Week 05: Module 12: Stress Assessment methods- a valuable tool toward stress
management
Introduction
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 give 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.
What are the benefits of measuring Stress?
✓ Identifying potential health risks- 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
✓ Evaluating effectiveness of interventions- By measuring stress before and after an intervention,
such as therapy or stress management techniques, individuals and healthcare professionals can
determine if the intervention is effective in reducing stress
✓ 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
✓ Increased productivity- Measuring stress levels in employees can help identify areas where
changes can be made to improve working conditions and reduce stress levels, ultimately leading
to increased productivity or also help productivity in everyday life.
What do we mean by ‘stress measurement’?
Biologically, the term ‘stress’ is used as an umbrella term representing experiences in which the
environmental demands of a situation outweigh the individual’s perceived psychological and
physiological ability to cope with it effectively. So, what we actually measure is the ‘Response to stress’
that can manifest in many different forms.
Different forms of stressors and stress responses
Since there could be many different causes i.e., stressors, leading to many possible outcomes (stress
responses), that is collectively termed as ‘STRESS’. Stressors may be either physical (environmental and
physiological) or psychological/mental (cognitive and emotional) or mixed.
• The physical and physiological stressor 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/physiologic demands of the human body. The more common form of
environmental stressors includes cold/hot temperatures, noise, hypoxia, physical work pressure,
and infectious agents/disease.
• Psychological stressors may be either cognitive (affecting thought processes) or emotional
(affecting feeling responses, such as anger or fear). Examples of emotional stressor include fear-
and anxiety-producing threats (injury, disease, pain, failure, loss), anger, aversive/emotional
movies, interpersonal feelings, financial problems, and divorce/marital conflict.
• Cognitive stressors may include mostly the perception of a situation as either challenging or
limiting, being in isolation and low self-esteem
Stress responses are a series of events that the body experiences as an adaptation to the stimulus
induced by a stressor or combination of stressors. Stress responses can be categorized as psychological,
behavioral, cognitive, and physiological reactions that can occur before, during, or after the exposure.
• Psychological stress responses include feelings of anxiety, fear, frustration, anger, and
helplessness
• Behavioral responses refer to the observable actions or behaviors that an individual exhibits when
faced with a stressor. These behaviors can include changes in eating habits, sleep patterns, social
interactions, and activity levels. Ex: avoidance, aggression, substance use, over or under eating
withdrawal from social interaction,
• Cognitive responses can include negative or distorted thinking patterns, such as catastrophizing,
rumination, self-blame/guilt, self-destructive thoughts, negative self-talk
• Physiological responses include, autonomic, neuroendocrine, immune and neural changes related
to stressor exposure.
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.
Criteria to take into consideration before selecting a method of Stress measurement
Among all four stress responses, only physiological response can be measured quantitatively using
specific biomarkers that directly or indirectly correlate to biological stress. On the contrary, all other stress
assessment tools are subjective measurement of stress wherein the outcomes are highly dependent on an
individual’s perception of stress. An individual with better resilience (mentally) will fare differently from
someone more vulnerable.
Some other important criteria to note before choosing the assessment method are as follows;
• Measurement window- time gap from stress exposure to measurement, whether it is immediate or
there is a lag
• Type of stressor identified to be the cause for stress (whether work stress, environmental stress)
• If it is a one-time exposure or the stressor affects the person repeatedly
• Age of an individual experiencing the stressor
• Socioeconomic status of the individual
Physiological stress assessment tools
Assessment Type Significance in Stress pathology
Blood Pressure (BP) • Stress can sharply elevate blood pressure due to the release
Normal range – 80-120mmHg of the 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.
Heart Rate Variability (HRV)- • Heart rate variability is the physiological phenomenon of
measured using a ECG machine variation in the time interval between heartbeats
• It is a measurable reflection of balance between
sympathetic and parasympathetic tone and has been used
as a marker for cardiac status and predicting CV outcomes,
that could be related to acute or chronic stress
• Research suggests that a person with higher HRV while
resting can provide more appropriate emotional responses
compared to those that have low HRV at rest
Skin Temperature- • When the sympathetic nervous system is activated in
measured using infrared camera response to stress, a reduction in peripheral circulation
occurs.
• This peripheral vasoconstriction leads to a reduction in
skin temperature
• Sudden drop in skin temperature indicates exposure to
stress or under the influence of stressful event
Cortisol (hormone) – • Normal cortisol levels are usually highest early in the
Measured in blood/urine samples morning and lowest about midnight. Normal ranges vary
depending on the type of test. For most tests, normal
ranges are:
6 to 8 a.m.: 10 to 20 micrograms per deciliter (mcg/dL)
Around 4 p.m.: 3 to 10 mcg/dL
• Elevated cortisol levels, especially after 6 pm indicate
underlying stress
Other Biomarkers of stress include
Enzymes like Alpha amylase, Immunoglobulin (IgA), Inflammatory markers (CRP) all which may
directly or indirectly correlate to stress.
Psychological, Behavioral and Cognitive assessment tools
These are generally based on questionnaires. A questionnaire is a list of questions or items methodically
structured and validated to gather data from respondents about their attitudes, experiences, or opinions.
Questionnaires are commonly used in social and health sciences as well as in the market research.
Depending on the type, they can be administered face to face, by telephone, or online.
Psychological stress assessment tools
Tool Name Assessment Parameter
The Perceived Stress Scale (PSS)- • Is a classic stress assessment instrument to measure the
developed by Cohen, Kamarck & perception of stress.
Mermelstein (1983) • It measures the degree to which life situations are
appraised as stressful
• Contains 10 questions on current levels of perceived
stress, through an analysis of thoughts relating to the
last month
Ex: In the last month, how often have you felt that you
were unable to control the important things in your life?
0 to 4
NIOSH Generic Job Stress • Generic and comprehensive questionnaire – applicable
Questionnaire – to all types of work
designed by the US national institute for • contains measures of 13 different job stressors as well
occupational safety and health (NIOSH) as a host of measures of individual distress and
modifiers of the stress response
• Some job stress dimensions that in covers include-
conflict at work, social support, work hazards,
workload and responsibility, mental demand etc.
Post Traumatic Stress Disorder (PTSD) • It is a standardized self-report rating scale for PTSD
checklist- for Civilians (PCLC)- comprising 17 items that correspond to the key
was developed by Frank Weathers and his symptoms of PTSD
colleagues at the National Center for PTSD • The PCL is self-administered
(1993) • It is designed to assess responses to traumatic
experiences encountered in the course of civilian
living, using a 5-point (1–5) scale, circling their
responses. Responses range from 1 Not at All – 5
Extremely.
Other examples – Becks Depression Scale, Pittsburgh Sleep Quality Index
Behavioral stress assessment tools
Tool Name Assessment Parameter
Adult Eating Behaviour Questionnaire • The AEBQ is a 35-item measure that assesses eight
(AEBQ)- appetitive traits on a 1–5 Likert agree/disagree scale.
developed by Hunot C et al., in the United • widely used and well-validated measure of individual
Kingdom differences in food approach (enjoyment of eating,
eating in response to food cues in the environment, and
eating in response to negative affect) and avoidance
• It covers aspects of emotional eating and anxiety
induced eating that correlate to stress
Cognitive stress assessment tools
Tool Name Assessment Parameter
Cognitive Control and Flexibility • 18-item self-report measure
Questionnaire (CCFQ)- • measures an individual's perceived ability to exert
Developed by Robert Gabrys and team, control over intrusive, unwanted (negative) thoughts
Ottawa, Canada and emotions, and their ability to flexibly cope with a
stressful situation
Challenges in the field of Stress measurement
Measuring biological stress is a complex and challenging task due to the following reasons:
• Multiple systems involved: Biological stress is a complex phenomenon that involves various
systems, including the nervous system, endocrine system, and immune system. Each of these
systems has its unique response to stress, which can be difficult to measure accurately.
• 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 minimal response. This variability
makes it challenging to develop a standard measurement that can apply to everyone.
• Lack of a single biomarker: Unlike other physiological processes that have a single biomarker,
such as heart rate for cardiovascular health or glucose levels for diabetes, biological stress has no
single biomarker that can be used to measure it accurately.
• Timing: The timing of the 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.
• 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.
• Ethical considerations: Some of the techniques used to measure stress, such as collecting blood
or saliva samples, may raise ethical concerns, particularly when it comes to vulnerable populations
like children and pregnant women
Given these challenges, measuring biological stress requires careful consideration of the methods used
and the interpretation of the results. 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. One should explore further to get a thorough understanding of individual tool and
assess their relevance.