YOGA FOR STRESS MANAGEMENT.

Module 12: Stress Assessment Methods

Namaste, I am Dr. Mithila, Associate Professor, Svyasa, Deemed to be University. Today we are
going to talk about the module entitled Stress Assessment Methods, a valuable tool towards
stress management. Measuring stress becomes an important tool in understanding the dynamics
of stress mechanism and also for developing suitable stress management methods. This way,
stress assessment and the outcomes of the assessment gives a valuable insight for both
researchers and clinicians. In this module, we will be discussing the possible ways to measure
stress and their significance in clinical research and stress management. So, what are the benefits
of measuring stress? Why do we actually need to measure stress? One of the biggest benefit is
identifying potential health risks, means prolonged or chronic stress can lead to numerous health
problems such as high blood pressure, heart disease, obesity and depression. Measuring stress
can help identify individuals who are at risk for these health problems and allow for early
intervention. Secondly evaluating effectiveness of the intervention by measuring stress before
and after an intervention such as a therapy or a stress management technique, individuals and
healthcare professionals can actually determine if the intervention is effective in reducing stress
or not or if they have to really modify the intervention according to the requirement. Next
personal awareness and self improvement measuring stress can help individuals become more
aware of their own stress levels and triggers which can help them develop strategies to manage
stress more effectively and increased productivity. So measuring stress levels in employees
especially can help identify areas which can change their working conditions and reduce stress
levels ultimately leading to increased productivity and also in general health productivity in
everyday life. So, these were the major benefits of measuring stress. When we say measuring
stress, what do we exactly mean by measurement here? What are we exactly measuring? So,
biologically the term stress is used as an umbrella term representing the various experiences in
which environmental demands of a situation outweigh the individual's perceived psychological
and physiological ability to cope with it effectively. So, what we are actually measuring is the
response to the stress that can manifest in many different forms. What are these forms of
different stressors and stress responses? By stressors, we mean the things that can trigger the
stress and the stress response are the events that are generated that happen inside our body as a
result of stressor. So, there could be many different causes leading to many possible outcomes
that is collectively termed as stress. So, stressors may be either physical which includes
environmental and physiological or psychological which includes cognitive and emotional or it
could be a mixed stressor. Coming to the physical and physiological stressor, it has a direct effect
on the body and induces direct metabolic or physiological changes. Physical stress may be an
external environmental condition or the internal physical or physiologic demands of the human
body. The more common form of environmental stressors include cold or hot temperatures,
noise, hypoxia meaning low oxygen and physical work pressure and infectious diseases or agents
and psychological stressors may be either cognitive which means they affect your thought
process or emotional affecting feeling of responses such as anger or fear and anxiety producing
threats such as injury, disease, pain, failure or loss and coming to the cognitive stressors, it
includes mostly the perception of a situation as either challenging or limiting, being in isolation
and also having low self-esteem also can act as a cognitive stressor. So, these were the different
types of stressors. Now coming to the stress response so stress responses are a series of events
that the body experiences as an adaptation to the stimulus induced by the stressor or a
combination of it. So, stress responses can be categorized as psychological, behavioral, cognitive
and physiological reactions that can occur before, during or after the exposure to a stressor. So,
physiological or psychological responses include feelings of anxiety, fear, frustration, anger and
helplessness and behavioral responses refer to the observable actions or behaviors
that an individual exhibits when faced with a stressor. So, these behaviors include changes in
eating habits, sleeping patterns, social interactions and activity levels. Example aggression,
substance overuse, over or under eating and withdrawal from social interaction all of them
constitute behavioral responses. Coming to the cognitive responses, they include negative or
distorted thinking patterns such as catastrophizing, rumination meaning thinking over and over
about the same stressful event, self-blame or guilt feeling, self-destructive thoughts and negative
self-talk also and physiological responses are diverse which can include autonomic response
neuroendocrine response, immune response and neural changes that are related to the stress
exposure So, looking at the myriad ways with which the body responds to a stressful incidence it
opens up that many possible ways to measure stress both qualitatively and quantitatively. So,
before actually going into discussing the stress measurement tools, we need to first understand
what criteria is important to take care of before actually choosing a tool because among all the
four stress responses that we discussed, only physiological response can be measured
quantitatively using specific biomarkers that directly or indirectly correlate to the biological
stress. On the contrary, all other stress assessment tools are mostly subjective measurement of
stress wherein the outcomes are highly dependent on an individual's perception of stress. An
individual with better resilience that means a person who is mentally more stronger will fare
differently from someone who is more vulnerable. So, it is very important to take into
consideration some of the important criteria before choosing the assessment method. Some of
them are measurement window. What do we mean by measurement window? It is the time gap
from the stress exposure to the measurement whether it is immediate or there is a gap that means
a person might have experienced stress just now or a week ago or few months ago. So, it is very
important to understand this time gap between the stress exposure or event and the measurement.
And next is the type of stressor identified to be the cause for stress. We just now discussed
different types of stressors. So, it is important to identify where is the root whether it is the work
stress or the family stress or the environmental stress that helps us to choose the better
measurement tool. And if it is a one-time exposure or the stress affects the person repeatedly.
Sometimes the stressful event may be a one-time incident or sometimes the stressor might be
affecting the person on a day-to-day basis. So, it is important to understand whether it is a one-
time exposure or whether it is a repeated exposure. And also the age of an individual
experiencing the stressor is a very important because children and adult both have different ways
to respond to the stress and also the coping mechanisms are also different. So, before choosing a
measurement tool it is important to take into account the age of an individual and also the socio-
economic status of the individual because socio-economic status decides the education of an
individual and also the financial status which have a huge impact on how an individual responds
to the stress. So, keeping in mind all of these factors we can choose the best suited measurement
tool for assessing the stress of an individual. Now, let us go into the details of the stress
assessment tools. Firstly, we are going to talk about the physiological stress assessment tools.
We will talk about the assessment type and also the significance in stress pathology. Firstly, the
most important thing that one can measure immediately is the blood pressure. Stress can actually
sharply elevate blood pressure due to the release of hormone adrenaline that makes the heart
pump faster. Although BP increases during a stressful event, it reduces once the body adapts but
in case of chronic stress, BP may remain elevated for longer than desired. This may lead to
development of hypertension. The normal range for a blood pressure is 80 to 120 mmHg.
Anything above this for a longer duration can seriously affect the person and lead to
hypertension. Next important stress measurement tool is the heart rate variability. So, heart rate
variability is used is measured using an ECG machine. So, HRV as it is called is the
physiological phenomenon of variation in the time interval between the heartbeats. That means,
each heartbeat is not equally spaced. There is irregularity in the spacing between two heartbeats.
So, this irregularity is what we called as the heart rate variability. It is a measurable reflection of
balance between sympathetic and parasympathetic tone and has been used as a marker for
cardiac status and productive cardiovascular outcomes that could be related to acute or chronic
stress and research also suggests that a person with higher heart rate variability while resting can
provide more appropriate emotional responses as compared to those that have low heart rate
variability at rest. That means, a higher HRV suggests or indicates that heart is stronger as
compared to a lower HRV. Now, moving on to the next measurement tool, it is the skin
temperature. So, the skin temperature is measured using an infrared camera. So, when the
sympathetic nervous system is activated in response to stress, a reduction in peripheral
circulation occurs. This peripheral vasoconstriction leads to a reduction in skin temperature. So,
the sudden drop in skin temperature indicates exposure to stress or even indicates that you are
under the influence of a stressful event. For a common day example, whenever we are getting
ready to write an exam or give a public speech, we can feel that our hands and feet feel really
cold. This is exactly an indication of a little stress that the body is experiencing. Next, coming to
the hormone cortisol, we have extensively discussed the effects of cortisol on the body in the
physiology of stress module. So, cortisol hormone is measured in the blood, urine or saliva
sample. So, the normal cortisol levels are usually highest in the early morning and lowest about
midnight. So, the normal ranges vary depending on the type of test, but for most tests, normal
ranges are10 to 20 micrograms per deciliter from between 6 and 8 am and 3 to 10 micrograms
per deciliter at around 4 pm. Elevated cortisol levels especially after 6 pm can indicate an
underlying stress. So, these were some of the most important physiological assessments for
measuring stress. Some other biomarkers of stress include enzymes like alpha amylase which is
released in saliva as an exposure to a stressful event and immunoglobulin A that means it is an
antibody which is released during a stressful event or even after a stressful event as an adaptation
to the stress and inflammation. So, when you measure inflammation, you can understand that
there is an underlying stress because chronic stress can lead to a lot of inflammation in the body.
The most commonly used inflammatory marker is the CRP which is the C-reactive protein. So,
all of these biomarkers may directly or indirectly correlate to stress. Now, let us move on to the
psychological, behavioral and cognitive assessment tools. So, these are generally based on
questionnaires. So, a questionnaire is a list of questions or generally called as items. They are
methodically structured and validated to gather data from respondents about their attitudes,
experiences or opinions. Questionnaires are commonly used in social and health sciences and as
well as in the market research. So, depending on the type they can be administered face to face,
via telephone or even online. Let us look into some of the psychological stress assessment tools.
First and foremost, the most important psychological assessment tool that was developed is
called as the Perceived Stress Scale, the PSS. It was developed by Cohen and his team in the year
1983. It is a classic stress assessment instrument to measure the perception of stress. It measures
the degree to which life situations are appraised as stressful. Whether the individual looks at the
situation as stressful or not, that is very important. That is what this PSS measures. It contains 10
questions on current levels of perceived stress through an analysis of thoughts relating to the past
month. For an example question, in the last month how often have you felt that you were unable
to control the important things in your life? This is one example question that is part of this PSS
questionnaire and the respondent will be rating the question from 0 to 4 where 0 means never
and 4 means very often. So, using these scores, we can calculate or assess the stress levels of an
individual. Next coming to generic job stress questionnaire so, it is designed by the US National
Institute for Occupational Safety and Health. So, this is a job stress related questionnaire and it is
a generic and comprehensive one applicable to all types of work. It contains measures of 13
different job stressors as well as a host of measures of individual distress and modifiers of the
stress response. Some of the stress dimensions that it covers include conflict at work, social
support, work hazards, workload and responsibility mental demand etc. So, using this
questionnaire you can assess whether the person is experiencing stress because of the job. Next
the post traumatic stress disorder checklist for civilians. So, this was developed by Frank
Weathers and his colleagues at the National Center for PTSD in 1993. So, PTSD means the post
traumatic stress disorder. So, it is a standardized self-reporting scale for PTSD comprising 17
items that correspond to the key symptoms of PTSD. Some of the key symptoms of PTSD are
always being in the guard behavior or defensive mindset or having self-destructive thoughts,
showing aggression. These are some of the important symptoms of PTSD and this questionnaire
is self-administered that means, a person can read the question by themselves and answer the
questions and it is designed to assess responses to the traumatic experiences encountered in the
course of a civilian living. Why do we why they have called it as a civilian questionnaire because
there is also one other variant of this questionnaire that is applicable to the military trauma,
people who undergo trauma because of the military experience or the war experience. So, this
particular questionnaire is applicable for civilians and the other variant is applicable for military
people and it uses a 5 point scale that means, rating between 1 to 5 and they circle their responses
ranging from 1 which means not at all and 5 meaning extremely. So, these were some of the
important psychological questionnaires and some other examples of psychological
questionnaires include Beck's depression scale to assist depression and Pittsburgh's sleep quality
index which assesses the sleep quality of a person and hospital trauma questionnaire which
assesses a trauma experience after a hospitalization of an individual. Now, let us move on to the
behavioral stress assessment tools. The most important behavioral mechanism or coping
mechanism will be the eating behavior. So, an adult eating behavior questionnaire that is the
AEBQ was developed by Junot et al in the United Kingdom. So, the AEBQ is a 35 item measure
which means there are 35 questions that assess 8 appetitive traits on a 1 to 5 Likert scale which
says you agree or disagree or strongly disagree or strongly agree like that. So, it is widely used
and well validated measure of individual differences in food approach whether the person is
eating food because of enjoyment or eating food because of the environmental conditions or
eating in response to a negative effect like stress and also avoiding food. So, it covers aspects of
emotional eating and anxiety induced eating that correlate to underlying stress. Moving on one
other important tool is the cognitive stress assessment tool. It is called as the Cognitive Control
and Flexibility Questionnaire CCFQ. It was developed by Robert Gabris and team in Ottawa
Canada and it is an 18 item self-report measure. It measures an individual's perceived ability to
exert control over intrusive unwanted that means negative thoughts and emotions and their
ability to flexibly cope with a stressful situation. Now, that we have understood the different
measures that are available or the measurement tools that are available to measure stress, we also
need to understand the different challenges this stress measurement entails. Measuring biological
stress is a complex and challenging task due to the following reasons. Firstly, multiple systems
involved. Biological stress is a complex phenomenon that involves various systems including
nervous system, endocrine system and immune system. Each of these systems has its unique
response to stress which can be difficult to measure accurately and individual variability. The
response to stress varies from one individual to another. Some people may have a strong reaction
to stress while others may have a very minimal response. So, this variability makes it challenging
to develop a standard measurement that can be applicable to everyone and there is a lack of a
single biomarker. Unlike other physiological processes that have a single biomarker for example,
you can measure heart rate to look at the cardiovascular health or you can measure glucose to
check the diabetes. But for biological stress, it has no single biomarker that can be used to
measure stress and timing. The timing of measurement can significantly affect the results. Stress
can have an immediate effect on the body but it can also have a long-term effect. Therefore,
measuring stress at different time points can yield different results and environmental factors.
Environmental factors such as noise, light and temperature can influence the response to stress
making it challenging to isolate the effect of stress alone. And lastly the ethical consideration as
we discussed some of the biomarkers that are used to measure stress requires collection of blood
samples and saliva samples. This may raise ethical concerns particularly when it comes to
vulnerable population like children and pregnant women. So, given these challenges measuring
biological stress requires careful consideration of the methods used and the interpretation of the
results also. Researchers must take into account the variability of individual responses and the
potential influence of environmental factors and use multiple measurements to obtain a
comprehensive understanding of stress. Overall, this module gives some insight into the
significance of stress measurement and briefly discusses the tools available. However, one
should explore further to get a thorough understanding of individual tools and assess their

relevance before implementation in the real world. Thank you .