Literature Review:

Stress

Stress 2: Gladys Galvez, Elise Howard, Meena Larijani, Rosa Michos, Abby Schwartz, Stephanie Serrano, Annie Yeung

BBH 416, Section 001

Instructor: Dr. Linda Wray

January 24, 2013

Introduction

Every individual has fallen victim to the draining and tiring attributes of stress, regardless

of its cause. Whether driven from school or work responsibilities, stress seems to be a universal

phenomenon. Yet the ways in which one copes with these events are subjective and instinctive.

Modern day-to-day living is full of grueling demands and persistent deadlines that cause us to

constantly feel “stressed” and, nonetheless, we continue to follow the same patterns and routines,

keeping stress a normal feature of life. While there is a positive side to stress—eustress, defined

as “psychological stress interpreted as being beneficial for the experiencer”—we more often than

not think of the negative side of stress, which is the body’s normal response to threatening and/or

upsetting events that upset the balance of the body (Merriam-Webster dictionary, 2012).

Regardless of age, modern day-to-day life entails social, physical, emotional and

intellectual demands, and our bodies produce biological responses to compensate for this change

in our lives. The stress response is a biological process, in which the brain and the nervous

system release hormones and chemicals to alert the body to prepare for action. For example, the

nerves you feel before a final exam are a part of the natural stress response of the body; the sweat

you produce in a life-threatening situation is also a part of the natural stress response. Many

people do not recognize the signs and symptoms of being overly stressed, which can be

detrimental to your not only your current state of health but especially to your future state of

health (“The University Health”, 2012). It is crucial for all individuals, including college

students, to recognize the triggers of stress and formulate ways in which to cope with them and

eventually eliminate the stressful feeling from your mind.

The Problems with Stress

Everybody experiences stress at some point in their lives, and college students perhaps

more so. Studies have documented that stress has been a problem in college students in the past

and that it is growing. A 1999 study  of United States college freshmen found that 30% of the

students reported feeling overwhelmed during their college experience, up from 16% in 1985

(Egan & Moreno, 2011). This same study found that 28% of females and 27% of males reported

that their stress levels were high enough that it negatively affected their academic work. More

recently, a study by the same researchers conducted on the interactions and statuses on Facebook

found that 36.8% of the 300 profiles of college freshmen referred to being stressed. Interactions

referring to stress occurred mostly around the months leading up to their first semester in college

and continued to remain at high levels through to returning from winter break. These stress

references were predominantly taken from status updates and centered around ambiguous

stressors and depressive references as well as weight concerns (Egan & Moreno, 2011).

But what is the cause of this clear increase in stress during the college years? Two types

of stressors may contribute to a person’s overall stress level: life events or experiences with

change accumulated over one’s lifespan, and chronic strains resulting from role overloads

(Pearlin, 1989). Although college students certainly experience changes in their lives as they

transition from high school to greater independence in college, Hudd and colleagues (2000),

indicate that the most common stressors experienced by college students are chronic strains

For example, Ross, Niebling & Heckery (1999) created the Study Stress Survey to

identify why college students were feeling more stressed and identified four categories of

stressors: Intrapersonal (e.g., change in sleeping and eating habits, new responsibilities),

interpersonal (e.g., roommate conflicts, fights with a significant other), environmental (e.g.,

vacation/breaks, longs lines, computer problems), and academic (e.g., increased workload,

searching for graduate schools or jobs). Nearly 4 in 10 (38%) of the survey respondents reported

that their stress was mainly due to intrapersonal reasons, while 28% reported environmental

reasons, 19% interpersonal reasons, and 15% academic reasons. Importantly, all of the 19% who

reported that interpersonal reasons were the cause of their increased stress levels described them

as daily. These interpersonal stressors could underlie why college students not only experience

more stress, but also experience high levels of it regularly. The top five stressors reported in the

Student Stress Survey were: change in sleeping habits, vacation/breaks (as they are difficult to

transition from), change in eating habits, increased workload, and more responsibilities (Ross,

Niebling & Heckery, 1999).

Prolonged exposure to stressors can result in negative behavioral, psychological, and

physiological outcomes. The behavioral aspect is very concerning especially regarding students

enrolled in majors with curricula centered on health and caring; they tend to have higher rates of

burnout and other stress-related issues. Burnout or, emotional exhaustion may lead to ineffective

academic and professional behaviors. Ultimately, this could lead to poor grades and a decline in

the quality of care that the student may provide to patients (Murff, 2005). Studies have also

shown that prolonged exposure to stressors are more likely to lead to negative health behaviors

like smoking, drinking, and illicit drug use, which may be used as coping mechanisms (Sinah,

2008). Along with higher affinity to abusing alcohol and illicit drugs, stress has been shown to

increase poor diet habits and decrease physical exercise which can lead to related diseases.

On the topic of stress and psychology, studies have shown a positive correlation with

prolonged exposure to high amounts of stress and mental illnesses. In particular, high levels of

stress has been linked to mental health issues like depression, anxiety, and suicide ideation

(Hudd et al., 2000). Stress also affects physiological processes within the body. High levels of

stress has been associated with the development of gastric ulcers, which may be caused by long

exposure time to higher amounts of adrenaline released during a stress response.Stress responses

also raise blood pressure which can cause lasting damage to the circulatory system, especially to

the heart. Another pressing problem with increased exposure to stress is the possible suppression

of the immune system. There is a delicate balance between a beneficial amount of stress and a

detrimental amount. When the body is overwhelmed with the amount of stress, immune defenses

decrease and make the body more susceptible to infections and decrease internal homeostasis

(McLeod, 2010).

The American Psychology Association (2010) reported on the frequency of negative

health outcomes due to stress. Nearly 3 in 10 (reported having stress-related high blood pressure

(29%), high cholesterol (28%); 25% reported being overweight or obese and 14% showed

clinical signs of depression. The report’s consensus was that stress is related to many diseases

and illnesses experienced by the population (American Psychological Association, 2010).

The literature on stress management is largely comprised of information on programs

aimed at helping students manage stress, but there is a dearth of studies examining the

effectiveness of stress management programs in populations of healthy college students.  Many

stress reduction intervention programs range from workshops based on ways to develop

problem- and emotion-focused coping strategies to online stress management programs.

Few existing studies describe successful stress management interventions in college

students.  In 2007, a stress management program attempted to lessen the mounting pressures and

rigors of medical school.  Researchers at the Oklahoma State University Center for Health

Sciences created a rather revolutionary mentor-based program called the Stress Management

Program. This program is essentially a voluntary intervention that involved small groups of first-

year medical students meeting with second-year student co-leaders who were trained by

Psychology faculty members who also served as program coordinators (Redwood, 2007).  At the

beginning of the fall semester, each group met one hour per week for seven consecutive weeks.

The objectives of the Stress Management Program included easing the transition of first-year

students to medical school, promoting personal stress management skills, maintaining a peer

support system, and creating a confidential outlet for discussing any concerns. Most participants

agreed that the program enabled them to manage stress more effectively. After 16 years, the

program remains an important part of the medical school curriculum and culture (Redwood,

2007).  Its use of small groups, transition-timing considerations, validation of importance of

stress management from faculty, and student feedback are key factors in the success of the Stress

Management Program.

Other programs have also been successful in alleviating the harmful effects of stress.

Computer-based programs offer students a confidential, nonjudgmental forum to disclose

personal information. This increased honesty may positively impact knowledge, attitudes, or

behaviors (Chiauzzi, Brevard, Thurn, Decembrele, & Lord, 2008). Studies comparing

questionnaires delivered through interviews, self-administration, and computer-assisted

administration have found that respondents are more likely to self-disclose sensitive information

regarding risk behaviors (Hamby, Sugarman, & Boney-McCoy, 2006). One such study explored

the use of a computer-based program called MyStudentBody-Stress, which was developed to

provide students with individualized motivational feedback about stress management, online

stress management tools, peer stories, and stress management strategies (Chiauzzi et al., 2008).

MyStudentBody-Stress allowed college health educators to connect with the entire student body

to offer stress management education as well as intervention. However, the computer-based

program alone is not enough.

Some researchers have suggested that future studies explore the combination of

computer-based intervention and face-to-face intervention in order to achieve greater effects.  In

one study that explored the effectiveness of blending online and person-to-person interaction, the

authors maintained that this combination may lead to more behavior change than traditional face-

to-face interaction (Williams, 2011). On an individual level, future research must determine

which individual characteristics, such as self-efficacy, might predict a positive response to online

intervention alone, or in accordance with face-to-face counseling intervention. Due to college

students' apparent lack of interest in formal intervention, the population-based dispersal of

information available via the Internet overcomes traditional outreach barriers (Chiauzzi, Brevard,

Thurn, Decembrele, & Lord, 2008). Interventions such as MyStudentBody–Stress can overcome

other logistical barriers, since the intervention is available at any time of day, can be accessed

confidentially, and can help students take more responsibility for their personal health.

The most commonly tested stress interventions are based on the influential work of

Lazarus and Folkman (1984), who developed a cognitive-behavioral theory that emphasizes the

importance of cognitive appraisals and coping responses. This theory uses the Transactional

Model of Stress and Coping as a framework for evaluating the processes of coping with stressful

events. Stressful experiences are interpreted as person-environment transactions. These

transactions depend on the impact of the external stressor. First, this is mediated by the person’s

appraisal of the stressor and secondly on his or her social and cultural resources (Lazarus &

Folkman, 1984). Generally any cognitive therapy technique, such as modeling or role-playing,

can be integrated into a stress management program.

Unfortunately, a majority of these studies have limitations that lessen effectiveness. For

instance, the counseling staff in workplaces and college campuses is often not able tend to the

needs of the population (Gallagher, Gill, & Zhang, 2001). In addition, college counseling

budgets have fallen due to the economy, which have made stress management interventions

difficult to implement (Kitzrow, 2003). Furthermore, students tend to not make the effort to

attend stress management seminars or clinics. The Stress Management Program at the Oklahoma

State University Center for Health Sciences may provide volunteer, peer-led counseling, but it

only addresses the needs of first-year medical students. Stress is likely to accumulate throughout

the undergraduate years—long before the first stressful year of medical school, law school, or

other graduate school programs.

What is not known about the problem with stress?

Today, students at all levels of education face increased pressure and stress to succeed

while managing studies, examinations and free time, all the while being continually plagued by

the pressure to pull through it all. Stress may in some aspects be good because it compels you to

continually take the action of reaching your personal goals but the constant wear and tear on your

body does take its toll. According to a study conducted by Behere and colleagues in nursing and

medical students, they measured stress on a yes or no questionnaire that would evaluate the

nature of the demand, the available resources, personal skills, and the presumed outcomes, that

will determine whether stress is experienced (Behere 2011). They found that female students had

better stress-coping skills compared to male sudents but the intervention itself did not result in

the students experiencing stress reduction. Behere’s explanation is simple: everyone responds

differently to stress and one-size-fits-all methods to reduce stress may not be effective.

     Another study found that, “participants only exhibited gains over controls in perceived

improvements, yet engagement in the intervention predicted benefits across all outcomes

assessed (Chen, 1999).” In addition, Conley found that her intervention increased students’

psychosocial skills and stress management skills just by attendance; however, the variability in

attendance could explain inconsistencies in effectiveness and differences in her own and other

mental health prevention initiatives. Conley recommends that, “future research should build on

this use of various assessment methods, to determine which measures of engagement most

effectively capture participants’ involvement in the intervention. In addition, research should

continue to assess multiple aspects of engagement, to determine which aspects most effectively

contribute to beneficial outcomes (Chen, 1999).” Heeding Colleen and Behere’s words, it is

apparent why most stress management programs fail: It is difficult to attract participants and

encourage them to be involved in an intervention; others may choose not to participate because

they feel they have their mental state under control and do not need help responding to stress.

     Every human experiences stress at all stages of life, it is just a matter of the stress being good

or bad and how often or how little you experience the stress. Many efforts have been made to

understand and deal with stress related to pregnancy, wor, and school, as well as post-traumatic

stress disorders and depression. Most studies cover how stress affects you but does not maintain

efforts to encourage participation in the study and also does not consider factors of how

differently everyone responds to their own stressors.

     When it comes to stress, we feel it is very important to learn various ways to relieve the

anxiety of stressors through ways that suit the individual person. Every person is different so not

every initiative or stress relieving effort will work for everyone. As noted by Charles Chen: in

his statement that, “researchers tend to focus more on the stressor phenomena than on probing

and explaining the psychological dynamics involved in the appraisal process. The Impact of a

stressor is mediated by the person's appraisal of the stressor in terms of risk to the person and his

or her ability to cope with the situation (Chiauzzi, 2008).” Everyone has different skills in

assessing their stress and need to find outlets in order to cope and relieve the tension. In Chen’s

research article, we felt he covered a lot of aspects that would be important in a stress relieving

initiative such as: counseling, building a support group, facilitating self-validation, and

enhancing adaptation competence (Chiauzzi, 2008).

     We feel “De-Stress to Be Your Best” will be an improvement on existing stress-reduction

programs because we expect to follow Chen’s recommendations while also incorporating our

own ideas of personalized stress relief activities. We would also incorporate ideas such as: free

exercise classes in the afternoon when cortisol levels are at their highest, nutrition classes for

stress eaters, quiet rooms to conduct school work, free art classes ranging from drawing to

sculpting, as well as guided meditation classes. These are just a few ideas that we would like to

incorporate into a program targeted to relieve the stress levels of our college population.

     We would like to know more about the psychological implications that trigger episodes of

stress and methods to relieve stress sooner and more effectively.

Summary

Most studies on stress in college students have demonstrated that college students

experience stress more often than others and experience it chronically and at higher levels.

Stressors experienced from chronic strain of interpersonal stress may cause college students to

experience those stressors on a daily basis. Therefore, it could have more damaging effects

because of constant and prolonged exposure, leading to negative outcomes that are not only

psychologically harmful but behaviorally such as drug and alcohol abuse.

The literature largely describes programs or interventions that aim to help

students manage or coping with stress, finding some success in medical school students. There

are also a few well-established and effective programs that help college students in general to

reduce stress during times of chronic strain that cause changes in sleep or diet or strain from

taking on new responsibilities. Most studies find limited success from stress counseling, classes

or workshops as well as a lack of student participation. The reason may be that every individual

has different ways of assessing and dealing with stressful situations.  Therefore, stress relieving

initiatives as well as an incorporation of personalizing stress relief activities would improve

stress levels among students. Such personalizing stress relieving activities would include art,

mediation, nutrition and exercise classes while making it accessible to students. In addition,

promoting and offering stress relief during final exams can be useful, especially because it is a

time when stress is deemed to be the most apparent for college students. A possible strategy

could be animal therapy, in which a puppy visiting center is offered to students during finals

week where students could simply have access to play with the puppies. This gives students a

break and lifts their spirits during that strenuous time of constant studying. Ultimately, a well-

established, effective program to help college students relieve their stress will assist in student’s

attempts to adapt to the stressors of college life.

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