AQA A-level Psychology Stress

The A-level psychology specification states you need to know the following for the physiology of stress:

• The physiology of stress, including general adaptation syndrome, the hypothalamic pituitary-adrenal system, the sympathomedullary pathway and the role of cortisol.

General adaptation syndrome (GAS) describes the physiological reaction that occurs in response to stress and was first proposed by Hans Selye (1936). There are 3 stages to GAS:

1. Alarm reaction - A threat or stressor is recognised and physiological responses are activated in preparation for the fight or flight response. The hypothalamus signals the sympathetic nervous system, which activates and stimulates the adrenal medulla to secrete adrenaline and noradrenaline. This helps increase heart rate, blood flow and blood sugar levels resulting in what is commonly known as the fight or flight response.

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2. Resistance - if the stressor continues, the body will attempt to adapt to the stressful situation. The sympathetic nervous system activity begins to decline, adrenaline and noradrenaline secretion also declines however it also increases from another part of the adrenal gland, the adrenal cortex. Physiological activity is still greater than normal and uses a lot of energy. The individual may appear to be coping however the body's resources are being consumed at a harmful rate. For example, stress hormones are produced in huge quantities and it is only a matter of time before they begin to cause damage to the heart and blood vessels. In response, the parasympathetic nervous system becomes activated to conserve energy for the long term as the stressor becomes chronic.

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3. Exhaustion - As the stress continues, the body's resources will become depleted and the adrenal gland will not function efficiently, blood sugar levels will drop and physical health will be affected resulting in stress-related illnesses such as high blood pressure, heart disease and ulcers etc. The immune system may become compromised and the individual may become more susceptible to other illnesses too.

• General adaptation syndrome is supported by research. Selye's initially experimented with rats, subjecting them to various stressors including cold, excessive muscular exercise and even surgical injury. He noticed the same typical collection of responses occurred regardless of the stressor and similar findings were also apparent in humans. This was seen to be a general response by the body that could not be attributed to any specific injury or bodily reaction to damage. The results of these findings supported his 'doctrine of non-specificity' and that there was a non-specific response by the body to any demand made upon it (i.e. the body reacted in the same way to any stressor).

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• A significant benefit that came from the development of general adaptation syndrome was it was the first theory to explain the physiological effects of stress and influenced a lot of later theories, especially into the negative effects of stress upon health. This has led to a number of treatments from medicine to CBT in an effort to manage stressful responses better.

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• Most research into general adaptation syndrome has been based on rats which makes the findings difficult to generalise to humans. This is because humans have a greater emotional and cognitive input that can influence the stress response and unlike rats who are more passive in their response to stress, humans generally respond more actively to tackle or lessen stressors.

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• One criticism however is that Selye's belief that individuals responded in the same way to all stressors was not actually true. Research by Mason (1995) showed that stressors varied in the amount of adrenaline and cortisol they produced depending on the amount of fear or anger created by stressors. There also appeared to be gender differences in the stress reactions as women engaged in the 'tend and befriend' response. This would suggest gender bias in the theory and limited application across both genders.

Prolonged and chronic stress activates the hypothalamic–pituitary adrenal system (HPA). The HPA takes longer to activate than the Sympathoemedullary Pathway (SMP) but can persist for several hours. When the hypothalamus is activated, it sends a signal to activate the sympathetic nervous system and also produces a hormone called corticotropin releasing factor (CRF) which is released into the bloodstream. CRF stimulates the anterior lobe of the pituitary gland which causes the release of adrenocorticotropic hormone (ACTH) into the bloodstream. ACTH travels to the adrenal glands located just above the kidneys, which triggers the release of stress related hormones, the most important of which being cortisol.

Cortisol is known as the stress hormone because it plays a central role in the bodies stress response. Some of cortisols function helps the body to cope with a stressor, for example, cortisol is a glucocorticoid hormone which permits a steady supply of blood sugar which provides an individual with a constant source of energy that is used to deal with stressors. The release of cortisol increases the capability to tolerate more pain than normal as well as leads to an impaired cognitive ability and reduced immune system performance.

The sympathetic nervous system (SNS) and sympathetic adrenal medullary system (SAM) make up the sympathomedullary pathway (SMP). The sympathomedullary pathway consists of the parts of the body involved in the immediate response to acute (short-term) stressors. Acute stressors activate the autonomic nervous system (ANS), which has two branches:

1. The sympathetic nervous system (SNS) is the 'troubleshooter' and is highly responsive to stimuli and once activated, is responsible for emotional states and heightened arousal.
2. The parasympathetic nervous system (PSNS) is the 'housekeeper' and responsible for maintaining equilibrium and calming bodily processes.

These two branches play the role of opposing forces that interact to produce the bodily state at any given point with the sympathetic division primarily activated by stressors and the parasympathetic division responsible for returning the body to a state of calm equilibrium.

When an individual is exposed to an acute stressor, the SNS is activated and simultaneously the sympathomedullary pathway stimulates the release of the hormone adrenaline into the bloodstream from the adrenal glands. Adrenaline prepares the body for the 'fight-or-flight' response by boosting supply of oxygen and glucose to the brain and muscles while suppressing non-emergency processes such as digestion. Once the stressor is no longer apparent, the parasympathetic system activates and the physiological arousal associated with the fight or flight response begins to decrease.

• Research into short and long-term stressors and their effects is complicated due to gender differences. Most research tends to rely on male animals because female hormones fluctuate due to ovulation and this confounds results. This would mean that conclusions drawn from earlier research into stress may reflect a male bias. Research by Taylor et al. (2000) suggests the female response to response tends to be different from a general fight or flight response, engaging in what is known as a 'tend and befriend' strategy. During the environment of evolutionary adaptiveness (the EEA) in our evolutionary past, this behaviour would have involved protecting themselves and their young through nurturing behaviours (tending) and forming protective alliances with other women (befriending). It is therefore possible that women have a completely different response for stress given their responses evolved in the context of being primary caregivers to children. Some animal studies using rats suggests a physiological response that inhibits the fight or flight response which involves the release of the hormone oxytocin. This increases relaxation, reduces fearfulness and decreases the physiological characteristics of the fight or flight response. This would ultimately mean that the standard description of the sympathomedullary system (SAM) and hypothalamic-pituitary-adrenal system (HPA) are gender-based theories.

• A criticism of physiological responses, be they short or long-term stress responses, is they ignore psychological factors such as cognitive appraisal. Lazarus (1999) argued that people make appraisals of stressors by actively working out whether it is a threat (primary appraisal) and whether we have the resources to cope with it (secondary appraisal). Additional support for cognitive factors comes from Speisman et al. (1964) who asked students to watch a primitive (and gruesome) medical procedure while their heart rates were measured. Changes to the heart rate were observed dependent on how they observed the procedure and when it was seen to be traumatic, heart rate increased while perception of the procedure being a joyful rite of passage, heart rates were seen to decrease. This would implicate a cognitive element which the purely physiological explanations cannot account for as it shows humans are not passive in the face of stressors as physiological theories assume. 

For the role of stress in illness, you will need to know about the following for A-level psychology:

• The role of stress in illness, including reference to immunosuppression and cardiovascular disorders.

The immune System consists of billions of cells produced in the spleen, lymph nodes, thymus and bone marrow which travel through the bloodstream as well as in and out of tissues and organs. They work to defend the body against antigens (foreign bodies), like bacteria, viruses and cancer cells. The main type of cells are leucocytes (white blood cells), which they are various types. Some immune cells produce and secrete antibodies, which buying to antigens and effectively destroy them.

As with chronic stress, which we covered previously, the immune systems ability to fight off antigens is compromised and infection becomes more likely. Stress itself does not actually cause infections, however it increases the body's vulnerability to infectious agents by immunosuppression, which is the temporary reduction of immune system functioning.

Occasional production of cortisol by the hypothalamic-pituitary-adrenal response and other corticosteroids do not harm the immune system, however if they are produced continuously due to chronic stress, they will interfere with leucocyte activity and the production of antibodies. Stressful events have also been linked to certain illnesses such as cancer, chronic fatigue disorder and even infections such as influenza. While cortisol in normal quantities can help protect against viruses and heal injured tissue, too much of it can suppress the immune system resulting in harming the very thing protects us from infection.

Kiecolt-Glaser et al. (1984)

Procedure: The Kiecolt-Glaser et al (1984) study into stress is a key study that investigated the effects of stress on the immune system. This study examined the effects of stress by studying students due to sit exams. 75 medical students gave blood samples twice, one month before the exam period (low-stress) and another sample on the day of the first exam itself (high-stress). The students also completed medical questionnaires measuring their sources of stress and self-reported psychological symptoms.

Findings: The study found that the activity of the NK and killer T cells decreased between the first and second samples given. This was evidence of their immune response being suppressed by a common stressor and this decline was most apparent in students who had reported feeling most lonely and other sources of stress such as experiencing significant events in their lives.

Cardiovascular disorders refer to any disorder of the heart (including coronary heart disease, CHD) circulatory system (such as hypertension which is also known as high blood pressure) as well as strokes (which occur when blood flow is restricted to the brain).

There is evidence to suggest that stress can contribute to the development of cardiovascular disorders such as heart disease and strokes. Stress can have immediate effects (acute) and longer-term effects (chronic) on cardiovascular diseases.

Stress activates the sympathetic nervous system (SNS), a branch of the autonomic nervous system, which leads to the production of adrenaline and noradrenaline. High levels of adrenaline will have the following effects:

• The heart begins to work harder resulting in increased heart rate which has a detrimental effect over time.
• The constriction of blood vessels results in increased blood pressure, which puts tension on the blood vessels, which can cause them to wear away over time.
• The increased pressure can also dislodge plaques on the walls of blood vessels and this can lead to blocked arteries (atherosclerosis) which can lead to a heart attack or stroke.

Williams et al. (2000)

Williams et al. (2000) conducted a study to see if anger was linked to heart disease. This is because anger is often linked to stress and the activation of the SNS.

Procedure: 13,000 participants completed a 10-question anger scale which included questions on whether they were 'hot-headed', whether they felt like hitting someone when angry, or whether they got annoyed when not recognised for doing good work. None of the participants were identified as suffering from heart disease at the outset of the study.

Findings: After six years, the health of participants was checked and it was found 256 had experienced heart attacks. The participants that had scored highest on the anger scale were over 2.5 times more likely to have had a heart attack than those with the lowest ratings. Participants that scored  moderately in the angle ratings were 35% more likely to experience a coronary event compare to those with lower ratings. This suggests that SNS arousal is closely linked with cardiovascular disorders.

• A criticism of research into how stress affects illnesses is much of the data is based on self-reports such as questionnaires which may be subjective in nature. For example, if an individual has a tendency towards negative perceptions and remembering unpleasant events over pleasant ones, this may lead to exaggerated scores on both measures. The result would therefore be a significant correlation being more likely, which results in an unjustified link between higher perceived stress and cardiovascular symptoms.

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• Some research has also shown that stress can benefit immunity which contradicts the fundamental assumption that stress suppresses the immune system. A study by Firdaus Dharbhar (2008) demonstrated that stress can have an immune-enhancing effect. Rats were subjected to mild stressors and this was found to stimulate a substantial immune response with lymphocytes (immune cells) flooding the blood stream and body tissues in preparation for physical damage. This demonstrated that while chronic stressors may be dangerous due to their immunosuppressive effect, acute stressors do not act on the immune system in the same way. Instead, it appears that acute stressors stimulate the immune system to give it protection against short-term stress. This demonstrates the relation between stress and the immune system is complex and not completely understood.

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• A link between certain cancers and the immunosuppressive effects of the stress has also been found in some studies. José Pereira et al. (2003) studied women who were HIV-positive and found women that experienced significant stressful events in their lives were also more likely to develop pre-cancerous lesions of the cervix one year later, compared to those who experienced fewer stressful events. This study demonstrated that the effects of stress on the immune system has wider and more direct consequences on health and illness beyond just cardiovascular diseases.

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• An issue ignored with research into how stress affects the immune system and leads to illnesses is individual differences that can mitigate for such. For example, people react differently to stress and there has been consistent findings of gender differences in the stress/immune system relationship. For example, women have more adverse hormonal and immunological changes in the way they react to marital conflict (Kiecolt-Glaser et al. 2005). Age is also a factor as stress can have a greater effect on those who are older (Segerstrom and Miller, 2004). Furthermore, some research suggests that the sympathetic branch of the ANS is more reactive in some individuals than others (Rozanski et al., 1999).

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• Research into whether stress has a direct or indirect effect is mixed however evidence for stress being a precipitating factor in cardiovascular diseases is stronger. For example, stress can increase the risk of a heart attack in people who already have cardiovascular diseases. A study by Kristina Orth-Gomer et al. (2000) showed that women with cardiovascular diseases, marital conflict subsequently created stress that tripled the risk of a heart attack for them. This offers an alternative explanation rather than simply attributing stress as the initial cause for CVDs. Therefore, stress may increase a persons vulnerability to developing CVDs through indirect effects such as lifestyle and behavioural changes that may activate the immune system.

The A level specification for AQA psychology states you need to know about the following for the stress topic:

• Sources of stress: life changes and daily hassles. Workplace stress, including the effects of workload and control.

Life changes as a source of stress refers to significant and relatively infrequent events in a persons life that can cause stress. They are considered stressful because the individual often has to expend significant psychological energy coping with changed circumstances.

Examples of such life events can be both positive and negative and it is dependent on the individual, for example, an ending of a relationship may be devastating for one person, however a blessing for another. Equally, when expected life changes do not occur, for example, someone getting a place at university or a job, this too can be stressful in their impact.

To measure stressful life events, self-report scales are used to determine links between the life changes and the stress related disorders. The most significant measurement is the Holmes and Rahe (1967) Social Readjustment Rating Scale (SRRS). This includes a list of 43 stressful life events that are believed to contribute to illness and scores events in terms of life change units (LCUs).

An example of some of the 43 significant life events are listed below from the Holmes and Rahe Social Readjustment Rating Scale (SRRS):

The higher the LCU value, the more adjustment the life change requires, making it more stressful. Early use of the SRRS was retrospective where participants ticked off all the life changes they could recall from the previous 12 months. The LCUs were then added up to produce a total score, and this would then be correlated with a measure of the illnesses the participants had experienced over the same period. Rahe (1972) suggested people that scored below 150 LCUs in a given year would likely experience reasonable health the following year. People who scored between 150 and 300 LCUs, 50% would experience illness the next year, while those who scored over 300 LCU would see up to 80% report illnesses within the next year.

Key Study: Rahe et al. (1970)

Procedure: Rahe et al. studied US navy personnel assigned to three aircraft carriers and participants completed an earlier version of the SRRS known as the Schedule of Recent Experiences. This measurement tool covered the six months before their deployment on a tour of duty with a total LCU score calculated for each participant and their retrospective 6-month period.

Once the personnel had boarded the ship, every illness, no matter how trivial had to be reported to the medical unit. Upon the ships return from their tour of duty, an independent researcher examined the medical records and calculated an illness score for each participant. Neither the participants or medical staff knew the purpose of the study.

Findings: A significant positive correlation was found (of .118) between the LCU scores for the six months before departure and the scores for illnesses on board the ship. What this meant was those who reported to have experienced the most stressful life events in the final six months before leaving the ship, also had the most (or most severe) illnesses in the following six months on the ship. Rahe et al. concluded life changes were a reasonably robust predictor of later illnesses.

• There is substantial evidence in support of the view that life changes are linked to illness. For example, Raija Lietzén et al. (2011) used data from the Health and Social Support Study (HeSSup) in Finland that followed over 160,000 who did not have asthma at the beginning of the study. They subsequently found that a high level of life change stress was a strong predictor for the onset of asthma in participants and this link was not explained by other known risk factors such as having pets or smoking. Follow-up studies have also found a robust and significant correlation between the stress of life changes and illnesses which further supports life changes as a source for illness through stress.

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• A criticism into sources of stress and particularly life changes, is that individual differences are ignored. Stress does affect everyone in the same way, for example, getting pregnant can either be a positive or negative based on whether the pregnancy was planned or unexpected. Equally a house move may be positive or negative dependent on the reasons for it. Research by Bryan and Whyte (1980) found that predicting heart attacks on the basis of life change scores only worked if the participants subjective interpretations were taken into account. The classic life changes approach does not consider the impact of such individual differences and perception which reduces its validity as an explanation of stress. In addition to personality, there are other individual differences that are ignored which likely also factor in to CVD vulnerability such as gender and age.

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• The SRRS is based on the assumption that all change is stressful and effectively models together several different types of life changes, including positive and negative changes. Psychologist now believe that positive and negative life changes have different effects. Turner and Wheaton (1995) found that when participants were asked to rate the desirability of the life changes from the SRRS, and they found undesirable or negative life events caused most of the stress measured by the scale, and not necessarily life changes themselves. This challenges the validity of the global life changes approach and promotes looking at the effects of specific life stressors instead.

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• Due to obvious ethical reasons, it is not possible to conduct experiments into the causes of cardiovascular diseases and therefore most evidence is based on correlational findings. The issue with this is causality cannot be established and it is not possible to establish wjocj factors are contributing the most in the development of cardiovascular diseases.

In contrast to life changes which are thought to be extremely stressful events, most stress is believed to come from daily hassles, everyday irritations and annoyances one experiences throughout a typical day. Examples might include queuing at the shop, being stuck at traffic or having a disagreement with a colleague. Daily hassles can also be offset by daily uplifts, which are positive experiences a person experiences that may counteract the effects of stress.

There are different explanations for the effect daily hassles has on individuals. One explanation is that the accumulation of minor daily stressors create persistent irritations, frustrations and hassles that lead to more significant stress related outcomes such as anxiety and depression (Lazarus, 1999).

Another explanation suggests that chronic stress due to major life changes may make people more vulnerable to daily hassles. Someone going through a messy divorce may find the squabbling between his children a major irritation. This may lead to them experiencing a higher-than-normal level of distress given the relatively trivial nature of the irritation. Due to the individual already being in a state of distress, other associated minor stressors may amplify the experience of stress. It may also be that a major life change may deplete the resources of the person mentally and physically which makes them less able to cope with minor stressors.

Another explanation by Lazarus suggests the psychological appraisal of daily hassles is important and stress is dependent on whether we engage in primary appraisal or secondary appraisal. When we experience a daily hassle, Lazarus suggests we engage in primary appraisal where we subjectively calculate how threatening it is to our psychological health. If the hassle is deemed as threatening, we then engage in secondary appraisal where we subjectively assess how well equipped we are to cope with the hassle. Therefore, the theory of daily hassles factors in the importance of psychological appraisal or interpretation of the meaning of hassles to individuals.

Key Study: Kanner et al. (1981)

Allen Kanner and Richard Lazarus looked to test if daily hassles may be a better predictor for illness than the life changes approach.

Procedure: 100 participants (48 men and 52 women) aged between 45-67 years completed the Hassles and Uplifts Scale (HSUP) for events over the previous month as well as every month following for up to 9 months. The participants also completed a life event scale for the six months preceding the start of the study as well as for the two yearly period prior to that. They also completed the life event scale at the end of the study. Two measures were used to assess their psychological well-being: the Hopkins Symptom Checklist, which assesses symptoms of anxiety and depression, and the Bradburn Morale Scale, which assesses positive and negative emotions. The psychological well-being assessments were completed every month.

Findings: A significant negative correlation between the frequency of hassles and psychological well-being was identified. What this meant was participants with the fewest daily hassles demonstrated higher levels of well-being. The study also found that the hassles and uplifts differed to those selected by another group of participants who were students; for example, the students identified more problems related to having to do too much work without being able to relax. Kanner et al. ultimately concluded that hassles were a better predictor of well-being than life events and uplifts.

• There is supporting evidence from studies that have reaffirmed the importance of daily hassles. Ruffin (1993) found that daily hassles were linked to greater psychological and physical dysfunction in comparison to major negative life events. Flett et al. (1995) investigated why this was and asked 320 students (160 men, 160 women) to read a scenario describing a male or female who had experienced a major life event or daily hassles. Participants were then tasked with rating the amount of support (emotional and practical) they would receive or seek from others. Flett et al. found that those who suffered major life events were rated higher in seeking and receiving support from significant others. This would suggest that the reason daily hassles are a greater source of stress is because their is less social and emotional support received in comparison to life events.

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• A criticism into daily hassles research is it is based on the participants ability to recall the hassles they have experienced accurately. Therefore issues of reliability occur which can distort the significance of daily hassles while more relevant ones may be suppressed or ignored. There are also issues of validity when using self-reports as people may not always report their experiences honestly. Social desirability may be a factor as people may not wish to show all their hassles because it puts them in a 'bad light'. For example, people may not wish to report they have problems with their children or may simply lack the ability to openly express themselves and their hassles. Therefore some issues may be played down or ignored completely which can invalidate the findings.

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• Individual differences is another issue with research into daily hassles, particularly in what constitutes a daily hassle between the genders. Helms et al. (2010) argued that men and women have different roles within mot families and therefore they would experience everyday hassles differently. Some researchers have highlighted that domestic chores performed rarely may be bearable or even enjoyable however it may become a hassle for someone that has to carry it out regularly. The implication is it is difficult to identify reliable daily hassles and extract valid results.

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• Research into daily hassles suffers from drawing cause and effect conclusions, the same as research into life changes. Although daily hassles research has shown consistent and significant correlations between hassles and illness, we are not able to conclusively claim that hassles cause illnesses. This is because other confounding variables may be the true cause that lays in-between these two variables, for example, depression.

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• A practical real-world application of research into daily hassles is the usefulness of findings and conclusions drawn that can help towards the formulation of effective stress management strategies. This can help develop ways to deal with the ever-rising number of stress related illnesses and deaths, both direct and indirect. 

To explain the issues of workload and control, the job demands-control model of workplace stress (Karasek, 1979) combines the two to offer an explanation. This explanation suggests that the workplace creates stress and illness in two ways:

1. Due to high workload which creates greater demands from the job. This involves the number of tasks and obligations individuals ahem to perform or complete within specified timeframes. The greater the workload for the individual, the more stress they will experience.
2. Low control over the job itself through deadlines, procedures and the degree of influence an individual has over their workload and job requirements. It is expected that the greater the control the individual has in their job, the lower their stress levels would be.

Key Study Supporting The Effects of Control: The Whitehall Study (Marmot et al.,1997)

Procedure: Sir Michael Marmot followed over 10,000 UK civil servants that worked in Whitehall from 1985. This included professional staff with high levels of workload and control (e.g. accountants) as well as lower grade staff that had less workload and control (administrative staff). Both sets of staff were thought to experience stress but for different reasons. At the start of the study, the participants completed a range of questionnaires assessing their job workload, subjective sense of control and the social support they had. Participants we're then examined 11 years later for their risk of developing coronary heart disease based on the effects of stress.

Findings: Researchers found the highest-grade workers tended to have the highest workload and also highest sense of control in their job. High workload was not associated with coronary heart disease however, low job control was. The combination of low job control and high workload, as described in the job demands-control model, was strongest among younger workers and this was not reduced by high levels of social support. Such participants were found to be more likely to develop CHD 5 years later, even when other risk factors such as lifestyle, smoking and diet were accounted for.

Key Study Supporting The Effects of Workload and Control: Swedish Sawmill (Johansson et al., 1978)

Procedure: Johannsson et al. studied 28 manual labourers in a sawmill. The high-risk group, that had high workload and low control, were 14 'wood finishers' who were compared to a low-risk group of stickers, repair men and maintenance workers, who were matched in terms of factors such as education and job experience. To assess stress, researchers measured levels of adrenaline daily as well as obtained self-reports of job satisfaction and illness.

Findings: The high-risk group were found to have higher rates of illness as well as adrenaline in their urine samples when compared to the low-risk group, as well as more reports of illnesses. The self-report data confirmed the high-risk group felt they had a greater workload and less control since their jobs were repetitive and constrained. These findings support the job demands-control model.

• A criticism of the job-demands control model is it is overly simplistic as an explanation. While lack of control and high workload may be stressors in some cultures, they are not the only ones. The amount of stress a worker experiences is the outcome of a number of complex factors between the type of work someone does, how well they use coping mechanisms and other factors such as the objective amount of control, support or workload an employee has compared to their perception of such. The job-demands model ignores such and therefore lacks validity due to its simplistic focus on just two job-related sources of stress.

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• Lazarus (1995) argued that individual differences were also ignored by such explanations that there are wide differences in the way people react and cope with stressors. Lazarus argued the degree to which a workplace stressor is perceived as stressful largely depends on the persons perceived ability to cope. For example, Schaubroeck et al. (2001) found that some workers were actually less stressed by having no control or responsibility. This study assessed participants immune system with saliva samples and found some had better immune responses in low-control situations. An explanation for this may be that some people view negative work outcomes as their fault and therefore high control can exacerbate the unhealthy effects of stress.

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• Most research into workplace stress is conducted through the use of questionnaires which raises criticisms of validity for data collected this way. For example, there are issues of social desirability bias, demand characteristics or people simply being dishonest in their responses. Keenan and Newton (1989) found that in a study of engineers, the use of interviews instead of questionnaires revealed stressors that were not usually identified. Similarly, role conflict and ambiguity, which were normally included in questionnaires were rarely mentioned as significant stressors. Interviews may therefore be better suited than questionnaires but this opens up other potential issues such as the interviewer projecting their own subjective interpretations to responses and how these are recorded.

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• There are other criticisms with research into workplace stress, such as the difficulty in isolate and testing single workplace stressors to determine which are specifically related to stress-related illness and to what extent. Also, not all workplace stressors are harmful, for example, the workplace provides opportunities to increase self-esteem, confidence and even motivation while providing individuals a sense of purpose and fulfilment. These are all factors which would contribute to positive physical and psychological well-being.

For this section of A-level psychology and the Stress topic, you will need to know the following:

• Measuring stress: self-report scales (Social Readjustment Ratings Scale and Hassles and Uplifts Scale) and physiological measures, including skin conductance response.

There are a number of scales used to measure stress however the two best known are:

1. Social Readjustment Ratings Scale (SRRS)
2. Hassles and Uplifts Scale (HSUP)

The Social Readjustment Ratings Scale was developed by Thomas Holmes and Richard Rahe (1967) to test their hypothesis about the relationship between life changes and physical illness. To do this, 5000 patient records were examined to identify 43 common life events reported by patients. These 43 life events were then scored by 400 participants based on how much readjustment would be required by the average person using a numerical figure. A baseline score of 50 was given for marriage and events that would take greater adjustment than this, would be scored higher. The scores were then totalled and averaged to produce life change units (LCUs) for each event.

The scale is then completed by selecting the life events which have occurred for an individual within a particular time period and the life change units scored are added up.

The Hassles and Uplifts Scale (HSUP) was developed by Allen Kanner et al. (1981) in order to test the hypothesis that hassles and uplifts were significant factors in illness. Kanner et al. asked research staff to generate a list of hassles and uplifts related to work, health, family, friends, the environment and practical considerations and chance occurrences. The total list consisted of 117 hassles and 135 uplifts which were rated on a 3-point scale and completed in reference to a specific time period over the last month or week.

Physiological measures of stress have included blood pressure and levels of adrenaline which are signs of arousal from the sympathetic nervous system. Another physiological measure used is the skin conductance response, also known as the lie detector test.

Immediate stress is related to sympathetic arousal of the autonomic nervous system and the rationale behind using the skin conductance response is based on the fight or flight response. When experiencing stress, the autonomic nervous system becomes aroused and one of the consequences of this is we sweat more with one of the most sensitive and practical parts of the body where this can be measured is the hand. Electrodes are attached to the index finger and middle finger to detect sweating and a tiny current hat is too weak to be felt is applied via the electrodes to measure how much electricity is being conducted. Human skin tends to be a good conductor of electricity, so the more an individual sweats, due to any form of stress, the more conductive their skin becomes. 

Individuals will have a higher skin conductance response scores when stressed compared to when not stressed, therefore readings need to be taken across both states to draw comparisons. The readings are measured through the use of a polygraph (lie detector test) which measures blood pressure, pulse, respiration as well as their skin conductance response. An individual will normally begin the test by sitting quietly for 30 minutes to establish a baseline score so readings from the test can then be compared to assess when they are becoming stressed.

• There are issues of validity particularly with self-report measures such as the SRRS and HSUP. Most of the items on self-report stress measures are like general categories rather than individual events. This means they are open to varying degrees of interpretations by different participants. Bruce Dohrenwend et al. (1990) demonstrated this point by asking participants what they thought each item meant.  items such as 'serious illness' and 'injury' were interpreted in a variety of different ways that ranged from someone having the 'flu' or 'sprained arm' to a 'life-threatening heart attack'. The death of a close friend was understood by some to mean childhood friends they had not been in contact with for a number of years. Dohrenwend (2006) highlights that people experiencing the greatest degree of stress when completing self-report scales place greater negative interpretations on the item (and vice versa). This problem of intra-category variability reduces the validity of self-report measures, making it difficult to assess the true relationship between stress, life events, daily hassles and illness.

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• There are issues of validity from self-report measures due to potential contamination of results. For example, the SRRS and HSUP are intended to be used as predictors of stress-related illness however many of the items on both scales overlap with symptoms of physical and psychological disorders individuals may have already. For example, 'personal injury or illness' on the SRRS and 'hospitalisation' on the HSUP may simply reflect existing illnesses rather than predict them. In addition, there has been criticism of the HSUP scale, particularly due to the sheer length of it as it contains over 250 items. It is likely that participants may not retain complete focused attention throughout the completion of the scale and test-retest correlations support this with a correlation of 0.48 on severity ratings and 0.60 for frequency ratings of uplifts.

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• The use of the skin conductance response to assess stressors provides more objective evidence and avoids some of the methodological issues associated with self-report measures such as social desirability bias. However, Lazarus points out that stress is not merely a physiological response and the way in which is is experienced may be a crucial element. Therefore such measurement tools only tell us part of the story, particularly when there are significant individual differences in individuals too. Some peoples SCRs vary little when at rest nor do they vary much due to internal thoughts or external events. Other people have SCRs that vary significantly even when they are at rest and therefore even a baseline SCR measurement may not be straightforward and produce invalidated results.

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• Tools developed to measure stress such as the skin conductance response has real-world applications, particularly in determining whether someone is lying. This has led to their usage for criminal matters through polygraph tests however these are not completely reliable or conclusive. For example, Oshumi and Ohira (2010) found that psychopaths are much less affected by being treated fairly or unfairly and generally lack emotional responsiveness which means they can lie without any physiological response. 

You will need to know the following for Individual differences in stress:

• Personality types A, B and C and associated behaviours
• Hardiness, including commitment, challenge and control.

Research into the link between personality, stress and illness begun in the 1950s by cardiologists Meyer Friedman and Ray Rosenman. They suspected their patients, many of which has coronary heart disease (CHD), shared common personality traits that were contributing to this. Their hypothesis was coronary heart disease was associated with certain behavioural characteristics which they classed as a Type A Personality.

Friedman (1996) classified Type A Personality into 3 major groups of behaviours that people would exhibit high levels of with this personality type:

• Competitiveness: They are driven and achievement-motivated, ambitious and aware of their own and other peoples status. They view life in terms of challenges, goals and targets.
• Time urgency: People with Type A Personality will be fast-talking impatient, determinedly proactive, see creative pursuits as time-wasting and have a preference for multi-tasking.
• Hostility: Those with Type A Personality may be aggressive, intolerant, inflexible and quick to anger.

Other characteristics for Type A Personality include insecurity about their status and a need to be admired by their peers in order to feel good about themselves. Type A Personality is associated with a heightened risk of hypertension and cardiovascular diseases.

Type B personalities are basically in contrast in every way with Type A. Individuals with Type B are:

• More 'laid back' and relaxed, tolerant and reflective as well as non-competitive in their manner compared to Type A personalities.
• Type B personality individuals are described as having the same level of ambition, but are steady and more self-confident.
• Capable of relaxing and doing nothing which is something Type A individuals struggle to do.

Such individuals are associated with lower stress levels and lower risk towards cardiovascular diseases.

Key Study into Type A and B Personality: Friedman and Rosenman (1959, 1974)

Friedman and Rosenman set up the WCG (Western Collaborative Group) to study the link between Type A behaviour and coronary heart disease.

Procedure: A longitudinal study was conducted with 3000 men aged 39 to 59 living in California. They were examined for signs of coronary heart disease and those already showing signs were excluded. Personalities were assessed by interview which consisted of 25 questions about how they responded to every day pressures, for example, how they would cope with having to wait in a long queue. The interview was conducted in a provocative manner to elicit Type A behaviour for example, the interviewer may talk slowly and hesitantly so a Type A person would likely interrupt. Based on this interview, participants were classed as either Type A or Type B.

Findings: After 8.5 years, 257 of the original participants had developed coronary heart disease. 12% of individuals classed with Type A personality had a heart attack compared to only 6% of individuals classed with Type B personalities. Type A individuals also had higher blood pressure and cholesterol with twice as many having died due to cardiovascular problems. Those with Type A personality were also more likely to smoke and have a history of CHD which contributed to their greater risk.

Type C personality individuals are believed to strongly suppress their emotions, particularly negative ones and are seen as passive, unassertive, 'people pleasers' that may manifest pathological niceness. They are seen to cope with stress in a way that ignores their own needs which includes physical needs that can result in negative consequences.

Type C personality traits have been linked to some cancers (Temoshok, 1987) due to stressors activating the autonomic nervous system, which is related to coronary heart disease. As most chronic stressors affect healthy immune system functioning, this in turn increases the risk for cancer.

Key Study into Type C Personality: Morris et al. (1981)

Tina Morris and her colleagues examined the link between Type C personality traits and cancer.

Procedure: Over a period of two years, women that were attending a cancer clinic in London were asked to take part in the study. A total of 75 women participated and were interviewed to assess typical behaviour patterns which included questions on how often they expressed affection, unhappiness by crying or losing control when angry. The interviewer was not aware of participants initial diagnosis of cancer.

Findings: The study by Tina Morris (1981) found that women who had cancerous breast lumps experienced and expressed far less anger than those women whose lumps were found to be non-cancerous. This supports the theory of a link between the suppression of anger in line with Type C personality traits.

• There are a number of criticisms of Type A and Type B personality classifications being linked to illness. For example, some researchers have failed to replicate Friedman and Rosenman's (1974) findings. Also, not all aspects of lifestyle were controlled in Friedman and Rosenman's study so it may be other factors such as hardiness that affects vulnerability to coronary heart disease. Further more, while Type A men are more at risk of developing CHD, the risk is relative as the vast majority of Type As do not, while some Type Bs do.

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• Ragland and Brand (1988) found 15% of Friedman and Rosenman's original had died of CHD with age, high blood pressure and smoking all proving to be significant factors in death, however little evidence of Type A personality being a risk factor. This undermines the theory that Type A personality may contribute to CHD.

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• There are issues of gender bias due to the original sample from Friedman and Rosenman's consisting of only men. Riska (2002) claimed the preoccupation with Type A behaviour was a reflection of the importance of traditional masculinity in the 1950s and 1960s given behaviours such as competitiveness and assertiveness are very masculine. Friedman et al. (1986) conducted a follow-up study this time with over 800 participants that included both men and women that had experienced CHD. Participants were then randomly allocated to either a treatment group that received cardiac and Type A counselling or a control group that received only cardiac counselling. The findings of this study were that the treatment group were less likely to have further CHD related problems (13% compared to 28%). This suggests that both men and women experience Type A behaviours and would benefit from treatments designed to reduce them.

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• Greer and Morris (1975) found a link between breast cancer and emotional suppression which was typical of Type C personality individuals however, this was only in women under the age of 50. Research into the link between Type C personality traits and cancer has produced inconsistent findings with low reliability in replicating any significant results (McKenna et al. 1999). This would suggest the relationship between Type C personality and cancer is not straight forward and moderated by a number of factors that may include age.

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• Most psychologists have accepted that Type A personality traits as a global personality construct is far too broad and instead researchers have focused on specific traits such as hostility as a component that may be linked to stress and coronary heart disease. Hostile people are seen to also be selfish, cynical, manipulative and mistrusting of others. Research by Theodore Dembroski et al. (1989) reanalysed the Western Colloborative Group study by Friedman and Rosenman and found that ratings of hostility was able to significantly predict later incidences of coronary heart disease. This was supported by Dorit Carmelli et al. (1991) who conducted a 27-year follow-up to find that exceptionally high CHD death rates could be attributed to a subgroup of men that scored high in hostility scores. This would cast doubt on the validity of the global conception of Type A personality traits but acknowledges some aspects of Type A personality is linked to CHD.

Hardiness, also known as the Hardy personality, was proposed by Suzanne Kobasa (1979) as a set of personality traits that make people more resistant against the negative effects of stress. The hardy personality type is associated with lower physiological arousal when faced with stressors which reduces stress-related disorders. Salvatore Maddi (1986) (a co-worker of Suzanne Kobasa) describes hardiness as giving us existential courage and the will or determination to keep going despite setbacks or uncertainties about the future.

The hardy personality includes a range of three characteristics known as the three Cs:

1. Control: Hardy people feel a sense of personal control over what they are doing and do not see external factors as key determinants of their lives.
2. Commitment: Hardy individuals are committed to what they are doing and have sense of self and purpose.
3. Challenge: People that have the hardy personality see problems as challenges to be mastered or overcome rather than threats or stressors. They see change as something to be expected and an opportunity for personal development.

Key Study: Kobasa (1979)

Procedure: Kobasa measured the stress levels of 800 American business executives aged between 40 and 49 years using an adapted version of Holmes and Rahe's (1967) Social Readjustment Rating Scale (SRRS). They were asked to identify the life events they had experienced in the previous 3 years as well as any illnesses and absenteeism from work. This enabled Kobasa to identify participants that experienced high-stress/low-illness or high-stress/high-illness. The results found some wide variations with 86 individuals in the high-stress/low-illness group as well as 75 participants that experienced high-stress/high-illness. Three months later, both sets of individuals were asked to complete several personality tests to determine their sense of control, commitment and challenge.

Findings: The results demonstrated that the executives did not respond to the same degree of stress in the same way. The individuals in the high-stress/low-illness scored highly for all three hardy personality traits whereas the high-stress/high-illness individuals scored lower on these traits. This supports the theory that people with a hardy personality are more resistant to illnesses.

• There are methodological issues with research studies into hardiness. This is because most research support for the link between hardiness and health has been obtained through self-report questionnaires. These questionnaires are lengthy and interpreted in ways which they are not intended. Also there is no way to objectively verify the responses and they may suffer from social desirability bias where respondents exaggerate responses either positively or negatively. There are also criticisms that such measurements suffer from low internal validity. For example Steven Funk (1992) points out that hardiness is measured by asking questions about negative traits such as powerlessness and alienation. A hardy individual would score low on such items and therefore a lack of such traits would be taken to indicate hardiness. It may in fact be that such scales are measuring neuroticism rather than hardiness because neurocism is characterised by anxiety, fear, moodiness and worry. This may mean that substantial research into hardiness and the relationship between stress and illness could lack validity and not measuring what it aims to.

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• A key benefit of research into hardiness is the possibility for real-world applications. Maddi et al., (1998) developed hardiness training as part of a programme designed to increase self-confidence and a sense of control so individuals could deal more successfully with change. This training programme was compared to relaxation/meditation conditions a well as a placebo/social support control group and found to be more effective in increasing self-reported hardiness, job satisfaction and decrease self-reported strain and illness severity. The appeal of hardiness training has been widespread and has reached into education as well as military units such as the navy seals who now screen for hardiness characteristics.

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• Kobasa's research into hardiness was done on wealthy American managers, therefore her results may not generalise to other sections of society or universally to other cultures. Recreating test conditions to assess the impact high levels of stress has on people is unethical and it is therefore difficult to objectively test hardiness in other ways with other groups of people that allows generalisation.

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• There is mixed evidence to suggest that not all three elements of the hardy personality are as important as one another. Sandvik et al. (2013) assessed 21 Navy candidates an found that despite all demonstrating hardy personality traits, those that were lower in the challenge component also had weaker immune responses which suggests they were more affected by stress. While this may suggest the challenge component may be key, other research suggests that control is more important. Julian Rotter (1966) and his work on locus of control demonstrated how individuals who have a high internal locus of control felt less stress and were affected by it less. This is supported by Kim et al. (1997) who found children with an internal locus of control showed less signs of stress when their parents divorced. Cohen et al. (1993) also found that individuals who felt their lives were uncontrollable and unpredictable (external locus of control) were twice as likely to develop colds in comparison to those who felt in control and had an internal locus of control. The key point here is that if hardiness boils down to just one trait rather than a cluster, then this is not likely to be a personality type.

The specification states you need to know about the following:

• Managing and coping with stress: drug therapy (benzodiazepines, beta blockers), stress inoculation therapy and biofeedback.
• Gender differences in coping with stress.
• The role of social support in coping with stress; types of social support, including instrumental, emotional and esteem support.

Benzodiazepines (BZs) are the most commonly used drugs to treat anxiety and stress. These drugs slowdown the activity of the central nervous system and are commonly known as Librium and Diazepam.

Benzodiazepines reduce anxiety by enhancing the actions of the neurotransmitter GABA (gamma-aminobutyric acid). GABA is the body's natural form of anxiety relief with approximately 40% of the neurons in the brain responding to GABA to induce a inhibiting effect. GABA does this by reacting with GABA-A receptors on the outside of postsynaptic neurons. Once GABA locks into these receptors, it opens a channel which increases the flow of chloride ions into the postsynaptic neuron. Chloride ions make it harder for the postsynaptic neuron to be stimulated by other neurotransmitters which slows down its activity and results in a person feeling more relaxed and less anxious. Benzodiazepines also dampen the excitatory effects of the neurotransmitter serotonin, which further slows down the activity of the nervous system and adds to the feeling of relaxation.

Beta blockers, also known as beta adrenergic blockers, act on the sympathetic nervous system by blocking areas which are normally activated by the hormones adrenaline and noradrenaline which are released in response to stressors. Unlike benzodiazepines which act on the brain, beta blockers block the transmission of nerve impulses by sitting on beta-adrenergic receptors that would normally be activated by hormones. Adrenaline and noradrenaline are produced as part of the sympathetic nervous pathway and circulate in the bloodstream when this pathway is triggered by a stressor. These hormones would then normally combine with beta-adrenergic receptors located throughout the cardiovascular system, principally receptors located in the heart and blood vessels which results in increased heart rate and blood pressure, symptoms normally linked to stress. Beta blockers effectively block the beta-adrenergic receptors from being stimulated by adrenaline and noradrenaline which slows down the heart, reduces blood pressure and causes the heart to pump less intensely. 

Beta blockers include atenolol and propranolol and reduce anxiety without altering consciousness since they do not operate directly on the brain. They are therefore most ideal for people who wish to eliminate the physical and psychological effects of stress while remaining alert.

• The effectiveness of drug therapies is usually established through the use of randomised controlled trials where one condition are given a placebo and another are given the drug itself. Kahn et al. (1986) studied over 250 patients over eight weeks and found that benzodiazepines were significantly more effective compared to placebos for the treatment of anxiety and stress. Lockwood (1989) also found beta blockers were effective when over 2000 musicians were studied. 27% of the musicians reported to be taking beta blockers and reported to feel better about their performances due to taking the drug therapy. Music critics consistently judged their performances as better too although Schweizer et al. (1991) found that not all kinds of beta blocker reduced participants subjective sense of stress.

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• Another strength with drug therapies such as benzodiazepines is they are relatively easy to administer. Drug therapies require little effort from the user beyond remembering to take the pill itself which is much easier than applying other psychological therapies such as stress inoculation which requires significant more time, effort and motivation. Therefore patients are more likely to engage with drug therapies which are easy to use, fast acting and cost effective.

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• Criticism and concerns around the appropriateness of drug therapies such as benzodiazepines include the potential for addiction. Patients taking benzodiazepines have shown withdrawal symptoms when trying to stop and due to this, it is recommended that benzodiazepines are taken for a maximum of four weeks (Ashton, 1997). Due to the potential for such addiction, BZs are not appropriate for treating everyday stress and mostly limited to people experiencing psychological disorders that have an anxiety component.

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• The other issue with drug therapies such as benzodiazepines is the potential for side-effects such as paradoxical symptoms, which are the opposite of what one would expect from their usage. These side effects include increased agitation, aggressiveness and cognitive side effects such as impaired memory. Most people fortunately do not suffer from such side effects however some research has linked them with an increased risk of developmental diabetes.

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• A strength of beta blockers is unlike benzodiazepines, they are not associated with dependency or addiction although they can have serious side effects such as cold extremities, tiredness, nightmares and hallucinations.

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• Another criticism into the appropriateness of using drugs such as benzodiazepines and beta blockers is the fact that they treat the symptoms rather than the actual cause of the problem. Such drug therapies are only effective as long as individuals continue to take them and as soon as they stop, their effectiveness stops also. There is an argument that the causes of stress may be better tackled through psychological therapies which may stop the stress response that contributes to anxiety by altering peoples perception of the stressor.

Stress inoculation therapy (Meichenbaum, 1977) is a form of cognitive behavioural therapy developed especially to cope with stress. The rationale behind it is that it is not always possible to avoid , change or eliminate stressors because we do not always have control over them. Instead, stress inoculation therapy involves a cognitive restructuring of the way people think about themselves, their lives and the way they think about stress itself. It is considered a cognitive approach because it targets the way a person thinks, in particular, negative thoughts that would lead to anxiety or depression and looks to replace them with more positive thoughts instead.

Meichenbaum proposed three main phases to stress inoculation therapy:

1. Conceptualisation phase: The client and therapist work together to identify and understand the stressors the client faces through a therapeutic relationship that is warm, collaborative and supportive. The therapist plays a facilitating role with the client retaining responsibility for their progress. The client is considered the expert on their own stress experiences rather than the therapist as they work to identify negative self-statements. The client is also educated about the nature of stress and how this can be caused by their own cognitive appraisals (thoughts). The client is encouraged to understand that stressors can be positively reframed as challenges that can be overcome, as well as understand what aspects of a situation they can and can't change.
   

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2. Skills acquisition and rehearsal phase: The therapist helps the client to develop and practise coping skills that will enable them to cope with stressors they have identified. This may include positive self-talk where they challenge their own negative thoughts that create feelings of anxiety or techniques such as relaxation exercises, social skills, communication or cognitive restructuring where the client thinks about the stressful situation in a more optimistic manner. This phase sees the client plan in advance how they would cope with stressors using such skills.

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3. Application and follow-through phase: Clients will visualise using the stress-reduction techniques learned from the skills acquisition and rehearsal phase and then apply them in role-play scenarios before applying them to real-life situations. The client may initially begin practicing with a non-threatening example such as imaging themselves dealing with the stressor. They may then move on to practice the coping strategy in a role play before finally applying it to real-life. The therapist may also set homework tasks, also known as personal experiments, for the client to use the skills in everyday life by deliberately seeking out moderately stressful situations where they can apply their learnt skills. This is then fed back to the therapist for discussion. An important feature of this phase is relapse prevention where the therapist helps prepare the client on how to cope with setbacks.

• A strength of stress inoculation therapy is its flexibility incorporating a wide range of stress management techniques in the skills acquisition phase. The therapy can be used with individuals, couples, groups and even families in a variety of settings. The duration of the training itself can range from 20 minutes to 40 or more hours and over several months with techniques tailored to meet the specific needs of the individual. This may include elderly people, those with learning difficulties or even adapted for use online (Litz et al. 2004). Stress inoculation therapy can even be used in situations where people face racism or homophobia which is a distinct advantage of this therapy.

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• A weakness of stress inoculation therapy is it is quite demanding for clients as it requires significant commitments of time and effort. Clients also have to be highly motivated for it to be most effective and requires a high degree of self-reflection and openness to learning new skills. Not everyone is capable of this and applying the learned skills to real life situations can be quite demanding. Failure in this respect can be demotivating which means some people do not continue with the treatment. A benefit is stress inoculation therapy factors in potential setbacks and helps people prepare for these while exploring ways to overcome them.

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• Another weakness to stress inoculation therapy is its difficulty in objectively verify its effectiveness. The therapies success  is based on subjective reports from clients. Clients may initially exaggerate their problems during the conceptualisation phase in order to gain support by a therapist. At the end of the treatment, patients may be grateful for any help they were given and may minimise the remaining problems they have. This might make the therapy seem more effective than it actually is and undermines its effectiveness.

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• Stress inoculation therapy is able to protect against current and future stressful situations and it is effective over long periods of time with no physiological side effects unlike drug therapies. Patients can continue to use the skills they have learnt in a number of other stressful situations and it can be generalised across different types of stressors. However, there are many threads to the therapy and it is difficult to work out which element is most important in addressing the negative effects of stress. For example, It may be that relaxation is the main skill that helps tackle stress and not necessarily cognitive appraisal or positive self talk.

Biofeedback is a behaviourist method of stress management that trains people to lower their stress levels by using physical signals from their bodies involuntary processes. Biofeedback targets the physiological response to stress and arousal of the sympathetic nervous system that leads to increased heart rate and blood pressure with the aim of learning to better manage this. It does this by attaching patients to a machine that gives visual or auditory feedback about their physiological activity and teaches them to learn to control these involuntary responses.

For example, a clients heart rate is monitored and a signal is amplified and fed back to the client via a display or the sound of a tone through earphones. Muscular tension can also be measured using an electromyogram (EMG), as well as brain activity via an electroencephalogram (EEG) and displayed on a screen.

Patients are trained to control their physiological responses through four processes:

1. Relaxation: The patient is taught relaxation techniques that help reduce the activity of the sympathetic nervous system and instead activates the parasympathetic nervous system which stops adrenaline and noradrenaline from being produced. The result should then be reduced heart rate, blood pressure and the symptoms normally associated with stress.

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2. Feedback: The patient is attached to various machines that provide feedback about their autonomic nervous system activity. This might include their heartbeat played as a sound or visual representation, live changes in blood pressure or muscle tension or any other physiological response. The patient then practices relaxation techniques while seeing or listening to the feedback from these involuntary responses and respond by relaxing themselves which should cause their activity to decrease.

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3. Operant conditioning: As the patient learns to use relaxation techniques to lower their physiological response, for example heart rate, this is seen as rewarding because the person achieves their goal and this reinforces the behaviour which increases its likelihood of being repeated. Learning to lower or manage ones arousal is conditioned eventually without any conscious thought as over time, this behaviour is cemented in.

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4. Transfer: The patient then attempts to transfer the skills they have learned to real-world situations using the relaxations techniques in response to any stressors they encounter.

Research into biofeedback: Henry Davis (1986)

Procedure: Thirteen 45-minute sessions of biofeedback were held over a period of 8 weeks where breast cancer patients learnt deep-breathing and relaxation techniques.

Findings: After eight months, the cortisol level in urine, as well as self-reported anxiety levels had lowered significantly in patients compared to the start of the study. A control group of participants who received no biofeedback therapy had increased levels of cortisol. The researchers therefore concluded that this was evidence of significant stabilisation of the hypothalamic-pituitary-adrenal system due to biofeedback.

• There are a number of research studies which have supported biofeedback being effective in reducing the stress response in people. Jane Lemaire et al. (2011) used medical doctors as her participant and trained them to use biofeedback three times a day over a 28-day period. They also completed questionnaires that measured their perception of how stressed they were. The mean stress scores for biofeedback users fell significantly more over the course of the study when compared to a control group demonstrating it was effective.

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• Another benefit to biofeedback is there are no noticeable side effects unlike drug therapies. The benefits of biofeedback training see it as a potential longterm strategy that can be employed when necessary and applied to a number of different stressful situations. Also, unlike drug therapies, the symptoms may not return because they stop taking the medication nor is there any risk of dependence or addiction. Research by Attanasio et al. (1985) also found biofeedback worked well with children, as they were more willing to engage and try hard in achieving success. This suggests the therapy is more suited to those who are motivated to engage and reduce their stress levels.

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• There is criticisms into the therapy that suggest the operant conditioning component may actually be irrelevant and the success of the therapy is merely down to relaxation techniques that encourage a patient to relax when they normally wouldn't be aware of doing this. If the success of biofeedback is mainly due to relaxation rather than feedback and conditioning, there really is no need for the expensive equipment and time-consuming procedure. The use of specialistic equipment also makes it expensive and only usable with supervision. The treatment time can also be quite lengthy spanning a number of weeks which may make it inappropriate. Biofeedback also requires a level of effort and motivation from the client which may present a barrier to its usage due to individual differences and some people also not understanding the relationship between their physiological functioning and the visual/auditory feedback they receive.

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• There are a number of real-world applications for biofeedback. For example, PTSD is just one of the many conditions which have been successfully treated with biofeedback. PTSD develops when a person experiences a traumatic event and therefore remains in a state of stress. Biofeedback had also been used in sports such as biathlon, where individuals are required to have control over bodily stress levels in order to be successful. The ability to manage ones arousal to keep themselves performing optimally has a number of advantages across a number of high-pressure sports too from tennis to football.

Most research investigating the physiology of stress has focused on male participants and the effects on the sympathomedullary pathway (SAM) and the hypothalamic pituitary-adrenal system (HPA). The main reason studies into stress have focused primarily on men is due to their hormone levels not altering due to an ovulation cycle. Research has shown there are significant gender differences in coping with stress by females compared to males, which appears to be biologically based.

During times of acute stress, Taylor et al. (2000) found that this produced the 'flight-or-flight' response in men, however in women a 'tend-and-befriend' response occurred. Women produce more oxytocin, a hormone that is released from the pituitary gland which promotes nurturing and cooperative behaviour. From an evolutionary perspective, fight-or-flight is disadvantageous for females as confronting or fleeing a predator would make it difficult to protect their children. Instead research has shown that women will engage in behaviour that looks to protect, calm or nurture offspring  as well as blend into the environment. The tend-and-befriend response also involves seeking support from social networks as a coping mechanism for stress. Research has shown that befriending behaviour among women is more selective during times of stress and it tends to be with other women (Lewis and Linder (2000).

In comparison, men are more reluctant to perceive or admit that stress impacts them negatively which affects the ways in which they cope with it. Males are less likely to make necessary changes to their lifestyle or seek professional help from therapists which has a negative impact on their mental health. Other research suggests men have a tendency to use problem-focused methods of coping with stress, compared to women who use more emotion-focused strategies. Richard Lazarus and Susan Folkman (1984) were the first to make this distinction suggesting problem-focused methods reduced stress by tackling its root causes in a direct, practical and rational way that looks to take control and remove or escape stressors. In comparison, emotion-focused methods reduce stress indirectly by tackling the anxiety associated with stressors. Strategies may include various forms of avoidance, distraction, or cognitive appraisal that sees the stressor differently.

• Research findings of gender differences in coping strategies are often based on self report measures that are prone to bias and are therefore difficult to objectively validate. For example, women may be more willing to reveal the emotional side of coping, whereas men may play down their emotional difficulties. Additionally, dividing the way in which people cope with stress down to gender differences is overly simplistic and can create a self-fulfilling prophecy where people react in a way they think they are supposed to simply because of their gender. There are significant individual differences between people which means men and women will not cope with stress in gender-stereotypical ways.

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• Another explanation, role constraint theory, suggests that gender differences in how men and women cope with stress is mainly down to the different stressors they face and coping strategies being highly situation-specific rather than broad, For example, work based stressors lend themselves to problem-focused coping strategies whereas relationship-focused stressors require more emotion-focus strategies. Pilar Matud (2004) found men and women experienced the same number of stress life changes, however they were different types of stressors. Women tended to report more family-related stressors which they perceived as negative and less controllable. Their responses also tended to be more emotion focused. Men on the other hand, reported more work-related stressors. The demonstrates that gender differences in coping strategies may be due to men and women experiencing different kinds of stressors rather than reflecting something fundamentally down to being a man or woman.

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• The tend-and-befriend response is seen as overly simplistic. For example, it would be adaptive for women to be aggressive also particularly to protect their offspring. Taylor et al. does not that while females are less aggressive than males, they are aggressive towards anyone that threatens their offspring. This suggests aggression in situations that require defence may be typical rather than the generalised 'fight' response seen by males. The same is true of the 'flight' response as animals that have offspring that are mobile will flee rather than stay huddled together. Therefore, the female response is not simply a tend-and-befriend but encompasses a range of strategies that are adapted to parental investment.

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• There is the issue of confounding variables that may be contributing to differences between how the genders cope with stress. For example, the degree of social support a person receives may act as a confounding variable as women are more likely to receive social support in comparison to men. Social support reduces the amount of stress a person experiences and this may mean women may experience less, thereby selecting different coping styles.

One factor that determines how well an individual will deal with stress is the level of social support they receive from friends, family and those available around them. The more social support they receive, the better able they will be at coping with stressful situations as social support acts as a buffer against stressors. In contrast, the lack of social support not only prevents individuals from dealing with stress, it can also lead to a sense of isolation and mental illnesses such as depression.

It is possible for someone to have a relatively small social support network and still get significant support from few people. It is also true of the opposite, where someone may have a large social network but this does not necessarily mean they will get support from it. Therefore, the amount and types of social support an individual will receive depends on several factors including how well integrated they are within their social networks. A number of other factors also play a role, for example, whether they are male or female (as females generally have wider social support systems) or even their cultural backgrounds (collectivist cultures have extended family networks that provide support).

Stroebe (2000) identified 5 distinct types of social support an individual may receive:

1. Esteem support: this type of support occurs when an individual perceives that others value them and hold them in high regard. This increases and strengthens their feelings of self-value which is helpful in stressful situations as it helps them feel competent enough to cope with the stressors.

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2. Emotional support: this type of support occurs when an individual perceives that others care and have sympathy for them with an understanding of the stressful situation they are faced with. This type of support expresses warmth, concern, affection, empathy and love. This support doesn't offer practical help but rather makes the stressed person feel better, to lift their mood.

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3. Appraisal support: this occurs when others assist an individual to identify and understand the stressors and the impact they are having on their health, which allows a realistic view of the situation.

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4. Informational support: this involves others giving advice and guidance on how to deal with the stressor and might come from a therapist, or from others on how the individual is coping.

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5. Instrumental support: instrumental support occurs when people provide practical and tangible assistance by physically doing something to help, for example, giving someone a lift to the doctors or loaning them money. This type of support is seen as a problem-focused type of support to coping with stress as it involves doing something.

Key study: Kamarck et al. (1990)

Procedure: 39 female psychology students volunteered to perform a mental task that was stressful while their physiological reactions were monitored. Each of the participants attended a laboratory session either alone or with a close same-sex friend. During the mental task, the friend was told to touch the participant on the wrist while they also completed a task. This was done so as to avoid the participant feeling like they were being evaluated by their friend but also to avoid the friend from monitoring what the participant was doing. All the participants also completed questionnaires related to their mood and personality.

Findings: Participants that were with a friend showed lower physiological arousal (e.g. lower heart rate) than those who were alone. For some of the tasks, only those with Type A personality showed reduced physiological responses which supports the hypothesis that social support acts as a buffer, although this may only be for those who already show a high response to stressors.

• There are significant gender differences demonstrating that men and women use social support differently when coping with stress. Men for example, have been found to have larger social networks than women, however the size of the network is not the crucial factor that influences the effectiveness of social support. During times of stress, on virtually every measure, women are more likely to seek out and use social support as well as provide it. This is supported by Luckow et al. (1998) who reviewed 26 studies into gender differences and social support. In 25 of the 26 studies, women were found to use social support as a means of coping with stress more than men. This difference was especially evidence in the case of emotional support.

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• An often overlooked point however is that social support is not always positive and there are negative effects to it too. What tends to matter is who provides the support and the type of social support they give. For example, emotional support is helpful when given by friends and family however instrumental support in the form of information and advice is more valued when coming from appropriate professionals. Also, there are times when emotional support from close friends or family is not helpful and may lead to people feeling more anxious. It is possible the benefits of social support are realised when the recipient seeks it rather than has it imposed on them.

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• There is research support for the benefits of social support. For example Fawzy et al. (1993) randomly allocated patients with malignant melanoma to a support group for six weeks. The group provided emotional support by giving patients the opportunity to express their feelings, as well gain instrumental support through gaining information and advice about their illness. Patients were examined six years later and it was found that patients who received social support had better NK cell (white blood cell) functioning and were more likely to be alive as well as cancer free in comparison to a control group. This demonstrated that the benefits of social support can be substantial, long-lasting and effective.

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• There are criticisms to the assumption social support is responsible for coping with stress. Different types of social support have been investigated and it is difficult to isolate and test the different types, which makes it difficult to assess which are the most influential in helping individuals cope with stress. Additionally, it is not fully understood how social support helps combat stress. It may be that social support raises self-esteem, which enables individuals to be more persistent in dealing with stressors which would mean that it is not necessarily social support that is helping people cope with increased stress but increased self-esteem or confidence. This raises the point around correlational research and being unable to establish the true cause and effect. Most research findings are based on correlations between stress and social support and as this demonstrates, there may be confounding variables involved.