Stress

Stress Management and Resilience Training Among Department of Medicine Faculty: A Pilot Randomized Clinical Trial

Amit Sood, Kavita Prasad, Darrell R. Schroeder +1 more · Journal of General Internal Medicine · 2011 · 409 citations

A single 90-minute one-on-one training session in the SMART (Stress Management and Resiliency Training) program produced statistically significant improvements in resilience, perceived stress, anxiety, and overall quality of life at 8 weeks compared to a wait-list control group among 40 Department of Medicine physicians at Mayo Clinic.

Stress Management and Resilience Training (SMART) Program to Decrease Stress and Enhance Resilience Among Breast Cancer Survivors: A Pilot Randomized Clinical Trial

Caitlin E. Loprinzi, Kavita Prasad, Darrell R. Schroeder +1 more · Clinical Breast Cancer · 2011 · 282 citations

Development of a new resilience scale: The Connor-Davidson Resilience Scale (CD-RISC)

Kathryn M. Connor, Jonathan Davidson · Depression and Anxiety · 2003 · 11,246 citations

Resilience may be viewed as a measure of stress coping ability and, as such, could be an important target of treatment in anxiety, depression, and stress reactions. We describe a new rating scale to assess resilience. The Connor-Davidson Resilience scale (CD-RISC) comprises of 25 items, each rated on a 5-point scale (0–4), with higher scores reflecting greater resilience. The scale was administered to subjects in the following groups: community sample, primary care outpatients, general psychiatric outpatients, clinical trial of generalized anxiety disorder, and two clinical trials of PTSD. The reliability, validity, and factor analytic structure of the scale were evaluated, and reference scores for study samples were calculated. Sensitivity to treatment effects was examined in subjects from the PTSD clinical trials. The scale demonstrated good psychometric properties and factor analysis yielded five factors. A repeated measures ANOVA showed that an increase in CD-RISC score was associated with greater improvement during treatment. Improvement in CD-RISC score was noted in proportion to overall clinical global improvement, with greatest increase noted in subjects with the highest global improvement and deterioration in CD-RISC score in those with minimal or no global improvement. The CD-RISC has sound psychometric properties and distinguishes between those with greater and lesser resilience. The scale demonstrates that resilience is modifiable and can improve with treatment, with greater improvement corresponding to higher levels of global improvement. Depression and Anxiety 18:76–82, 2003. © 2003 Wiley-Liss, Inc.

Stress Management and Resiliency Training (SMART) Program among Department of Radiology Faculty: A Pilot Randomized Clinical Trial

Amit Sood, Varun Sharma, Darrell R. Schroeder +1 more · EXPLORE · 2014 · 164 citations

The impact of stress on students in secondary school and higher education

Michaela C. Pascoe, Sarah Hetrick, Alexandra Parker · International Journal of Adolescence and Youth · 2019 · 1,204 citations

Students in secondary and tertiary education settings face a wide range of ongoing stressors related to academic demands. Previous research indicates that academic-related stress can reduce academic achievement, decrease motivation and increase the risk of school dropout. The longer-term impacts, which include reduced likelihood of sustainable employment, cost Governments billions of dollars each year. This narrative review presents the most recent research concerning the impact of academic-related stress, including discussion of the impact on students’ learning capacity and academic performance, mental health problems, such as depression and anxiety, sleep disturbances and substance use.

A randomized controlled trial of the effects of a stress management programme during pregnancy

Christina Tragea, George P. Chrousos, Evangelos C. Alexopoulos +1 more · Complementary Therapies in Medicine · 2014 · 73 citations

Brief mindful coloring for stress reduction in nurses working in a Hong Kong hospital during COVID-19 pandemic: A randomized controlled trial

Janet Shuk Yan Fong, Anna N. N. Hui, Ka Man Ho +2 more · Medicine · 2022 · 28 citations

BACKGROUND: Effective interventions to promote well-being at work are required to reduce the prevalence and consequences of stress and burnout especially during the COVID-19 pandemic. This study determined the effects of mindful coloring on perceived stress levels, mental well-being, burnout, and state and trait mindfulness levels for nurses during COVID-19. METHODS: This was a single-center, two-armed, parallel, superiority, blinded randomized controlled trial. Seventy-seven participants were randomly allocated (by computer-generated sequence) to either mindful coloring (n = 39) or waitlist control groups (n = 38). Twenty-seven nurses in the mindful coloring group and 32 in the control group were included in the full compliance per protocol analysis. The mindful coloring intervention included participants viewing a 3-minutes instructional video and coloring mandalas for at least 5 working days or 100 minutes in total during a 10-day period. Participants in both groups completed the Perceived Stress Scale (total score 0-40), short Warwick-Edinburgh Mental Well-being Scale (total score 7-35), Maslach Burnout Inventory-Human Services Survey for Medical Personnel (3 subscales), Five Facets Mindfulness Questionnaire-Short Form (total score 24-120) and Mindful Attention Awareness Scale-State version (total score 0-30) instruments. The primary outcome was the perceived stress level. RESULTS: Baseline prevalence of moderate to high perceived stress level was high (79.2%). There was a large mindful coloring effect on reducing mean perceived stress levels (Mean difference [MD] in change between groups -3.0, 95% CI: -5.0 to -1.00; Cohen's d = 0.80). Mindful coloring may lead to a small improvement in mental well-being level (P = .08), with an improvement found in the intervention group (MD 0.9, 95% CI 0.0-1.8, P = .04) through enhanced state mindfulness (P < .001). There were no effects on changing burnout subscales or trait mindfulness levels. No adverse reactions were reported. CONCLUSION: Coloring mandalas may be an effective low-cost brief intervention to reduce perceived stress levels through enhancing state mindfulness and it may promote mental well-being. Hospitals may promote or provide mindful coloring as a self-care and stress-relief practice for nurses during their off hours or work breaks.

The Effect of Music on the Human Stress Response

Myriam V. Thoma, Roberto La Marca, Rebecca Brönnimann +3 more · PLoS ONE · 2013 · 476 citations

BACKGROUND: Music listening has been suggested to beneficially impact health via stress-reducing effects. However, the existing literature presents itself with a limited number of investigations and with discrepancies in reported findings that may result from methodological shortcomings (e.g. small sample size, no valid stressor). It was the aim of the current study to address this gap in knowledge and overcome previous shortcomings by thoroughly examining music effects across endocrine, autonomic, cognitive, and emotional domains of the human stress response. METHODS: Sixty healthy female volunteers (mean age = 25 years) were exposed to a standardized psychosocial stress test after having been randomly assigned to one of three different conditions prior to the stress test: 1) relaxing music ('Miserere', Allegri) (RM), 2) sound of rippling water (SW), and 3) rest without acoustic stimulation (R). Salivary cortisol and salivary alpha-amylase (sAA), heart rate (HR), respiratory sinus arrhythmia (RSA), subjective stress perception and anxiety were repeatedly assessed in all subjects. We hypothesized that listening to RM prior to the stress test, compared to SW or R would result in a decreased stress response across all measured parameters. RESULTS: The three conditions significantly differed regarding cortisol response (p = 0.025) to the stressor, with highest concentrations in the RM and lowest in the SW condition. After the stressor, sAA (p=0.026) baseline values were reached considerably faster in the RM group than in the R group. HR and psychological measures did not significantly differ between groups. CONCLUSION: Our findings indicate that music listening impacted the psychobiological stress system. Listening to music prior to a standardized stressor predominantly affected the autonomic nervous system (in terms of a faster recovery), and to a lesser degree the endocrine and psychological stress response. These findings may help better understanding the beneficial effects of music on the human body.

Stress Recovery during Exposure to Nature Sound and Environmental Noise

Jesper Alvarsson, Stefan Wiens, Mats E. Nilsson · International Journal of Environmental Research and Public Health · 2010 · 858 citations

Research suggests that visual impressions of natural compared with urban environments facilitate recovery after psychological stress. To test whether auditory stimulation has similar effects, 40 subjects were exposed to sounds from nature or noisy environments after a stressful mental arithmetic task. Skin conductance level (SCL) was used to index sympathetic activation, and high frequency heart rate variability (HF HRV) was used to index parasympathetic activation. Although HF HRV showed no effects, SCL recovery tended to be faster during natural sound than noisy environments. These results suggest that nature sounds facilitate recovery from sympathetic activation after a psychological stressor.

Stress Management Training for Surgeons—A Randomized, Controlled, Intervention Study

Cordula M. Wetzel, Akram George, George B. Hanna +5 more · Annals of Surgery · 2011 · 140 citations

BACKGROUND: Stress and coping influence performance. In this study, we evaluate a novel stress management intervention for surgeons. METHODS: A randomized control group design was used. Sixteen surgeons were allocated to either the intervention or control group. The intervention group received training on coping strategies, mental rehearsal, and relaxation. Performance measures were obtained during simulated operations and included objective-structured assessment of technical skill, observational teamwork assessment for surgery, and end product assessment rated by experts. Stress was assessed using the state-trait-anxiety-inventory, observer rating, coefficient of heart rate variability (C_HRV), and salivary cortisol. The number of applied surgical coping strategies (number of coping strategies [NC]) was assessed using a questionnaire. A t test for paired samples investigated any within-subject changes, and multiple linear regression analysis explored between-subject effects. Interviews explored surgeons' perceptions of the intervention. RESULTS: The intervention group showed enhanced observational teamwork assessment for surgery performance (t = -2.767, P < 0.05), and increased coping skills (t = -4.690, P < 0.01), and reduced stress reflected inheart rate variability (t = -4.008, P < 0.01). No significant changes were identified in the control group. Linear regression analysis confirmed a significant effect on NC (β = -0.739, P < 0.01). Qualitative data analysis revealed improved technical skills, decision making, and confidence. CONCLUSIONS: The intervention had beneficial effects on coping, stress, and nontechnical skills during simulated surgery.

Healthcare worker stress, anxiety and burnout during the COVID-19 pandemic in Singapore: A 6-month multi-centre prospective study

Irene Teo, Junxing Chay, Yin Bun Cheung +21 more · PLoS ONE · 2021 · 222 citations

AIM: The long-term stress, anxiety and job burnout experienced by healthcare workers (HCWs) are important to consider as the novel coronavirus disease (COVID-19) pandemic stresses healthcare systems globally. The primary objective was to examine the changes in the proportion of HCWs reporting stress, anxiety, and job burnout over six months during the peak of the pandemic in Singapore. The secondary objective was to examine the extent that objective job characteristics, HCW-perceived job factors, and HCW personal resources were associated with stress, anxiety, and job burnout. METHOD: A sample of HCWs (doctors, nurses, allied health professionals, administrative and operations staff; N = 2744) was recruited via invitation to participate in an online survey from four tertiary hospitals. Data were gathered between March-August 2020, which included a 2-month lockdown period. HCWs completed monthly web-based self-reported assessments of stress (Perceived Stress Scale-4), anxiety (Generalized Anxiety Disorder-7), and job burnout (Physician Work Life Scale). RESULTS: The majority of the sample consisted of female HCWs (81%) and nurses (60%). Using random-intercept logistic regression models, elevated perceived stress, anxiety and job burnout were reported by 33%, 13%, and 24% of the overall sample at baseline respectively. The proportion of HCWs reporting stress and job burnout increased by approximately 1·0% and 1·2% respectively per month. Anxiety did not significantly increase. Working long hours was associated with higher odds, while teamwork and feeling appreciated at work were associated with lower odds, of stress, anxiety, and job burnout. CONCLUSIONS: Perceived stress and job burnout showed a mild increase over six months, even after exiting the lockdown. Teamwork and feeling appreciated at work were protective and are targets for developing organizational interventions to mitigate expected poor outcomes among frontline HCWs.

Heart Rate Variability Characteristics in a Large Group of Active-Duty Marines and Relationship to Posttraumatic Stress

Arpi Minassian, Mark A. Geyer, Dewleen G. Baker +3 more · Psychosomatic Medicine · 2014 · 105 citations

OBJECTIVE: Heart rate variability (HRV), thought to reflect autonomic nervous system function, is lowered under conditions such as posttraumatic stress disorder (PTSD). The potential confounding effects of traumatic brain injury (TBI) and depression in the relationship between HRV and PTSD have not been elucidated in a large cohort of military service members. Here we describe HRV associations with stress disorder symptoms in a large study of Marines while accounting for well-known covariates of HRV and PTSD including TBI and depression. METHODS: Four battalions of male active-duty Marines (n = 2430) were assessed 1 to 2 months before a combat deployment. HRV was measured during a 5-minute rest. Depression and PTSD were assessed using the Beck Depression Inventory and Clinician-Administered PTSD Scale, respectively. RESULTS: When adjusting for covariates, including TBI, regression analyses showed that lower levels of high-frequency HRV were associated with a diagnosis of PTSD (β = -0.20, p = .035). Depression and PTSD severity were correlated (r = 0.49, p < .001); however, participants with PTSD but relatively low depression scores exhibited reduced high frequency compared with controls (p = .012). Marines with deployment experience (n = 1254) had lower HRV than did those with no experience (p = .033). CONCLUSIONS: This cross-sectional analysis of a large cohort supports associations between PTSD and reduced HRV when accounting for TBI and depression symptoms. Future postdeployment assessments will be used to determine whether predeployment HRV can predict vulnerability and resilience to the serious psychological and physiological consequences of combat exposure.

Psychometric evaluation of three versions of the Italian Perceived Stress Scale

Marina Mondo, Cristina Sechi, Cristina Cabras · Current Psychology · 2019 · 247 citations

Effect of park prescriptions with and without group visits to parks on stress reduction in low-income parents: SHINE randomized trial

Nooshin Razani, Saam Morshed, Michael A. Kohn +5 more · PLoS ONE · 2018 · 161 citations

INTRODUCTION: Exposure to nature may reduce stress in low-income parents. This prospective randomized trial compares the effect of a physician's counseling about nature with or without facilitated group outings on stress and other outcomes among low-income parents. MATERIALS AND METHODS: Parents of patients aged 4-18 years at a clinic serving low-income families were randomized to a supported park prescription versus independent park prescription in a 2:1 ratio. Parents in both groups received physician counseling about nature, maps of local parks, a journal, and pedometer. The supported group received additional phone and text reminders to attend three weekly family nature outings with free transportation, food, and programming. Outcomes measured in parents at baseline, one month and three months post-enrollment included: stress (using the 40-point Perceived Stress Scale [PSS10]); park visits per week (self-report and journaling); loneliness (modified UCLA-Loneliness Scale); physical activity (self-report, journaling, pedometry); physiologic stress (salivary cortisol); and nature affinity (validated scale). RESULTS: We enrolled 78 parents, 50 in the supported and 28 in the independent group. One-month follow-up was available for 60 (77%) participants and three-month follow up for 65 (83%). Overall stress decreased by 1.71 points (95% CI, -3.15, -0.26). The improvement in stress did not differ significantly by group assignment, although the independent group had more park visits per week (mean difference 1.75; 95% CI [0.46, 3.04], p = 0.0085). In multivariable analysis, each unit increase in park visits per week was associated with a significant and incremental decrease in stress (change in PSS10-0.53; 95% CI [-0.89, -0.16]; p = 0.005) at three months. CONCLUSION: While we were unable to demonstrate the additional benefit of group park visits, we observed an overall decrease in parental stress both overall and as a function of numbers of park visits per week. Paradoxically the park prescription without group park visits led to a greater increase in weekly park visits than the group visits. To understand the benefits of this intervention, larger trials are needed. TRIAL REGISTRATION: ClinicalTrials.gov NCT02623855.

Reduction in perceived stress as a migraine trigger

Richard B. Lipton, Dawn C. Buse, Charles B. Hall +5 more · Neurology · 2014 · 143 citations

OBJECTIVE: To test whether level of perceived stress and reductions in levels of perceived stress (i.e., "let-down") are associated with the onset of migraine attacks in persons with migraine. METHODS: Patients with migraine from a tertiary headache center were invited to participate in a 3-month electronic diary study. Participants entered data daily regarding migraine attack experience, subjective stress ratings, and other data. Stress was assessed using 2 measures: the Perceived Stress Scale and the Self-Reported Stress Scale. Logit-normal, random-effects models were used to estimate the odds ratio for migraine occurrence as a function of level of stress over several time frames. RESULTS: Of 22 enrolled participants, 17 (median age 43.8 years) completed >30 days of diaries, yielding 2,011 diary entries including 110 eligible migraine attacks (median 5 attacks per person). Level of stress was not generally associated with migraine occurrence. However, decline in stress from one evening diary to the next was associated with increased migraine onset over the subsequent 6, 12, and 18 hours, with odds ratios ranging from 1.5 to 1.9 (all p values < 0.05) for the Perceived Stress Scale. Decline in stress was associated with migraine onset after controlling for level of stress for all time points. Findings were similar using the Self-Reported Stress Scale. CONCLUSIONS: Reduction in stress from one day to the next is associated with migraine onset the next day. Decline in stress may be a marker for an impending migraine attack and may create opportunities for preemptive pharmacologic or behavioral interventions.

A Randomized Cross-over Exploratory Study of the Effect of Visiting Therapy Dogs on College Student Stress Before Final Exams

Sandra Barker, Randolph T. Barker, Nancy L. McCain +1 more · Anthrozoös · 2016 · 160 citations

This exploratory study investigated the effect of visiting therapy dogs on college-student perceived and physiological stress the week prior to final exams. Students (n = 78) were randomly assigned to order of a therapydog intervention and attention-control condition, each 15 minutes long. Students completed the Perceived Stress Scale (PSS), a stress visual analog scale (SVAS), and provided saliva for measuring nerve growth factor (sNGF) and alpha amylase (sAA), prior to randomization. Saliva samples and SVAS were again collected after each condition. There was no effect of group order on demographics, PSS, or initial SVAS. Repeated measures models were used to analyze the complete data sets of 57 students. There were no significant differences in sAA between or within students completing the intervention and control conditions. sNGF was not subjected to analysis as most levels were undetectable. Significant differences in SVAS scores were found between the intervention and control condition, with large effect sizes. SVAS scores were lower following the intervention, regardless of condition order (intervention first, p = 0.0001, d = 1.87; intervention second, p = 0.0004, d = 1.63). No SVAS differences were found for the control condition. Based on these findings, campus events with visiting therapy dogs represent a costeffective, easily accessible activity to reduce perceived, but not physiological, stress for college students prior to final exams.

The upside of stress

Kelly McGonigal · Penguin Publishing Group · 2015 · ★ 3.0 (1)

The Upside of Stress: Why Stress Is Good for You, and How to Get Good at It

Kelly McGonigal · Penguin · 2016

Changing your mindset about stress—from "stress is harmful" to "stress can enhance performance and growth"—can reduce the negative health effects of stress and improve resilience, focus, and social connection, based on a synthesis of experimental, longitudinal, and neurobiological studies.

Evaluating an online stress management intervention for college students.

Samuel Hintz, Patricia Frazier, Liza Meredith · Journal of Counseling Psychology · 2014 · 132 citations

The goal of this study was to assess the feasibility and effectiveness of a theory-based online intervention designed to improve stress management in undergraduate students. The intervention focused on present control because it has been found to be associated with a range of positive outcomes, including lower levels of depression, anxiety, and stress, controlling for a range of other variables (e.g., Frazier et al., 2011, 2012). Two pilot studies were first conducted to confirm that our intervention could increase present control. We then randomly assigned psychology students (n = 292) who were prescreened to have lower scores on the present control subscale of the Perceived Control Over Stressful Events Scale (Frazier et al., 2011) to 1 of 3 conditions: the present control intervention, the present control intervention plus feedback, and stress-information only. Seventy-six percent (n = 223) began the intervention, and 87% (n = 195) of those completed the posttest and 3-week follow-up. The 2 present control intervention groups had lower levels of stress, depression, and anxiety symptoms (on the Depression Anxiety Stress Scales; Lovibond & Lovibond, 1995) and perceived stress (on the Perceived Stress Scale; Cohen, Kamarck, & Mermelstein, 1983) relative to the stress-information-only group at posttest and 3-week follow-up (mean between group d at follow-up = .35, mean within group d for intervention groups at follow-up = -.46). Further, mediation analyses revealed that these effects were mediated by changes in present control. Our intervention represents a potentially valuable tool for college mental health services.

Expressive writing and post‐traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity

Joshua M. Smyth, Jill R. Hockemeyer, Heather Tulloch · British Journal of Health Psychology · 2008 · 184 citations

Objectives. This study investigates the boundary conditions (feasibility, safety, and efficacy) of an expressive writing intervention for individuals with post‐traumatic stress disorder [PTSD]. Design. Randomized trial with baseline and 3‐month follow‐up measures of PTSD severity and symptoms, mood states, post‐traumatic growth, and (post‐only) cortisol reactivity to trauma‐related stress. Methods. Volunteers with a verified diagnosis of PTSD ( N = 25) were randomly assigned to an experimental group (writing about their traumatic experience) or control group (writing about time management). Results. Expressive writing was acceptable to patients with PTSD and appeared safe to utilize. No changes in PTSD diagnosis or symptoms were observed, but significant improvements in mood and post‐traumatic growth were observed in the expressive writing group. Finally, expressive writing greatly attenuated neuroendocrine (cortisol) responses to trauma‐related memories. Conclusions. The present study provides insight into several boundary conditions of expressive writing. Writing did not decrease PTSD‐related symptom severity. Although patients continue to exhibit the core features of PTSD, their capacity to regulate those responses appears improved following expressive writing. Dysphoric mood decreased after writing and when exposed to traumatic memories, participants' physiological response is reduced and their recovery enhanced.

Analysis of Psychophysiological Stress Response in Higher Education Students Undergoing Clinical Practice Evaluation

Ana Isabel Beltrán-Velasco, Pablo Ruisoto, Alberto Bellido-Esteban +2 more · Journal of Medical Systems · 2019 · 65 citations

Posttraumatic Stress, Heart Rate Variability, and the Mediating Role of Behavioral Health Risks

Paul A. Dennis, Lana L. Watkins, Patrick S. Calhoun +5 more · Psychosomatic Medicine · 2014 · 87 citations

OBJECTIVE: Posttraumatic stress disorder (PTSD) has been linked to reduced heart rate variability (HRV), which is in turn a risk factor for cardiovascular disease and death. Although hyperarousal and anxiety are thought to underlie this association, behavioral health risks, including smoking, alcohol dependence, obesity, and sleep disturbance, represent potential mechanisms linking PTSD and HRV. METHODS: To test this hypothesis, short-term laboratory-based and 24-hour ambulatory measures of HRV were collected from 227 young adults (18-39 years), 107 of whom were diagnosed as having PTSD. Latent variable modeling was used to assess the relationship of PTSD symptoms with HRV along with potential behavioral health mediators. RESULTS: PTSD symptoms were associated with reduced HRV (β = -0.21, p = .002). However, this association was reduced in models that adjusted for cigarette consumption and history of alcohol dependence and was rendered nonsignificant in a model adjusting for sleep disturbance. Independent mediation effects were deemed significant via bootstrapping analysis. Together, the three behavioral health factors (cigarette consumption, history of alcohol dependence, and sleep disturbance) accounted for 94% of the shared variance between PTSD symptoms and HRV. Abdominal obesity was not a significant mediator. CONCLUSIONS: These results indicate that behavioral factors-specifically smoking, alcohol overuse, and sleep disturbance-mediate the association between PTSD and HRV-based indices of autonomic nervous system dysregulation. Benefits from psychiatric and psychological interventions in PTSD may therefore be enhanced by including modification of health behaviors.

Depression and Stress Reactivity in Metastatic Breast Cancer

Janine Giese‐Davis, Frank H. Wilhelm, Ansgar Conrad +7 more · Psychosomatic Medicine · 2006 · 117 citations

Objective: Cancer-related distress due to the psychological and physical challenges of metastatic breast cancer (MBC) may result in symptoms of depression, which negatively affects quality and may influence quantity of life. This study investigated how depression affects MBC stress reactivity, including autonomic (ANS) and hypothalamic–pituitary–adrenal (HPA) axis function. Method: Forty-five nondepressed and 45 depressed patients with MBC underwent a modified Trier Social Stress Test (TSST) while affect, cardiovascular, respiratory, and cortisol responses were measured. Results: At study entry, depressed compared with nondepressed patients had significantly lower log cortisol waking rise levels (p = .005) but no other HPA differences. Positive affect (p = .025) and high-frequency heart-rate variability (lnHF) (p = .002) were significantly lower at TSST baseline in depressed patients. In response to the TSST, depressed patients reported significantly lower positive (p = .050) and greater negative affect (p = .037) and had significantly reduced lnHF (p = .031). In secondary analyses, at TSST baseline both low-frequency (lnLF) (p = .002) and very-low-frequency (lnVLF) (p = .0001) heart rate variability were significantly lower in the depressed group. In secondary analyses during the TSST, those who were depressed had significantly lower lnVLF (p = .008) and did not increase aortic impedance reactivity as much as did the nondepressed during the stressor (p = .005). Conclusion: Depression in patients with MBC was associated with alterations in autonomic regulation, particularly reductions in respiratory sinus arrhythmia, a measure of cardiac vagal control, at baseline and during the TSST. In addition, depression was associated with blunted HPA response to awakening. Both MBC groups had relative cortisol hyporesponsiveness to acute stress. ANS = autonomic nervous system; BMI = body mass index; BP = blood pressure; BRC = baroreflex control of heart rate; CO = cardiac output; CVD = cardiovascular disease; DBP = diastolic blood pressure; ECG = electrocardiogram; HDL = high-density lipoprotein; HPA axis = hypothalamic–pituitary–adrenal axis; HR = heart rate; HRSD = Hamilton Rating Scale of Depression; HRV = heart rate variability; ICG = impedance cardiogram; lnHF = natural log of high-frequency HRV; lnLF = natural log of low-frequency HRV; lnVLF = natural log of very low frequency HRV; LDL = low-density lipoprotein; MBC = metastatic breast cancer; MDD = major depressive disorder; ND = nondepressed; PANAS = Positive and Negative Affect Schedule; pCO2 = partial pressure of carbon dioxide; PEP = preejection period; RR interval = time between two consecutive R waves of the ECG; RSA = respiratory sinus arrhythmia; RSATF = transfer function respiratory sinus arrhythmia; SBP = systolic blood pressure; SNRI = serotonin–norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor; TSST = Trier Social Stress Test; VLDL = very-low-density lipoprotein.

Cardiac coherence, self-regulation, autonomic stability, and psychosocial well-being

Rollin McCraty, Maria A. Zayas · Frontiers in Psychology · 2014 · 288 citations

The ability to alter one's emotional responses is central to overall well-being and to effectively meeting the demands of life. One of the chief symptoms of events such as trauma, that overwhelm our capacities to successfully handle and adapt to them, is a shift in our internal baseline reference such that there ensues a repetitive activation of the traumatic event. This can result in high vigilance and over-sensitivity to environmental signals which are reflected in inappropriate emotional responses and autonomic nervous system dynamics. In this article we discuss the perspective that one's ability to self-regulate the quality of feeling and emotion of one's moment-to-moment experience is intimately tied to our physiology, and the reciprocal interactions among physiological, cognitive, and emotional systems. These interactions form the basis of information processing networks in which communication between systems occurs through the generation and transmission of rhythms and patterns of activity. Our discussion emphasizes the communication pathways between the heart and brain, as well as how these are related to cognitive and emotional function and self-regulatory capacity. We discuss the hypothesis that self-induced positive emotions increase the coherence in bodily processes, which is reflected in the pattern of the heart's rhythm. This shift in the heart rhythm in turn plays an important role in facilitating higher cognitive functions, creating emotional stability and facilitating states of calm. Over time, this establishes a new inner-baseline reference, a type of implicit memory that organizes perception, feelings, and behavior. Without establishing a new baseline reference, people are at risk of getting "stuck" in familiar, yet unhealthy emotional and behavioral patterns and living their lives through the automatic filters of past familiar or traumatic experience.

Effectiveness of an abbreviated version of the automated attention training technique (ATT) for stress reduction in a non-clinical sample—A randomized controlled trial

Anna Baumeister, S Boger, L. Schindler +2 more · Journal of Contextual Behavioral Science · 2024 · 2 citations

Stress is one of the leading risk factors for mental health problems. The attention training technique (ATT), developed in the context of metacognitive therapy, is a method for increasing flexible control of attention and might thus reduce the impact of stressful events on mental health. Developed as a 12-minute exercise, ATT is primarily used in a clinical context. To ensure low-threshold implementation by the general population in everyday life, we developed an abbreviated 5-minute version of the ATT. The present study examined the effectiveness of this abbreviated ATT in reducing stress in a three-armed randomized controlled trial by comparing the abbreviated version (ATTabbr; n = 74) with the long version (ATTlong; n = 67) and a waitlist control group (WCG; n = 77) in a non-clinical sample. The primary outcome was change on the Depression, Anxiety, and Stress Scale (DASS-21). In the intention-to-treat analysis of changes from baseline to follow-up, both the abbreviated ATT version and the long ATT version were superior to the WCG in the reduction of stress (d = 0.67 for the abbreviated version and d = 0.44 for the long version). From post to follow-up, reductions in stress were greater for the abbreviated version than the long version (d = 0.37). We also observed effects of both ATT versions on depression and anxiety but no effect on attention control, perseverative thinking, or quality of life. For the abbreviated version, we found preliminary evidence a dose-response relationship. Participants with access to the abbreviated version conducted the training twice as often compared with those with access to the long version. These results suggest that the abbreviated version of the ATT is associated with greater adherence and possibly greater effects on stress than the long version. If these results are confirmed, the abbreviated version could be used to reduce stress and increase mental well-being in the general population.

Temporal analysis of heart rate variability as a predictor of post traumatic stress disorder in road traffic accidents survivors

Abeer Shaikh Al Arab, Laurence Guédon-Moreau, François Ducrocq +7 more · Journal of Psychiatric Research · 2012 · 64 citations

Psychophysiological and Cortisol Responses to Psychological Stress in Depressed and Nondepressed Older Men and Women With Elevated Cardiovascular Disease Risk

C. Barr Taylor, Ansgar Conrad, Frank H. Wilhelm +9 more · Psychosomatic Medicine · 2006 · 92 citations

Objective: The objective of this study was to compare psychophysiological and cortisol reactions to psychological stress in older depressed and nondepressed patients at risk for cardiovascular disease (CVD). Methods: Forty-eight depressed participants and 20 controls with elevated cardiovascular risk factors underwent a psychological stress test during which cardiovascular variables were measured. Salivary cortisol was collected after each test segment. Traditional (e.g., lipids) and atypical (e.g., C-reactive protein) CVD risk factors were also obtained. Results: At baseline, the groups did not differ on lipid levels, flow-mediated vasodilation, body mass index, or asymmetric dimethylarginine. However, the depressed patients had significantly higher C-reactive protein levels. Contrary to our hypothesis, there were no differences in baseline cortisol levels or diurnal cortisol slopes, but depressed patients showed significantly lower cortisol levels during the stress test (p = .03) and less cortisol response to stress. Compared with nondepressed subjects, depressed subjects also showed lower levels of respiratory sinus arrhythmia (RSATF) during the stress test (p = .02). Conclusions: In this sample, older depressed subjects with elevated risk for CVD exhibited a hypocortisol response to acute stress. This impaired cortisol response might contribute to chronic inflammation (as reflected in the elevated C-reactive proteins in depressed patients) and in other ways increase CVD risk. The reduced RSATF activity may also increase CVD risk in depressed patients through impaired autonomic nervous system response to cardiophysiological demands. ACTH = adrenocorticotropic hormone; ADH = antidiuretic hormone; ADMA = asymmetric dimethylarginine; ANS = autonomic nervous system; BMI = body mass index; BP = blood pressure; BRC = baroreflex control; CAD = coronary artery disease; CBT = cognitive behavioral therapy; CHD = coronary heart disease; CO = cardiac output; CON = nondepressed control; CPM = cycles per minute; CVD = cardiovascular disease; DBP = diastolic blood pressure; DISH = Depression Interview and Structured Hamilton; ECG = electrocardiogram; FMVD = flow-mediated vasodilation; HDL = high-density lipoprotein; HPA = hypothalamic–pituitary–adrenal axis; HR = heart rate; HRSD = Hamilton Rating Scale of Depression; HRV = heart rate variability; LDL = low-density lipoprotein; MDD = major depressive disorder; MI = myocardial infarction; NO = nitric oxide; PANAS = Positive and Negative Affect Schedule; pCO2 = partial pressure of carbon dioxide; PEP = preejection period; PSS = Perceived Stress Scale; RSA = respiratory sinus arrhythmia; RSATF = transfer function respiratory sinus arrhythmia; SBP = systolic blood pressure; SVR = systemic vascular resistance; TSST = Trier Social Stress Test; VLDL = very-low-density lipoprotein.

Influence of stress-specific interventions on biomarker levels and cognitive function in cancer patients: Systematic review and meta-analysis.

Ding X, Zhu M, Zhao F +3 more · Br J Health Psychol · 2024 · 3 citations

Stress-specific interventions (mindfulness, cognitive-behavioural therapy, relaxation training, and yoga) improved subjective cognitive function in cancer patients (standardised mean difference = 0.28, 95% CI 0.09 to 0.47, p = 0.004) but had no reliable effect on objective executive function, and produced mixed, mostly non-significant effects on inflammatory biomarkers (cortisol, IL-6, TNF-α, CRP) — meaning if you want to test stress reduction for cognitive benefits, you should measure how you *feel* about your thinking, not just how you perform on cognitive tests.

A systematic review and meta-analysis of interventions to reduce perceived stress in breast cancer patients.

Ding X, Zhao F, Zhu M +4 more · Complement Ther Clin Pract · 2024 · 23 citations

Are Salivary Cortisol Levels Elevated in Periodontitis Patients Experiencing Stress Compared to Those without Stress? A Systematic Review and Meta-analysis.

Al-Ak'hali MS, Al-Moraissi EA, Fageeh HN +4 more · J Contemp Dent Pract · 2025 · 4 citations

Comparative Efficacy of Various Interventions to Reduce Perceived Stress Among Older Adults: A Systematic Review and Network Meta-Analysis.

Zhu M, Chen H, Wang Q +2 more · Worldviews Evid Based Nurs · 2025 · 3 citations

Reminiscence therapy (structured life-review conversations) had a 98.6% probability of being the most effective intervention for reducing perceived stress in older adults, followed by exercise (68.1%) and yoga (56.1%), based on a network meta-analysis of 23 randomised controlled trials involving 1,847 participants aged 60 and older.

Anxiety sensitivity moderates the subjective experience but not the physiological response to psychosocial stress

Travis Wearne, Abbie Lucien, Emily Trimmer +5 more · International Journal of Psychophysiology · 2019 · 35 citations

Perceived stress and diet quality in women of reproductive age: a systematic review and meta-analysis.

Khaled K, Tsofliou F, Hundley V +2 more · Nutr J · 2020 · 89 citations

Higher perceived stress is moderately associated with poorer diet quality in women aged 18–49 (r = −0.35), meaning that as stress goes up, diet quality goes down — but the relationship is highly variable across individuals and studies, so you cannot assume stress always worsens your eating.

Autonomic reactivity to stress in multiple sclerosis: A meta-analytic review.

Ranfaing S, Degraeve B, Lenne B +1 more · Mult Scler Relat Disord · 2026 · 0 citations

People with multiple sclerosis show a large reduction in autonomic responses to psychological stress compared to healthy controls (d = −1.21), meaning their heart rate, heart rate variability, and blood pressure barely budge during stress — suggesting the disease damages the brain circuits that normally prepare the body to handle emotional challenges.

Effectiveness of stress management interventions to change cortisol levels: a systematic review and meta-analysis.

Rogerson O, Wilding S, Prudenzi A +1 more · Psychoneuroendocrinology · 2024 · 66 citations

Stress management interventions, particularly mindfulness/meditation and relaxation techniques, can effectively improve cortisol levels in healthy adults, with the most pronounced effects seen when measuring the cortisol awakening response.

Quantitative meta-analysis of heart rate variability finds reduced parasympathetic cardiac tone in women compared to men during laboratory-based social stress.

Hamidovic A, Van Hedger K, Choi SH +3 more · Neurosci Biobehav Rev · 2020 · 48 citations

Effectiveness of interventions on the stress management of schoolteachers: a systematic review and meta-analysis.

Paudel NR, Adhikari BA, Prakash KC +3 more · Occup Environ Med · 2022 · 23 citations

Stress and Heart Rate Variability: A Meta-Analysis and Review of the Literature.

Kim HG, Cheon EJ, Bai DS +2 more · Psychiatry Investig · 2018 · 2,193 citations

This meta-analysis of 37 studies confirms that psychological stress consistently reduces heart rate variability (HRV), specifically by lowering parasympathetic (vagal) activity — meaning a stressed heart beats more monotonously — and supports using HRV as a non-invasive, objective biomarker for stress in self-experiments.

Physical relaxation for occupational stress in healthcare workers: A systematic review and network meta-analysis of randomized controlled trials.

Zhang M, Murphy B, Cabanilla A +1 more · J Occup Health · 2021 · 104 citations

The Effects of Cognitive-Behavioral Stress Management for Breast Cancer Patients: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Tang M, Liu X, Wu Q +1 more · Cancer Nurs · 2020 · 47 citations

Cognitive-behavioral stress management (CBSM) — a structured program combining cognitive therapy techniques with relaxation training — produces small-to-moderate improvements in relaxation, benefit-finding, positive mood, and reductions in anxiety, depression, and the stress hormone cortisol in breast cancer patients, but does not reliably reduce overall perceived stress or general mood disturbance.

Cognitive-behavioral intervention effects on mood and cortisol during exercise training

Frank M. Perna, Michael H. Antoni, Mahendra Kumar +2 more · Annals of Behavioral Medicine · 1998 · 43 citations

The purpose of the present study was to assess the effect of a time limited cognitive-behavioral stress management program (CBSM) on mood state and serum cortisol among men and women rowers (N = 34) undergoing a period of heavy exercise training. After controlling for life-event stress (LES), CBSM was hypothesized to reduce negative mood state and cortisol among rowers during a period of heavy training; mood and cortisol changes over the intervention period were hypothesized to be positively correlated. LES was positively associated with negative affect at study entry. After covariance for LES, rowing athletes randomly assigned to the CBSM group experienced significant reductions in depressed mood, fatigue, and cortisol when compared to those randomized to a control group. Decreases in negative affect and fatigue were also significantly associated with cortisol decrease. These results suggest that CBSM may exert a positive effect on athletes' adaptation to heavy exercise training.

Music therapy reduces stress and anxiety in critically ill patients: a systematic review of randomized clinical trials.

Umbrello M, Sorrenti T, Mistraletti G +3 more · Minerva Anestesiol · 2019 · 185 citations

A systematic review of 11 randomized trials (959 total patients) found that a single 30-minute session of music therapy consistently reduced anxiety and stress in critically ill ICU patients, as measured by self-reported scales and physiological signs like heart rate and blood pressure — but the evidence is limited by small sample sizes, lack of blinding, and wide variation in how music therapy was delivered.

Mindfulness mediates the physiological markers of stress: Systematic review and meta-analysis.

Pascoe MC, Thompson DR, Jenkins ZM +1 more · J Psychiatr Res · 2017 · 556 citations

Yoga, mindfulness-based stress reduction and stress-related physiological measures: A meta-analysis.

Pascoe MC, Thompson DR, Ski CF · Psychoneuroendocrinology · 2017 · 513 citations

A meta-analysis of 42 randomised controlled trials found that practising yoga asanas (physical postures) — with or without mindfulness-based stress reduction — reduces cortisol, resting heart rate, systolic blood pressure, fasting blood glucose, and cholesterol compared to active control activities like walking or stretching, with effect sizes ranging from small to moderate.

Stress and Work Performance Responses to a Multicomponent Intervention for Reducing and Breaking up Sitting in Office Workers: A Cluster Randomized Controlled Trial.

Maylor BD, Hough J, Edwardson CL +2 more · J Occup Environ Med · 2023 · 2 citations

A workplace intervention to reduce and break up sitting led to a large but non-significant trend toward lower daily cortisol levels (d=0.79, p=0.06) and significant improvements in self-reported vigour and cognitive liveliness after 8 weeks, suggesting that reducing sedentary time may improve both physiological stress markers and perceived work performance.

Can we influence the neurological development and hair cortisol concentration of offspring by reducing the stress of the mother during pregnancy? A randomized controlled trial.

Puertas-Gonzalez JA, Romero-Gonzalez B, Mariño-Narvaez C +3 more · Stress Health · 2023 · 6 citations

A cognitive behavioural therapy (CBT) stress management program during pregnancy reduced maternal psychological stress and cortisol levels, and led to lower hair cortisol concentrations in newborns at birth and significantly higher cognitive and motor development scores at 6 months of age, compared to standard prenatal care.

Digital Meditation to Target Employee Stress: A Randomized Clinical Trial.

Radin RM, Vacarro J, Fromer E +12 more · JAMA Netw Open · 2025 · 7 citations

A large randomized trial found that 10 minutes of daily app-based meditation for 8 weeks produced large reductions in perceived stress (Cohen d = 0.85) and small-to-moderate improvements in job strain, burnout, and work engagement among 1,458 healthcare employees, with effects largely maintained at 4-month follow-up.

Mindfulness-Based Stress Reduction Alleviates Depression, Anxiety, and Internalized Stigma Compared With Treatment-as-Usual Among Head and Neck Cancer Patients: Findings From a Randomized Controlled Trial.

Zhang Z, Zhang Q, Lu P +7 more · Depress Anxiety · 2025 · 0 citations

Chronic stress and functional health in older adults with concerns about falling: a study protocol of a randomized controlled trial with multicomponent exercise intervention (FEARFALL).

Britting S, Kob R, Görlitz A +3 more · Trials · 2024 · 7 citations

App-Based Mindfulness for Attenuation of Subjective and Physiological Stress Reactivity in a Population With Elevated Stress: Randomized Controlled Trial.

Kirk U, Staiano W, Hu E +6 more · JMIR Mhealth Uhealth · 2023 · 18 citations