ASSESSMENT OF PSYCHOLOGICAL STRESS

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ASSESSMENT OF PSYCHOLOGICAL STRESS

• Pittsburgh Mind-Body Center Summer Institute
• June 4, 2008
• Tom Kamarck, Ph.D.
• Barbara Anderson, Ph.D.

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Low Socioeconomic Status Natural
Disasters Bereavement
Unemployment
DEFINITION
SOCIAL ENVIRONMENT
PSYCHOLOGICAL STRESS

VULNERABILITY TO DISEASE
MEASUREMENT
Marital Strain Job stress
Caregiving Discrimination
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• GOALS
• Major approaches to conceptualization and
  measurement of stress pros and cons.
• 2. Initiatives by PMBC faculty to improve our
  ability to quantify chronic stress exposure.

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ENVIRONMENT
ORGANISM
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ENVIRONMENT
ORGANISM
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DEFINITIONS OF STRESS

• Response-based model
• (Selye, 1974) Stress is the nonspecific response
  of the body to any demand made upon it.
• Stimulus-based model
• (Holmes Rahe, 1967) Stress involves events
  whose adventrequires a significant change in the
  ongoing life pattern of the individual.
• Transactional model
• (Holroyd Lazarus, 1982) Stress involves the
  judgment that environmental or internal demands
  tax or exceed the individuals resources for
  managing them.

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THE TEMPORAL DIMENSION
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THE TEMPORAL DIMENSION
ACUTE
CHRONIC
RESPONSE-BASED
STIMULUS-BASED
TRANSACTION
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DEFINITIONS OF STRESS

• Response-based model
• (Selye, 1974) Stress is the nonspecific response
  of the body to any demand made upon it.
• Stimulus-based model
• (Holmes Rahe, 1967) Stress involves events
  whose adventrequires a significant change in the
  ongoing life pattern of the individual.
• Transactional model
• (Holroyd Lazarus, 1982) Stress involves the
  judgment that environmental or internal demands
  tax or exceed the individuals resources for
  managing them.

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DEFINITIONS OF STRESS

• Response-based model
• (Selye, 1974) Stress is the nonspecific response
  of the body to any demand made upon it.
• NEUROBIOLOGICAL RESPONSES
• STRENGTHS
• Objective assessments
• WEAKNESSES
• Many-to-one relationship between response
  determinants and neurobiological responses.

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DEFINITIONS OF STRESS

• Response-based model
• (Selye, 1974) Stress is the nonspecific response
  of the body to any demand made upon it.
• SELF-REPORT RESPONSES
• STRENGTHS
• Salient, face valid.
• WEAKNESSES
• Psychological symptoms are frequently
  characterized as outcome measures in the
  relationship between stress and adaptation rather
  than as predictors.

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DEFINITIONS OF STRESS

• Response-based model
• (Selye, 1974) Stress is the nonspecific response
  of the body to any demand made upon it.
• Stimulus-based model
• (Holmes Rahe, 1967) Stress involves events
  whose adventrequires a significant change in the
  ongoing life pattern of the individual.
• Transactional model
• (Holroyd Lazarus, 1982) Stress involves the
  judgment that environmental or internal demands
  tax or exceed the individuals resources for
  managing them.

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Stimulus-based model

• What is stressful about the demands of the
  environment? Relevant psychological processes.
• What are the major temporal domains that are
  important to assess? (daily hassles, life events,
  chronic difficulties)
• How do the demands of the environment summate?
• What are the relevant life domains that should be
  the focus of our attention (occupation, marriage,
  caregiving responsibilities)?

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Stimulus-based model

• Life events approach
• Adolf Meyers life chart (1866-1950)
• Harold Wolff NY Hospital-Cornell
• Thomas Holmes 1955
• Schedule of Recent Experiences
• Richard Rahe
• Social Readjustment Rating Scale

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Stimulus-based model

• Life events approach
• Assumptions of the original method
• What makes stress stressful? Adaptation.
• Impact of events is linear, additive and
  cumulative.
• Equal effects across individuals.

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Schedule of Recent Experience (1967)EXAMPLE ITEMS

• Mark under the appropriate time periods when
  there has been either a lot more or a lot less
  trouble with the boss.
• Mark under the appropriate time periods when
  there was a major change in number of
  family-get-togethers (e.g., a lot more or a lot
  less than usual).
• Mark the number of times in each appropriate time
  period that you had an outstanding personal
  achievement.
• Mark the number of times in each appropriate time
  period that there was a major change in working
  hours or conditions.
• 32. Mark the number of times in each appropriate
  time period that there was a major change in
  living conditions (building a new home,
  remodeling, deterioration of home or
  neighborhood).

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Stimulus-based model

• Life events approach
• STRENGTHS In theory, these measures allow us to
  identify the environmental sources of stress in a
  manner that is unconfounded by the individuals
  reaction or coping style.
• WEAKNESSES
• 1. Problems with subjectivity (threshold for item
  endorsement)
• 2. Problems with reliability (retest not bad, but
  only 60 of items endorsed at one time are also
  endorsed at another).
• 3. Problems with memory accessibility (fall off
  about 5 per month).
• 4. Problems with content validity.
• 5. Uneven representation of chronic difficulties.

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Stimulus-based model

• Life events approach
• STRENGTHS In theory, these measures allow us to
  identify the environmental sources of stress in a
  manner that is unconfounded by the individuals
  reaction or coping style.
• WEAKNESSES
• 1. Problems with subjectivity (threshold for item
  endorsement)
• 2. Problems with reliability (retest not bad, but
  only 60 of items endorsed at one time are also
  endorsed at another).
• 3. Problems with memory accessibility (fall off
  about 5 per month).
• 4. Problems with content validity.
• ONE PROPOSED SOLUTION INVESTIGATOR-BASED METHODS

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A key distinction between Investigator-Based (IB)
and Self-Report (SR) Methods

• In IB methods, the responsibility for identifying
  and rating severity of stressors lies with the
  investigator not with the respondent.
• Final interpretation and ratings are made by
  trained staff /investigator in conjunction with
  the subjects self-report. Severity ratings are
  based upon contextual circumstances surrounding
  each stressor (for example, pregnancy with or
  without stable family circumstances) and with the
  assistance of dictionary or coding manual,
  rather than upon respondents subjective reaction
  to the event in the course of its description.

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Example of a checklist item Serious illness
of a close family member

• How serious is serious
• How close is close
• What constitutes an illness
• Who constitutes a family member

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What is LEDS?

• Life Events and Difficulties Schedule
• (LEDS Brown Harris, 1979 1989)
• Semi-structured interview that allows one to
  identify current life stressors that threaten
  ones goals and commitments, using behavioral
  indicators of threat (verbal or written job
  performance ratings) goal investment (primary vs.
  secondary wage earner). Severity ratings are
  based on the life circumstances of the
  individual.
• LEDS is considered to be the gold standard
  of investigator-based assessment of life stress.

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Stimulus-based model

• LEDS
• Calendar method
• Multiple domains
• Dictionary coding system
• Assumptions
• What makes stress stressful? Contextual threat
  threat to important values and commitments.
• Impact of events involves threshold model.
  Interrelated events are not double counted.
• Effects of stress assumed to vary according to
  individuals biographical characteristics.

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How do you implement LEDS?

• Three part process
• 1. Interview
• 2. Rating procedure
• 3. Consensus process

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Why Use These Methods? Advantages

• Checklists have demonstrated poor test-retest
  reliability.
• IB methods allow greater precision in the
  consistent identification of stressors as well as
  their onset and offset.
• McQuaid et al. (1992) 62 of checklist-
  identified
• stressors were found to be discrepant with
  those identified by
• the LEDS.

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Why Not Use These Methods? Disadvantages

• Cost of implementation
• Training is necessary
• Respondent/investigator burden in terms of time
  and effort for administration is considerable
• Rating and independent review of ratings can be
  lengthy
• Research considerations
• Not widely used in the literature because of cost
  and training
• Extant evidence supporting their use in terms of
  predictive validity is limited

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DEFINITIONS OF STRESS

• Response-based model
• (Selye, 1974) Stress is the nonspecific response
  of the body to any demand made upon it.
• Stimulus-based model
• (Holmes Rahe, 1967) Stress involves events
  whose adventrequires a significant change in the
  ongoing life pattern of the individual.
• Transactional model
• (Holroyd Lazarus, 1982) Stress involves the
  judgment that environmental or internal demands
  tax or exceed the individuals resources for
  managing them.

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DEFINITIONS OF STRESS

• Transactional model
• (Holroyd Lazarus, 1982) Stress involves the
  judgment that environmental or internal demands
  tax or exceed the individuals resources for
  managing them.
• ASSUMPTIONS
• Stress involves balance between demands and
  resources.
• The mechanism by which these are compared
  involves a judgment or a cognitive appraisal
  process.

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DEFINITIONS OF STRESS

• Transactional Model
• Primary Appraisal What is at stake?
• Secondary Appraisal Can I cope?

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DEFINITIONS OF STRESS

• Transactional Model
• Appraisal as final common pathway by which
  diverse personal and environmental variables
  influence the outcomes of stressful encounters.
• Transactional model

person
environment
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Perceived Stress ScaleCohen, Kamarck
Mermelstein (1983). J Health and Soc Bhr, 24,
386-96.
2. In the last month, how often have you felt
that you were unable to control the important
things in your life? 6. In the last month, how
often have you felt confident about your ability
to handle your personal problems? 7. In the last
month, how often have you felt that things were
going your way? 14. In the last month, how often
have you felt difficulties were piling up so high
that you could not overcome them?
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DEFINITIONS OF STRESS

• Transactional Model

STRENGTHS Takes into consideration individual
differences in perception or appraisal. WEAKNESSES
Confounded with a number of dimensions, such as
depressive symptoms and neuroticism, which may be
important to disaggregate from the construct of
stress.
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Cognitive Appraisal and the Brain
Joseph LeDoux
Cognitive appraisal may not be necessary in order
for a stimulus to elicit an emotional response
that alters the physiology of the organism.
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THE TEMPORAL DIMENSION
ACUTE
CHRONIC
RESPONSE-BASED
STIMULUS-BASED
TRANSACTION
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THE CHALLENGE OF EXPOSURE ASSESSMENT

• As with other environmental risk factors (e.g.,
  passive smoking, radiation) the impact of
  psychosocial stress on health should be expected
  to vary as a function of the frequency, duration,
  or intensity of daily exposure.
• Documenting the extent of environmental risk
  exposure (not just intensity but also frequency
  and duration) is a challenge for epidemiologists
  who study the risk factors related to disease,
  and all the more so when such risk factors
  involve psychosocial processes.
• When it comes to the measurement of psychosocial
  stress, we have not yet adequately addressed this
  challenge.

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EXPOSURE BIOLOGY PROGRAM

• Enhance our ability to assess environmental
  exposures (e.g., environmental and chemical
  toxins) that may interact with genetic
  propensities to influence health
• environmental toxins, drugs chemical agents,
  nutritional factors, physical activity,
  psychosocial stress.

Common Denominator Frequency and duration of
exposure to these factors may be difficult to
assess using standard methods.
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THE CHALLENGE OF EXPOSURE ASSESSMENT

• INVESTIGATOR-BASED INTERVIEW APPROACH
• Accuracy in assessment of stressor onset ,
• offset using objective criteria
• duration of stressor
  exposure.

ECOLOGICAL MOMENTARY ASSESSMENT

• Ability to collect representative time
  samples frequency and
  duration of exposure.

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THE TEMPORAL DIMENSION
CHRONIC
RESPONSE-BASED
ECOLOGICAL MOMENTARY ASSESSMENT
EMA
INVESTIGATOR-BASED INTERVIEW APPROACH
STIMULUS-BASED
TRANSACTION
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THE CHALLENGE OF EXPOSURE ASSESSMENT

• INVESTIGATOR-BASED INTERVIEW APPROACH
• Accuracy in assessment of stressor onset ,
• offset using objective criteria
• duration of stressor
  exposure.

Life Events and Difficulties Schedule (LEDS)
(Brown Harris, 1989). --chronic difficulties
as well as acute events --extensive training,
administration scoring time
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LIFE EVENTS ASSESSMENT PROFILE (LEAP)
Barbara Anderson (Pitt) and Elaine Wethington
(Cornell University)
--maintained contextual assessment features of
LEDS. --maintained calendar methods for
determining onset, offset of chronic stressors
that takes into consideration fluctuation in
magnitude of effects over time. -- Extracted key
contextual features of stressors imbedded in
coding system of LEDS structured
behavior-specific probes.
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LIFE EVENTS ASSESSMENT PROFILE (LEAP)
Computer Assisted Personal Interview
(CAPI) system with relational database features
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LIFE EVENTS ASSESSMENT PROFILE (LEAP)

• 10 different life domains in LEAP, skip patterns
  can be quite complex.
• Relational database features will allow us to
  interact with calendar system, updated throughout
  the interview, allowing us to characterize the
  onset, offset of events and difficulties across
  domains.
• Use of computerized algorithms for navigating
  through interview is expected to result in
  considerable time savings in interview
  administration.
• Automated and instantaneous scoring of protocol
  will eliminate need for scoring, consensus
  meetings, further reducing time requirements.

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LIFE EVENTS ASSESSMENT PROFILE (LEAP)

• CAPI will permit us to administer the LEAP by
  phone.
• One of first attempts to develop automated
  administration system for comprehensive interview
  assessment of life stressors.

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THE CHALLENGE OF EXPOSURE ASSESSMENT
ECOLOGICAL MOMENTARY ASSESSMENT

• Ability to collect representative time
  samples frequency and
  duration of exposure.

Assumption Chronic stress leaves its signature
on the behavioral and biological events of our
daily lives. Limitations of autobiographical
memory for reconstructing frequency, duration of
daily events (Bradburn et al., 1987).
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ECOLOGICAL MOMENTARY ASSESSMENT (EMA) APPROACH TO
THE ASSESSMENT OF PSYCHOSOCIAL STRESS

• RATIONALE
• EMA measures may allow us to more accurately
  capture the frequency and duration of
  psychosocial stress exposure as it pertains to
  our daily experience.
• EMA measures allow us to examine mechanistic
  hypotheses linking stress with disease can be
  linked with moment-to-moment changes in
  biological processes, e.g., endocrine or
  hemodynamic activity.
• EMA measures allow us to examine the importance
  of setting effects relevant to the occurrence and
  consequences of stress (e.g., social interactions
  with partner vs. others health effects of job
  demands vs. household demands vs. neighborhood
  demands).

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Five psychological processes linked with stress,
acute cardiovascular activation, and disease risk

• NEGATIVE AFFECT
• AROUSAL
• TASK DEMAND
• TASK CONTROL
• SOCIAL CONFLICT

Kamarck et al. (1998). Health Psychology, 17,
17-29.
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• KARASEK JOB CONTENT QUESTIONNAIRE
• Psychological Demands
• My job requires working very fast.
• My job requires working very hard.
• I am not asked to do an excessive amount of
  work. (R)
• I have enough time to get the job done. (R)
• I am free from conflicting demands that others
  make. (R)
• Decision Latitude e.g.,
• My job allows me to make a lot of decisions on my
  own.
• 2. On my job, I have very little freedom to
  decide how I do my work.(R)
• 3. I have a lot of say about what happens on my
  job. (R)

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TASK DEMAND Activity last 10 minutes Required
working hard? NOYES Required
working fast? NOYES
Juggled several tasks at once?
NOYES
Adapted from Karasek Job Content
Questionnaire
DECISIONAL CONTROL Activity last 10
minutes Could change activity if you chose
to? NOYES Choice in
scheduling this activity? NOYE
S
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TABLE 1. DIARY RATINGS AT HOME AND WORK (n
176) Home Work t p Task
Demand 3.97 5.60 15.36 .0001 Dec
Control 8.22 6.76 -10.50 .0001 Negative
Affect 3.45 3.61 3.15 .0019 Arousal 7.41 8.40
15.24 .0001 Social Conflict 2.64 2.61 -.64 .5215
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Five psychological processes associated with
moment-to-moment changes in blood pressure

• SBP p
• NEGATIVE AFFECT .38 .0001
• AROUSAL .54 .0001
• TASK DEMAND .18 .0003
• TASK CONTROL -.09 .02
• SOCIAL CONFLICT .41 .0001

Kamarck et al. (2002). Physiology and Behavior,
77, 699-704.
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TABLE 2. FOUR MONTH TEST-RETEST RELIABILITY OF
DIARY SUBSCALES (N 354) r p Task
Demand .73 .0001 Dec Control .70 .0001 Nega
tive Affect .75 .0001 Arousal .76 .0001 So
cial Conflict .73 .0001
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GLOBAL VS. MOMENTARY RATINGS OF DEMAND AND
CONTROL (N152)
Global Job Ratings Demand Control Mean Momentary
Ratings at Work Demand r .53
---- Control ---- .31
lt .0001
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Aggregated over 6-day period, mean ratings of
Task Demand and Task Control associated with
chronic elevations of blood pressure during daily
life
Kamarck et al. (2002). Physiology and Behavior,
77, 699-704.
Mean Task Demand / Mean Task Control
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Mean ratings of Task Demand and Task Control
related in the expected direction with measures
of carotid artery atherosclerosis
Kamarck et al. (2004). Health Psychology, 23,
24-32.
b.02, F (1, 328) 8.44, r2 .02, p .004
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Mean ratings of Task Demand and Task Control
related in the expected direction with measures
of carotid artery atherosclerosis

• Global questionnaire measures of Psychological
  Demands and Decision Latitude (JCQ) were not
  significantly correlated with mean IMT.
• e.g., Demands (b.00, p.59, r2 .00).

Kamarck et al. (2004) Health Psychology, 23,
24-32.
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Mean ratings of Task Demand and Task Control
related in the expected direction with measures
of carotid artery atherosclerosis

• Task Demand ratings were associated with
  atherosclerosis even among those who were not
  employed during the study (n141).
• (b.02, p.03, r2 .03).
• Among employed Ss (n152), association did not
  differ as a function of whether ratings were
  derived from inside or outside of the workplace.
• Work (b.02, p.02, r2 .03).
• Nonwork (b.02, p.05, r2 .02).

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Mean ratings of Task Demand and Task Control
related in the expected direction with measures
of carotid artery atherosclerosis
Kamarck et al. (2007). Health Psychology, 26,
324-332.
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ECOLOGICAL MOMENTARY ASSESSMENT (EMA) APPROACH TO
THE ASSESSMENT OF STRESS

• Conclusion There may be some important utility
  to this new assessment approach as a means of
  understanding how the cumulative effects of
  chronic psychosocial stress impact on health
  outcomes over the course of daily living.

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THE CHALLENGE OF EXPOSURE ASSESSMENT
ECOLOGICAL MOMENTARY ASSESSMENT

• Ability to collect representative time
  samples frequency and
  duration of exposure.

• Our contribution at this point
• Development of more user-friendly assessment
  technologies.
• Refine our elaborate upon our measures, in order
• to be able to best characterize the types of
  daily stressors
• that are strongest triggers for biological
  systems thought
• to enhance our susceptibility to disease.

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e-Watch (Siewiorek, Smailagic) Human Computer
Interaction Institute (HCII, CMU)
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• E-WATCH
• In contrast to standard PDA, more flexible in
  terms of number of input, output, and prompting
  modalities available.
• Interview presentation
• visual (watch face)
• auditory (earbug)
• Responses
• manual (button push on watch)
• speech (earbug phone)
• gestural (accelerometer in watch)

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• E-WATCH
• We are in process of examining
• relative advantages of e-watch over PDA
• (user satisfaction and compliance)
• relative merits of each of these input and
  output modalities under various situations and
  for those (low literacy, manual laborers) assumed
  to have difficulty with traditional PDA
  assessments.

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OUR GOALS IN THE YEARS AHEAD
EXPOSURE BIOLOGY PROGRAM

• Phase 1 (Year 1)
• Development of testing devices for each of these
  two methods.
• Phase 2 (Year 2-3)
• Item analysis and validation of instrument
  content.
• Phase 3 (Year 3-4)
• Cross validation and reliability testing.
• Phase 4 (Year 4)
• Documentation, standardized training
  procedures, manufacturing plans.

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• EXPOSURE
• BIOLOGY
• PROGRAM
• University of Pittsburgh
• Computer-assisted technologies for tracking
  exposure to psychosocial stress.
• Johns Hopkins NIDA
• Real-time assessment of individual and
  neighborhood exposure to drugs and stress using
  hand-held electronic diaries and position
  technology (Kirk, Preston)
• University of Memphis
• Wireless skin patch sensors to dtect and transmit
  addiction and psychosocial stress data (Kumar)
• Rensselear Polyutechnic Institute
• A personal light-monitoring device for reducing
  psychosocial stress (Rea)
• UCLA
• Handheld salivary biosensor of psychosocial
  stress (Shetty)
• MIT
• Enabling population-scale physical activity and
  experience sampling measurement on common mobile
  phones (Intille)

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Were just getting off the ground