck and Emery (1985) a vulnerable person is one who: has the perception of being subjected to dangers of external or internal nature over which he has no control or, at least, has no control which he considers sufficient to give him a sense of security. Vulnerability to stress: Vulnerability to stress Leighton (1998) mentions that, in the 1950’s, there was a belief in the aetiological destabilising power of environmental factors. This is currently being questioned, because it is recognised that there are individuals who suffer the impact of adverse circumstances without suffering great damage from them. Vulnerability to stress: Vulnerability to stress The effects of stress on the individual are greatly mediated by a certain number of variables, of biological, psychological and social nature, some of which lessen its effects and others, on the contrary, emphasize them (Leighton, 1998). Vulnerability to stress: Vulnerability to stress Brown (1993) mentions that it became necessary in the mid-70’s to distinguish between life events and the vulnerability factors that change an individual’s response to occurrences. Vulnerability represents the increased risk of reacting in a negative way before a given life event. Vulnerability to stress: Vulnerability to stress This formulation implies the presence of an interaction between the life event and the vulnerability factor. According to Brown (1993) the concept of vulnerability must be understood within the specific relation which is established between the individual and the circumstance. Vulnerability to stress: Vulnerability to stress In clinical practice, it is often proved that the vulnerability to stress varies a great deal from individual to individual. There are persons who decompensate before the slightest annoyance, whilst others appear to resist a large number of unpleasant situations, even those who threaten the individual’s life and security. Vulnerability to stress: Vulnerability to stress Kessler and Magee (1994), mention that the relation established between the stress-inducing events and the consequent psychological disturbances explains less than 10% of the variance. Coyne and Whiffen (1995), note that most people do not become depressed, even when faced with clearly serious stress-inducing circumstances. Vulnerability to stress: Vulnerability to stress Due to these facts, there is a growing interest in the identification of the factors that protect people or make them vulnerable to stress. Allow us to mention a study we made on vulnerability to stress. A study on vulnerability to stress: A study on vulnerability to stress In order to construct a scale, following a revision of the literature, Vaz Serra (2000) selected 64 questions related to vulnerability to stress, about : negative personality characteristics, positive personality characteristics, practice of regular physical exercise, access to a confident, social and family support, and adverse life conditions . A study on vulnerability to stress: A study on vulnerability to stress Each question may be answered in any of 5 ways. The value attributed to it varies between 0 and 4, the highest score corresponding to the most negative aspects of the individual’s description. In order to avoid answering tendencies, some questions were constructed to represent positive aspects, and others to represent negative aspects. A study on vulnerability to stress: A study on vulnerability to stress We asked each respondent to fill in, in addition to the scale, some psychometric instruments which are directly or indirectly related to psychopathology : Brief Symptom Inventory (BSI, L. DeRogatis, 1982) Eysenck Personality Inventory (EPI, H.J. Eysenck e Sybil B.G. Eysenck, 1964). Problem Resolution Inventory (PRI, Vaz Serra, 1987) which evaluates coping strategies. A study on vulnerability to stress: A study on vulnerability to stress When correlating the items of the scale of vulnerability to stress with the above-mentioned psychometric inventories we assumed that we would learn the profile of the individual who is more prone to developing psychopathological manifestations in stress conditions. A study on vulnerability to stress: A study on vulnerability to stress The work was conceived as follows : Cause Individual Effect Stressful event Psychopathology Tolerance (no psychopathology) A study on vulnerability to stress: A study on vulnerability to stress Each respondent was evaluated in 7 possible classes of stress inducing situations: Traumatic events Major life events Chronic stress events Hassles Macro stressors Nonevents Early life traumatic events A study on vulnerability to stress: A study on vulnerability to stress The sample: general population Female Male Total Mean Age 368 184 184 42.43 42.70 42.15 p N.S. 80 40 40 20’s 30’s 40’s 50’s 60’s 80 40 40 80 40 40 80 40 40 48 24 24 A study on vulnerability to stress: A study on vulnerability to stress Each respondent recorded whether himself, a parent or any other relative suffered or had once suffered from some “nervous” infirmity, a designation which usually is associated to emotional disturbances. The self-record of “nervous infirmities” helped us construct, at the end, a cut-off point, between vulnerable and non-vulnerable individuals, corresponding to the value of 43. A study on vulnerability to stress: A study on vulnerability to stress The sample was constituted by individuals of the general population distributed by all educational levels. As regards their civil status, most were married. The scale was finalised with 23 questions. Due to this fact, it was called 23 QVS (23 Questions to measure Vulnerability to Stress). A study on vulnerability to stress: A study on vulnerability to stress As for the selection of items: 41 of the 64 initial questions were excluded for the following reasons: 20 questions showed statistically significant differences between genders. 8 items failed to correlate with BSI, EPI or PRI. 7 questions showed a ceiling effect (most of the individuals described themselves as “too perfect”) . Cronbach’s -value led to the exclusion of 6 items which affected internal consistency . A study on vulnerability to stress: A study on vulnerability to stress Odd/Even correlation =.732 and Spearman-Brown Coeff. =.845 Cronbach’s = .824 for all items. This value decreased if any one of the selected items was excluded, which underlines their importance as a contributive element to a good homogeneity. Good internal consistency = A study on vulnerability to stress: A study on vulnerability to stress The correlation of each question with the global note was positive and highly significant, both when the analysed item was included in the global note and when it was not. This fact confirms that it corresponds to an unidimensional scale, which defines a concept. A study on vulnerability to stress: A study on vulnerability to stress Lack of self-assertion Low tolerance to frustration Difficulty in facing and solving problems Excessive concern with events of everyday life High emotionability. The highest correlations with the global note suggest that, the more an individual is vulnerable to stress, the more he tends to show the following profile: A study on vulnerability to stress: A study on vulnerability to stress Each item of the scale showed to be sensitive to variations of extreme groups, which underlines its discriminative power. The item correlation matrix showed that no correlation presented a particularly high value, which means that there are no redundant items. The test/retest correlation was undertaken within a minimum of 30 and a maximum of 239 days, with a median of 49 days. Value of r =.816 (N = 105). A study on vulnerability to stress: A study on vulnerability to stress Underlying dimensions: We did a principal components factor analysis, followed by an orthogonal varimax-type rotation. We obtained through this 7 factors which explain 57.5 % of the total variance. A study on vulnerability to stress: A study on vulnerability to stress The highest-loading items in the various factors led us to admit that they express the significance which follows: F1 : Perfectionism and intolerance to frustration. F2 : Inhibition and functional dependence. F3 : Lack of social support. F4 : Adverse life conditions. F5 : Dramatisation of existence. F6 : Subjugation, and F7 : Deprivation of affection and rejection. A study on vulnerability to stress: A study on vulnerability to stress A study on vulnerability to stress: A study on vulnerability to stress Correlations between 23 QVS and E.P.I., P.R.I., B.S.I. E.P.I. B.S.I. 23 QVS .674 Neurot. Extrav. -.182 SGI .640 TPS PSI .570 .487 N = 368 p < .001 for all P.R.I. -.639 A study on vulnerability to stress: A study on vulnerability to stress The higher the value of 23 QVS, the higher the likelihood that it corresponds to an individual who is: emotional with poor coping strategies prone to developing psychopathology Summing up : A study on vulnerability to stress: A study on vulnerability to stress Using the value of 43 as the cut-off point, we analysed the 7 stress-inducing classes in the 368 subjects of the sample, separated in two groups according to the said value. The group of individuals with a 23 QVS value ≥ 43 showed a higher number of stressors in all classes of events. A study on vulnerability to stress: A study on vulnerability to stress Hassles, chronic stress events and macro stressors were particularly evident. Serious traumas and early life traumatic events were the least frequent. Nevertheless, they showed a higher prevalency in the group with a 23 QVS value ≥ 43. A study on vulnerability to stress: A study on vulnerability to stress Vaz Serra et al. (1991) had already found that individuals with poorer coping strategies tend to feel a higher number of problems in various areas of their lives, as compared with those who show better strategies. A study on vulnerability to stress: A study on vulnerability to stress Vaz Serra et al. (1991) suggest that the individuals with poor coping strategies tend to “see a problem in everything” or “making a problem out of everything”. The prominence of hassles, chronic stress and macro stressors in individuals with higher 23 QVS values suggests that they use inadequate strategies in dealing with their everyday problems. Air traffic controllers: Air traffic controllers In a study of 155 air traffic controllers, Isabel Mota (2002) used the PRI, the 23 QVS and an analogical scale of stress perceived under work conditions. The average value of 23 QVS for the group equalled 30, which makes us admit that their elements were not particularly vulnerable to stress. Air traffic controllers: Air traffic controllers Having undertaken a logistical regression for the study of stress perceived under work conditions, she found a significant effect connected to gender and factors 1, 3, 4 and 7 of the 23 QVS. According to Isabel Mota the odds ratio showed that a woman’s probability of having a higher stress perception than a man under the same work conditions is 4.3 times higher. Air traffic controllers: Air traffic controllers The personal characteristics indicating: Perfectionism and intolerance to frustration (F1). Lack of social support (F3). Existence of adverse life conditions (F4); and Deprivation of affection and rejection (F7) are associated to higher levels of perceived stress . A unit by unit increase of the scores of each of the above factors increases between 2 and 3 times the risk of belonging to “a group of higher perceived stress”. Stress in hotel industry: Stress in hotel industry José P. Cruz and Helena Costa (2002) made a study about stress in the hotel industry in 135 individuals working for a major chain of hotels in the Algarve region. By using the 23 QVS, they found a positive and highly significant correlation (r = .520; p < .001) between that scale and the stress mentioned by the respondents. War stress in Marine troops: War stress in Marine troops Monteiro Ferreira (2002) studied 196 former Special Marines of the Portuguese Navy who were engaged in combat in Angola, Mozambique and Guinea-Bissau. They were designated for particularly complex and dangerous missions. The number of years as Marines spanned between 2 and 11, with a median of 6 years. War stress in Marine troops: War stress in Marine troops The 196 subjects of the sample were individually submitted to an interview which consisted of a simplified form of CAPS - Clinician Administered PTSD Scale (Blake et al., 1995) and also replied to 23 QVS. War stress in Marine troops: War stress in Marine troops Two groups of veterans were identified . With suspicion of PTSD (N=116; 59,2 % of the sample). Without suspicion of PTSD (N=80; 40,8 % of the sample). War stress in Marine troops: War stress in Marine troops The two groups showed no statistically significant differences as regards age and educational level. Nearly all elements of both groups were married. The next slide shows the results which were obtained. War stress in Marine troops: War stress in Marine troops 23 QVS F1 F2 F3 F4 F6 F5 F7 53.41 3.52 1.51 0,93 1.54 1.96 2.27 1.21 37.81 2.88 0.76 0.80 1.22 1.11 1.91 0,32 .000 .000 .000 N.S. .05 .000 .05 .000 PTSD N=116 No PTSD N=80 p Means War stress in Marine troops: War stress in Marine troops Following a study of sensitivity and specificity, it was noted that the 23 QVS scale correctly identified: 85 % of those affected by PTSD and 83 % of those not affected by PTSD. It thus proved to be a scale with good sensitivity and specificity. Quality of life in patients with MS: Quality of life in patients with MS Multiple Sclerosis is a CNS disease which begins in one’s late teens or early adult life. It shows recurrent episodes of dysfunction of the upper spinal cord, brain stem, cerebellum, optical nerves and the brain, resulting from foci of destruction of mielinised fibres (Adams, Victor and Ropper, 1998). Mohr and Cox (2001) mention that there is a relation between the way in which people deal with life events and the episodes of remission and aggravation of the disease. Quality of life in patients with MS: Quality of life in patients with MS Sofia Cruz et al. (2004) made a study about the influence of resilience and vulnerability to stress on the quality of life of Multiple Sclerosis patients. Being a disease with a low prevalency the authors could built up a sample of 34 patients – 15 female and 19 male. Quality of life in patients with MS: Quality of life in patients with MS Quality of life was evaluated with FAMS (Functional Assessment of Multiple Sclerosis - Cella et al., 1996). Resilience to stress was measured with Aaron Antonowsky’s The Sense of Coherence Questionnaire, (SCQ). The 23 QVS was used to evaluate the vulnerability to stress. Quality of life in patients with MS: Quality of life in patients with MS Aida Mendes et al. (2004) found these results: A correlation of -.63 (p<.00) between 23 QVS and FAMS. Utilising 43 as a cut-off point for the 23 QVS they found that the individuals above that value mentioned a worse quality of life (p=.004). A positive correlation (p<.000) between SCQ and FAMS. A negative correlation of -.683 (p<.000) between 23 QVS and SCQ. Quality of life in patients with MS: Quality of life in patients with MS They came to the following conclusions: The quality of life of Multiple Sclerosis patients is inversely related to their vulnerability to stress. There is a negative and highly significant correlation between resilience and vulnerability to stress. Mental schemas: Mental schemas Mental schemas are a generalised representation of the experiences that regularly appeared to a given individual. Once developed, they can persist throughout one’s entire life. They become organisers of principles for the individual’s emotional and behavioural performance. They can induce an adequate and adaptative behaviour, or an inadequate and maladaptative behaviour. Mental schemas: Mental schemas The mental schemas organise the experience in the various contexts an individual goes through, and enable him to give it a significance. They define what is expected to be seen, heard or remembered. When an individual enters a given situation, he will decode it according to his previous experiences, which will indicate him what he can expect from it and how he should act. In brief:: In brief: Information processing Mental Schemas Attitudes and behaviour Vulnerability to stress No vulnerability to stress Adaptatives Maladaptatives + - Attitudes and behaviour Early Maladaptive Schemas: Early Maladaptive Schemas Jeffrey Young (1990) mentions that early maladaptive schemas are extremely stable and enduring themes that develop during childhood and are elaborated upon throughout an individual’s lifetime. Schemas are unconditional beliefs about oneself in relation to the environment. Early Maladaptive Schemas: Early Maladaptive Schemas They are self-perpetuating and resistant to change; they are the core of the individual’s self-concept. They are disfunctional in some significant and recurring manner. They are usually activated by events in the environment, relevant to the particular schema. Once they are triggered, they are closely tied to high levels of negative affect. Early Maladaptive Schemas: Early Maladaptive Schemas Vaz Serra (2005) correlated the 23 QVS to the Schema Questionnaire by Young and Brown, 1989. The sample comprised 180 indivíduals: 90 were under treatment due to anxiety disorders (Social Phobia, Panic Disorder, GAD, PTSD, Specific phobias, OCD, etc.) and 90 were normals, matched to the sample of patients. Early Maladaptive Schemas: Early Maladaptive Schemas Patients (90) Normals (90) p Mean 23 QVS total Young total S.D. Mean S.D. 50.722 11.144 31.756 7.291 336.078 98.568 207.422 48.132 0.000 0.000 Mean Age S.D. 31.067 9.455 31.244 10.274 N.S Early Maladaptive Schemas: Early Maladaptive Schemas 23 QVS total Young total .803 P = .000 for all Correlations Schemas Early Maladaptive Schemas: Early Maladaptive Schemas A stepwise regression, with the total value of the 23 QVS as the dependent variable, selected the following variables: The Young total score, the following schemas and D (being or not being patient): Y(1), Y (2), Y (3), Y (5), Y (6), Y (10), Y (15) and D. Df: 9 170 F-ratio 57.601 p = .000 Squared multiple R: .753 Meaning of the Schemas: Meaning of the Schemas Domain These schemas mean: Y(1): Dependence Y(2): Subjugation/Lack of Individuation Y(10): Social Undesirability Y(15): Entitlement/Insufficient Limits Expectations and Limits Worthiness Connectedness Autonomy Y(3): Vulnerability to Harm and Illness Conclusions: Conclusions There are reasons to admit the existence of individual differences as regards vulnerability to stress. The psychological vulnerabilities may be understood according to the influence that the mental schemas have on the way in which each individual processes the information from the environment, which then influences attitudes and behaviours. 23 QVS proved to be a sensitive instrument in detecting vulnerability to stress and distinguishing between a large variety of psychopathological conditions. Future research topics: Future research topics To make a prospective study in the general population in order to know the association between vulnerability to stress, social support and illness. To perform more clinical research with larger samples in order to know what are the predominant profiles within the vulnerability to stress dimensions. References: References Adams,R.D., Victor,M e Ropper,A.H. (1998) – 6.ª edição do Compêndio de Neurologia – McGraw Hill. Beck,A.T. e Emery,G. (1985) – Vulnerability: The Core of Anxiety Disorders – pp. 67-81 in “Anxiety Disorders and Phobias: A Cognitive Perspective” - U.S.A.: Basic Books. Brown,G.W. (1993) – The role of life events in the aetiology of depressive and anxiety disorders – pp. 23-50 in “STRESS – From Synapse to Syndrome”, S.C. Stanford e P. Salmon (eds.) – Hartcourt Brace & Company, Publishers – Academic Press. Coyne,J.C. e Whiffen,V.E. (1995) – Issues in personality as diathesis for depression: the case of sociotrophy-dependency and autonomy-self-criticism – “Psychological Bulletin”, 118 : 358-378. Cruz,S., Almeida,A., Ferreira,S. e Mendes,A.C. (2004) - Qualidade de vida em doentes com Esclerose Múltipla: estudo da influência da vulnerabilidade e da resiliência ao stress na sua avaliação – Psiquiatria Clínica, 25(2) : 107-114. References: References Kessler,R.C. e Magee,W.J. (1994) – The disaggregation of vulnerability to depression as a function of the determinants of onset and recurrence – Cap. 9, pp. 239-258 in “Stress and Mental Health : Contemporary Issues and Prospects for the Future”, W. R. Avison e I. H. Gotlib (eds.) - New York: Plenum Press. Leighton,A.H. (1998) – A Perspective on Adversity, Stress and Psychopathology - Cap. 28, pp. 506-520 in “Adversity, Stress and Psychopathology”, B.P. Dohrenwend (ed.) – New York, Oxford: Oxford University Press. Mohr and Cox (2001) – Multiple Sclerosis: Empirical Literature for the Clinical Health Psychologist – Journal of Clinical Psychology, 57 : 479-499. Mota,I. M. P. S. (2002) - Percepção de Stress em Controladores de Tráfego Aério – tese de mestrado apresntada à Universidade Fernando Pessoa. Vaz-Serra,A., Firmino,H., Pocinho,F., Figueiredo,A.M. (1991) - Coping Mechanisms and Stressful Life Events – Acta Psiquiátrica Portuguesa, 37 : 5-12 Vaz-Serra,A. (1999) – O stress na vida de todos os dias – Edição de autor: Coimbra – Distribuidora Dinapress. References: References Vaz-Serra,A. (2000) - Construção de uma escala para avaliar a vulnerabilidade ao stress: a 23 QVS - Psiquiatria Clínica, 20 (4) : 279-308. Vaz-Serra,A. (2005) – Esquemas Mentais e Vulnerabilidade ao Stress – Psiquiatria Clínica (aguarda publicação). Young,J. (1994) – Cognitive Therapy for Personality Disorders: A Schema-Focused Approach (Revised edition) – Sarasota, Florida: Professional Resource Press. Young,J., Klosko,J.S. And Weishaar,M.E. (2003) – Schema Therapy – A Practitioner’s Guide – New York, London: The Guilford Press.