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The purpose of this study was to evaluate the effects of short-term, group-based
cognitive-behavioral stress management training on endocrine responses and cognitive appraisal
under acute stress in a population of healthy young male students. In order to find participants,
the research team sent out a recruiting email for a study involving stress management to all
students of the Swiss Federal Institute of Technology in Zurich, Switzerland. Within the email, a
link was provided to a website that briefly described the study. Those interested in partaking in
the study had the opportunity to enroll online. Following enrollment, each volunteer subject
received a screening questionnaire, which contained exclusion criteria. These criteria were
specifically designed to eliminate confounding factors that have been shown to affect
physiological dependent measures, and included the female gender and smokers. Additionally,
participants that reported any acute or chronic somatic or psychiatric disorder were excluded as
well. Subsequent to the providing of complete written and oral descriptions of the study, the
subjects were required to fill out written consent forms.
First, the research team needed to induce the same type of stress on each of the
participants, so they decided to use a psychosocial stress test. It has been found that the Trier
Social Stress Test (TSST) has consistently induced significant endocrine and cardiovascular
responses in a large majority of study participants (70-80%). Subjects were introduced to the
TSST subsequent to basal samples of salivary free cortisol. Then, they were ordered to go to a
different room, in which they had ten minutes to prepare and to complete a questionnaire
designed to assess cognitive appraisal processes regarding the anticipated stress scenario. Then,
the subjects returned to the testing room, where each of them took part in a simulated
five-minute job interview and a five-minute mental arithmetic task in front of an audience of two
people. To assess salivary free cortisol levels, saliva samples were taken immediately before and
after the Trier Social Stress Test, in addition to further samples taken at ten, twenty, thirty,
forty-five, and sixty minutes.
After stress was induced, all participants were subject to the stress management training. Each of
them attended group-based cognitive-behavioral stress management training following the
principles of stress inoculation training. Four groups attended group therapy sessions. Groups 1
and 2 met separately on two alternate Saturdays. Groups 3 and 4 also met separately on two
alternate Sundays. Each group consisted of twelve people and each session lasted from 1000
hours to 1700 hours. Each group was led by a qualified, postdoctoral psychotherapist in training
using a training manual. The groups were assisted on each training day by two psychology
students. The intervention mainly focused on the four cognitive–behavioral stress-reducing
techniques, including stress management (cognitive restructuring, problem-solving,
self-instruction) and relaxation training modules (progressive muscle relaxation). The first
session of group therapy consisted of a theoretical introduction and a group discussion regarding
transactional stress concepts. Two hours later, they had a one-hour lunch break. After, each stress
inoculation module was introduced and practiced in groups of four for one hour. At the end of
the first session, subjects received a training manual containing a summary of the transactional
stress concept and of all stress-reducing techniques that were introduced. The manual also
included a set of flash cards that briefly described what each stress-reducing technique entailed.
For “homework”, all study participants were encouraged to assess stress-relevant cognitions, to
carry and use the flashcards consistently, and to apply the techniques before the second group
session. The second group session began with a two-hour homework review, then a one-hour
lunch break, and afterwards, each technique was discussed and practiced again.
As for protocol, the research team implemented certain factors into their study. “Upon
return of all screening questionnaires, all subjects fulfilling the selection criteria were randomly
assigned to four groups by drawing numbers out of an envelope. Because the a priori power
calculation resulted in an optimal sample size of N = 48 (see below), only 48 subjects were
randomized. The remaining subjects were excluded. After randomization but before the group
treatment or waiting condition, all participants were given a set of questionnaires in order to
obtain comprehensive descriptions of relevant personality and stress factors (TICS, MESA,
FKK). Groups 1 and 2 underwent the TSST after completing the SIT while Groups 3 and 4
received the TSST before the SIT. Thus, Groups 1 and 2 served as treatment groups, while
Groups 3 and 4 formed the waiting control condition. The TSST committee did not know
whether or not the respective participant had performed the SIT beforehand. The TSST was
performed in different rooms from the SIT.”
In order to take measurements from the participants, sampling methods and biochemical
analyses were put in place. Saliva was collected by the subjects using Salivette collection devices
and stored at room temperature until completion of the session and stored at room temperature
until completion of the session. Samples were then stored at -20 degrees Celsius until they could
be biochemically analyzed. The free cortisol concentration in saliva was determined using a
time-resolved immunoassay with fluorometric detection. Inter- and intra-assay coefficients of
variance were below 10% for all analytes. In regards to psychometric measures, several
questionnaires were used in order to allow for comparison of relevant parameters between the
randomized groups. The first was the Trier Inventory of Chronic Stress (TICS), and this measure
was used to assess perceived chronic stress. The subjects were required to indicate how often
they individually experienced stressful situations throughout the past year. Trier Inventory of
Chronic Stress was constituted six subscales: work overload, work discontent, social stress, lack
of social recognition, worries, and intrusive memories. The second questionnaire was the
Competence and Control Orientation (FKK). This was comprised of thirty-two items that
assessed the following personality traits: “self-concept of own competence”, “internality”,
“powerful others control”, and “chance control”. The third questionnaire included in the study
was called Stress susceptibility (MESA). This was a thirty-six-item questionnaire, which
assessed stress susceptibility on six different subscales. Psychometric pre and post evaluation of
the stress inoculation training and the control-waiting condition was performed with the
Perceived Stress Scale (PSS). A German translation of the Perceived Stress Scale was used to
assess the degree to which situations in life experienced during the previous month are perceived
as stressful. Items in the PSS were designed to assess how predictable, uncontrollable, and
overloading participants find their own individual lives. The Primary Appraisal Secondary
Appraisal Scale (PASA) was the questionnaire that assessed anticipatory cognitive appraisal
processes in the TSST. This scale was specifically constructed to assess cognitive appraisal
processes in the TSST according to the transactional stress theory. The Primary Appraisal
Secondary Appraisal Scale is composed of four situation-specific subscales assessing primary
appraisals such as “Challenge” and “Perceived Threat”, as well as secondary appraisals like
“Self-Concept of Own Competence” and “Control Expectancy”. In order to assess anticipatory
cognitive appraisals, the PASA was administered at a time between the introduction and the
actual TSST. After collecting the data, statistical analyses were made. ANCOVAs and ANOVAs
for repeated measures were computed in order to analyze endocrine responses between groups,
controlling for differences in endocrine baseline levels when indicated. All reported results were
corrected by the Greenhouse-Geisser procedure where appropriate, and correlations were
computed as Pearson product-moment correlations. For all endocrine parameters, areas under
the total response curve (AUC), expressed as area under all samples, were calculated using the
trapezoidal method. Data were tested for normal distribution and homogeneity of variance using
a Kolmogorov–Smirnov and Levene’s test before statistical procedures were applied. The
optimal total sample size of N = 48 to detect an expected large effect size of f2 = 0.35
(representing a large effect size) with a power 0.85 and α = 0.05 was calculated a priori with the
statistical software G-Power (Buchner et al., 1997). For all analyses, significance level was α =
5%. Unless indicated, all results shown are means ± standard error of means (SEM).”
The Trier Social Stress Test had significant results involving salivary free cortisol
responses. The first saliva cortisol sample as covariate, ANCOVA, proved that baseline
differences between the groups did not substantially influence endocrine stress response. It was
found that groups had significant differences in their salivary free cortisol stress responses over
time, with subjects in the stress inoculation training group showing an attenuated salivary free
cortisol response. Also, subjects in the stress inoculation training group had a significantly lower
integrated salivary free cortisol response. In order to determine whether group differences in
cognitive appraisal of the Trier Social Stress Test had an influence on the salivary free cortisol
stress response, the PASA scales were included in the calculations as covariates. ANCOVA
results suggested that primary stress appraisal had a notable influence on the salivary free
cortisol stress response. The fact that this psychological factor was included was important
because it eliminated the observed significant group differences in the salivary free cortisol
response over time and the integrated salivary free cortisol response. It can also be concluded
that there was no significant association between the number of days between the stress
inoculation training and the Trier Social Stress Test and the integrated salivary free cortisol
response. It is also important to note that the groups differed significantly in their anticipatory
cognitive appraisal of the TSST. In comparison with controls, subjects in the stress inoculation
training group had lower primary stress appraisal and higher self efficacy appraisal. Groups did
not differ much in their perception of Novelty, with stress inoculation participants demonstrating
a decrease in perceived stress post treatment levels.
This study concluded that short, group-based, cognitive-behavioral stress management
training reduces the salivary free cortisol stress response to an acute stressor in healthy male
participants. These endocrine response differences were affected by the observed differences in
the cognitive appraisal of the situation. Subjects in the treatment group appraised the situation as
less stressful and displayed more competence in coping with the situation. It was found that all
reported effect sizes for significant endocrine and psychometric group differences in the Trier
Social Stress Test were large. On the other hand, the pre and post changes in perceived stress
were only of medium effect size.
The salivary free cortisol responses observed in our sample is somewhat higher than
those published by other groups using the TSST. This could be a consequence of the altered
TSST protocol we used in order to obtain data concerning the anticipatory appraisal processes.
However, this difference in the response magnitude does not seem to be a result of group
differences, since groups did not differ significantly in the basal cortisol levels and the respective
psychometric scales.
Female subjects were excluded from this study because had they been included, their
menstrual cycle phases would have to be controlled, along with the use of oral birth control. The
research team did this aware that it may have weakened the external validity of the study,
however they did it anyways in order to enhance the internal validity. However, since gender
differences of HPA axis stress responses seem to be mediated through differences in sex
hormone levels and the observed response differences in our study were mediated through
differences in the cognitive appraisal, the researchers were confident that the stress inoculation
training has similar neuroendocrine effects in females.
This is the first study to report that short, group-based, cognitive–behavioral stress
management training attenuates the endocrine and psychological response to acute stress in
healthy subjects. Alterations of HPA axis functioning have been linked to the development and
maintenance of psychosomatic and psychiatric disorder and somatic illness. According to the
concept of allostatic load, which represents a marker of cumulative biological burden exacted on
the body through attempts to adapt to life’s demands, several conditions of how stress leads to
alterations of the HPA axis can be distinguished. These include repeated activation during
chronic stress and failure to habituate to repeated stressors. With the observed attenuation of the
neuroendocrine stress response and the changes in cognitive appraisal of the stress situation, it is
possible that group-based, cognitive–behavioral stress management training could prove useful
in preventing detrimental consequences of stress-induced neuroendocrine responses, such as the
risk of developing hypertension and metabolic syndrome. However, it is important to note that
we have not assessed the effects of short, group-based, cognitive–behavioral stress management
training on markers of allostatic load, but rather on mechanisms that have been discussed to lead
to the development of allostatic load. There is consensus that the relation between HPA axis
parameters and health is not linear, thus both too much and too little HPA axis activity and
reactivity can be linked to disease and health complaints. As a consequence, the findings of a
reduced neuroendocrine stress response should not be considered to be protective per se, but
rather with regard to its possible role in the development of stress-related health complaints.
Since cortisol has been considered a primary mediator in the development of allostatic load,
further studies are necessary in order to evaluate possible long-term effects of the
neuroendocrine response differences that were observed.
Source #5: Meditation Programs for Psychological Stress and Well-being: A Systematic
Review and Meta-analysis
The purpose of this study was to evaluate the effects of short-term, group-based
cognitive-behavioral stress management training on endocrine responses and cognitive appraisal
under acute stress in a population of healthy young male students. In order to find participants,
the research team sent out a recruiting email for a study involving stress management to all
students of the Swiss Federal Institute of Technology in Zurich, Switzerland.
First, the research team needed to induce the same type of stress on each of the
participants, so they decided to use a psychosocial stress test. (Gaab, 2002) It has been found that
the Trier Social Stress Test (TSST) has consistently produced significant endocrine and
cardiovascular responses in a majority of study participants. (Gaab, 2002) Subjects were
introduced to the TSST subsequent to basal samples of salivary free cortisol. (Gaab, 2002) Then,
they were ordered to go to a different room, in which they had ten minutes to prepare and to
complete a questionnaire designed to assess cognitive appraisal processes regarding their
prospective individual stress scenario. (Gaab, 2002) After that, the subjects returned to the
testing room, where each of them took part in a simulated five-minute job interview and a
five-minute mental arithmetic task in front of an audience of two people. (Gaab, 2002) To assess
salivary free cortisol levels, saliva samples were taken immediately before and after the Trier
Social Stress Test, in addition to further samples taken at ten, twenty, thirty, forty-five, and sixty
minutes. (Gaab, 2002)
After stress was induced, all participants were subject to the stress management training.
(Gaab, 2002) Each of them attended group-based cognitive-behavioral stress management
training following the principles of stress inoculation training. (Gaab, 2002) Four groups
attended group therapy sessions. Each group was led by a qualified, postdoctoral psychotherapist
in training using a training manual. (Gaab, 2002) The intervention mainly focused on the four
cognitive–behavioral stress-reducing techniques, including stress management (cognitive
restructuring, problem-solving, self-instruction) and relaxation training modules (progressive
muscle relaxation). (Gaab, 2002) The first session of group therapy consisted of a theoretical
introduction and a group discussion regarding transactional stress concepts. (Gaab, 2002) After,
each stress inoculation module was introduced and practiced in groups of four for one hour.
(Gaab, 2002) At the end of the first session, subjects received a training manual containing a
summary of the transactional stress concept and of all stress-reducing techniques that were
introduced. (Gaab, 2002) The manual also included a set of flashcards that briefly described what
each stress-reducing technique entailed. (Gaab, 2002) For “homework”, all study participants
were encouraged to assess stress-relevant cognitions, to carry and use the flashcards consistently,
and to apply the techniques before the second group session. (Gaab, 2002)
In order to take measurements from the participants, sampling methods and biochemical
analyses were put in place. (Gaab, 2002) Saliva was collected by the subjects using Salivette
collection devices and stored at room temperature until completion of the session and stored at
room temperature until completion of the session. (Gaab, 2002) Samples were then stored at -20
degrees Celsius until they could be biochemically analyzed. (Gaab, 2002) The free cortisol
concentration in saliva was determined using a time-resolved immunoassay with fluorometric
detection. (Gaab, 2002) Inter- and intra-assay coefficients of variance were below 10% for all
analytes. In regards to psychometric measures, several questionnaires were used in order to allow
for comparison of relevant parameters between the randomized groups. (Gaab, 2002) The first
was the Trier Inventory of Chronic Stress (TICS), and this measure was used to assess perceived
chronic stress. (Gaab, 2002) The subjects were required to indicate how often they individually
experienced stressful situations throughout the past year. (Gaab, 2002) Trier Inventory of
Chronic (Gaab, 2002) Stress was constituted six subscales: work overload, work discontent,
social stress, lack of social recognition, worries, and intrusive memories. (Gaab, 2002) The
second questionnaire was the Competence and Control Orientation (FKK). (Gaab, 2002) This
was comprised of thirty-two items that assessed the following personality traits: “self-concept of
own competence”, “internality”, “powerful others control”, and “chance control”. (Gaab, 2002)
The third questionnaire included in the study was called Stress susceptibility (MESA). (Gaab,
2002) This was a thirty-six-item questionnaire, which assessed stress susceptibility on six
different subscales. (Gaab, 2002) Psychometric pre and post evaluation of the stress inoculation
training and the control-waiting condition was performed with the Perceived Stress Scale (PSS).
(Gaab, 2002) A German translation of the Perceived Stress Scale was used to assess the degree
to which situations in life experienced during the previous month are perceived as stressful.
(Gaab, 2002) Items in the PSS were designed to assess how predictable, uncontrollable, and
overloading participants find their own individual lives.(Gaab, 2002) “The Primary Appraisal
Secondary Appraisal Scale (PASA) was the questionnaire that assessed anticipatory cognitive
appraisal processes in the TSST. This scale was specifically constructed to assess cognitive
appraisal processes in the TSST according to the transactional stress theory.” (Gaab, 2002) The
Primary Appraisal Secondary Appraisal Scale is composed of four situation-specific subscales
assessing primary appraisals such as “Challenge” and “Perceived Threat”, as well as secondary
appraisals like “Self-Concept of Own Competence” and “Control Expectancy”. (Gaab, 2002) In
order to assess anticipatory cognitive appraisals, the PASA was administered at a time between
the introduction and the actual TSST. (Gaab, 2002)
The Trier Social Stress Test had significant results involving salivary free cortisol
responses. (Gaab, 2002) The first saliva cortisol sample as covariate, ANCOVA, proved that
baseline differences between the groups did not substantially influence endocrine stress response.
(Gaab, 2002) It was found that groups had significant differences in their salivary free cortisol
stress responses over time, with subjects in the stress inoculation training group showing an
attenuated salivary free cortisol response. (Gaab, 2002) Also, subjects in the stress inoculation
training group had a significantly lower integrated salivary free cortisol response. (Gaab, 2002)
In order to determine whether group differences in cognitive appraisal of the Trier Social Stress
Test had an influence on the salivary free cortisol stress response, the PASA scales were
included in the calculations as covariates. (Gaab, 2002) ANCOVA results suggested that primary
stress appraisal had a notable influence on the salivary free cortisol stress response. (Gaab, 2002)
The fact that this psychological factor was included was important because it eliminated the
observed significant group differences in the salivary free cortisol response over time and the
integrated salivary free cortisol response. (Gaab, 2002) It can also be concluded that there was no
significant association between the number of days between the stress inoculation training and
the Trier Social Stress Test and the integrated salivary free cortisol response. (Gaab, 2002) It is
also important to note that the groups differed significantly in their anticipatory cognitive
appraisal of the TSST. (Gaab, 2002) In comparison with controls, subjects in the stress
inoculation training group had lower primary stress appraisal and higher self efficacy appraisal.
(Gaab, 2002) Groups did not differ much in their perception of Novelty, with stress inoculation
participants demonstrating a decrease in perceived stress post treatment levels. (Gaab, 2002)
This study concluded that short, group-based, cognitive-behavioral stress management
training reduces the salivary free cortisol stress response to an acute stressor in healthy male
participants. (Gaab, 2002) These endocrine response differences were affected by the observed
differences in the cognitive appraisal of the situation. (Gaab, 2002) Subjects in the treatment
group appraised the situation as less stressful and displayed more competence in coping with the
situation. (Gaab, 2002) It was found that all reported effect sizes for significant endocrine and
psychometric group differences in the Trier Social Stress Test were large. (Gaab, 2002) On the
other hand, the pre and post changes in perceived stress were only of medium effect size. (Gaab,
2002)
The salivary free cortisol responses observed in the sample were somewhat higher than
those published by other groups using the TSST. (Gaab, 2002) This could be a consequence of
the altered TSST protocol they used in order to obtain data concerning the anticipatory appraisal
processes. (Gaab, 2002) “However, this difference in the response magnitude did not seem to be
a result of group differences, since groups did not differ significantly in the basal cortisol levels
and the respective psychometric scales.”(Gaab, 2002) Another study yielded similar results that
cognitive-behavioral stress management reduced cortisol levels, and in turn minimized stress.
(Antoni, 2000)
The research team made the decision to exclude female subjects from this study because
their menstrual cycle phases would have to be controlled, along with the use of oral birth control.
(Gaab, 2002) They made this decision knowing that it may have weakened the external validity
of the study, however they did it anyways in order to enhance the internal validity.(Gaab, 2002)
However, since gender differences of HPA axis stress responses seem to be mediated through
differences in sex hormone levels and the observed response differences in our study were
mediated through differences in the cognitive appraisal, the researchers were confident that the
stress inoculation training has similar neuroendocrine effects in females. (Gaab, 2002)
This is the first study to report that short, group-based, cognitive–behavioral stress
management training attenuates the endocrine and psychological response to acute stress in
healthy subjects. (Gaab, 2002) Alterations of HPA axis functioning have been linked to the
development and maintenance of psychosomatic and psychiatric disorder and somatic illness.
(Gaab, 2002) “With the observed attenuation of the neuroendocrine stress response and the
changes in cognitive appraisal of the stress situation, it is possible that group-based,
cognitive–behavioral stress management training could prove useful in preventing detrimental
consequences of stress-induced neuroendocrine responses, such as the risk of developing
hypertension and metabolic syndrome.” (Gaab, 2002) However, they have not assessed the
effects of short, group-based, cognitive–behavioral stress management training on markers of
allostatic load, but rather on mechanisms that have been discussed to lead to the development of
allostatic load. (Gaab, 2002) There is consensus that the relation between HPA axis parameters
and health is not linear, thus both too much and too little HPA axis activity and reactivity can be
linked to disease and health complaints. (Gaab, 2002) “As a consequence, the findings of a
reduced neuroendocrine stress response should not be considered to be protective per se, but
rather with regard to its possible role in the development of stress-related health complaints.”
(Gaab, 2002) Since cortisol is considered a primary mediator in the development of chronic
stress, further studies are necessary in order to evaluate possible long-term effects of the
neuroendocrine response differences that were observed. (Gaab, 2002)
Meditation Programs for Psychological Stress and Well-being: A Systematic Review and
Meta-analysis
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Michael H. Antoni, et al. (2000) Cognitive-behavioral stress management reduces distress and
24-hour urinary free cortisol output among symptomatic HIV-infected gay men, Annals of
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