QUANTITATIVE ASSESSMENT OF STRESSORS AND
STRESS REACTION: A REVIEW
Satoko EZOE* and Kanehisa MORIMOTO*
To survey methods for assessing stress and to examine the relationship of stress to health and the factors of lifestyle, we reviewed the literature on stressors and stress reactions. Firstly, we reviewed the representative methods for assessing stressors. Secondly, self-report questionnaires based on a theoret ical model of occupational stressors were surveyed and factors in work stress were listed. Then, we re viewed stress reactions including physiological, psychological and behavioral reactions. Finally, we examined the relationship of perceived stress measured by a single question to mental health status determined by the General Health Questionnaire (GHQ-28), lifestyles and personality based on the Ego gram in Transactional Analysis. It is suggested that we need to assess subjective aspects as well as using objective indices such as data from physical examinations, to evaluate the level of stress and to promote mental health.
Key words: stressor; stress reaction; occupational stress; lifestyle; personality
INTRODUCTION
Since H. Selye proposed the theory of stress, many studies have made to examine the various aspects of stress. Stress is an important risk factor in somatic as well as mental diseases. It is also closely associated with social behavior as well as defense mechanisms of organisms such as immunocompetence.
Considerable attention has been paid to prob lems of stress in the fields of hygiene and public health, and many studies have been conducted, in particular, in working populations. Indices for stress assessment including self-reporting methods have been widely used. However, the reliability and validity of many indices have not been ex amined. Furthermore, although the relationship of stress to hormone levels and immunocom petence was examined, no specific index of stress has been established. Since stress itself is in fluenced by various factors, multidimensional ap proaches to stress assessment are required.
This article reviews the literature on stressors and stress reactions, surveys the methods for assessing stress, and examines the relationship of stress to health and lifestyle factors.
SELF-REPORT MEASURES FOR THE ASSESSMENT OF STRESSORS
Representative methods of assessing stressors include the Social Readjustment Rating Scale by Holmes and Rahe.1) Daily Hassles by Lazarus2) etc., and the reliability and validity of each were examined.
Brugha et al. reported that the Questionnaire of the List of Threatening Experiences (LTE-Q) has high test-retest reliability and that its sensi tivity and specificity were 0.89 and 0.74, respec tively.3)
It was reported that the Work Stress Assess ment (WSA) Questionnaire and the Short Form of the Questionnaire on Resources and Stress (QRS-F) have high construct validity and internal consistency.4-7)
The high internal consistency and test-retest reliability of the Strain Questionnaire were re ported, and its construct validity, concurrent validity and discriminant validity were confirmed.8) Levenstein et al. administered the Perceived Stress Questionnaire (PSQ) to English and Italian subjects and reported that its coefficients of test retest reliability and internal consistency were 0.82 and more than 0.9, respectively.9)
Methods for assessing stressors in specific pop ulations include the following: The Questionnaire on Resources and Stress for Families with Chron
* Department of Hygiene and Preventive Medicine , Osaka University School of Medicine
ically Ill or Handicapped Members (ORS),10) Hospital Stress Rating Scale (HSRS)11) for in patients, Speech-Language Pathologist Stress In ventory (SLPSI),12) The Nurse Stress Checklist,13)
Clinical Stress Questionnaire (CSQ)14) for nursing students, Undergraduates Stress Questonnaire (USQ)15) and Prenatal Social Environment In ventory16) for pregnant women. Reliability and validity of these methods were confirmed.
STRESSORS IN OCCUPATIONAL POPULATIONS
Stressors in working populations were, in particular, examined in detail. Popular methods based on the theoretical model of occupational stressors include the Job Content Questionnaire,17) Generic Job Stress Questionnaire by NIOSH,l8) a questionnaire by Caplan et al.19) a questionnaire by House et al.,20) the Questionnaire of Employ ment Quality Survey,21) Job Characteristics In ventory,22) the Questionnaire of Perceived Work Environment,23) the Questionnaire of Job Diag nostic Survey24) and Work Environment Scale.25) Kawakami et al. selected 22 items for psycho logical job demands, decision latitude, supervisor support and coworker support in the Job Content Questionnaire, translated it into Japanese and examined its reliability and validity.26) Haratani et al. prepared the Japanese version of the Generic Job Stress Questionnaire by NIOSH.27-29)
Next, occupational stressors based on the review by Davidson, and Cooper will be listed.30)
1. Factors intrinsic to the job. Factors in trinsic to the job include poor physical working conditions, shift work, work overload, work underload, physical danger, person-environment fit (P-E) and job satisfaction. Shift work is known to affect neurophysiological rhythms, such as blood temperature, metabolic rate, blood sugar levels, mental efficiency and work motivation.31,32) Cobb and Rose reported a four-fold the preva lence of hypertension as well as a higher incidence of mild diabetes and peptic ulcers among air traffic controllers than in a control group of second class airman.32)
2. Role in the organization. Stress related to a person's role at work involves role ambiguity (i.e., a lack of clarity about one's job) and role conflict (i.e., conflicting job demands), as well as responsibility for people and conflicts stemming
from organizational boundaries.33) Rizzo et al. developed a questionnaire of role stressors.34) According to the studies of French and Caplan,35) Beehr, Walsh and Taber36) and Shirom et al.,37) these organizational stressors stemming from role ambiguity and conflict can result in stress-related illnesses such as chronic heart diseases. Further more, Cooper and Marshall33) have concluded that less physical occupations, such as professional, managerial and clerical, are more prone to occupa tional stress associated with role conflict.
3. Career development. Career development refers to "the impact of overpromotion, under promotion, status incongruence, lack of job security, thwarted ambition. .."33) Conditions related to career development are associated with dissatisfaction with life, low self-esteem and phys ical conditions.
4. Human relation at work. Relationships at work include the nature of relationships and social support from one's boss, colleagues and subordinates. French and Caplan35) suggested that poor relationships with other members of an organization may be precipitated by role ambiguity in the organization, which in turn may produce psychological strain in the form of low job satis faction. According to Caplan et al.,19) strong social support from colleagues relieved job strain and attenuated the effects of job stress on blood pressure, glucose, cortisone, and cessation of cigarette smoking as well as the number of cig arettes smoked.
5. Organizational structure and climate. Or ganizational structure and climate include factors such as office politics, lack of effective consulta tion, lack of participation in the decision-making process, and restrictions on behavior.33,39) Ac cording to Margolis et al.40) and French and Caplan,35) greater participation led to improved performance, lower staff turnover, higher produc tivity and lower levels of physical and mental illness.
6. Other factors. Added to the above factors which Davidson and Cooper listed, lack of tech nical utilization, conflicts between job and other
activities and technological development are known to be factors related to occupational stress.41)
STRESS REACTION
Stress reactions include physiological, psycho logical and behavioral reactions. Physiological reactions include hemodynamic reactions such as blood pressure, cardiac output and coronary blood flow, reactions of autonomic nervous systems such as R-R intervals, hormonal responses of catechol amines in blood and urine and immunological responses. In this section, hormonal and immuno logical responses will be reviewed in greater detail.
1. Hormonal Responses. Teshima et al. re ported the effects of anxiety due to school ex amination on hormones.42) They found that serum adrenaline levels were markedly increased by stressors in persons with high state anxiety and decreased in persons with low state anxiety, and that they were increased by stressors in persons with high trait anxiety. Another study reported that serum adrenaline levels were in creased by physical stressors.43) It was reported that urine adrenaline levels were higher in groups with higher stress than in those with lower stress.44) Another study also reported that urine adrenaline levels were higher in inhabitants under chronic stress at Three-Mile Island.45)
Teshima et al. found that serum noradrenaline levels were decreased by stressors in persons with either high or low state anxiety.42) They were also reported to decrease in persons with low trait anxiety.42)
It was reported that serum cortisol levels were decreased by stressors in persons with low state anxiety and also in persons with low trait anxiety.42) Another study reported that serum cortisol levels were higher in depressive patients.46) It was reported that urine cortisol levels were higher in lonely patients47) and in inhabitants under chronic stress at Three-Mile Island.45)
It was also reported that serum histamine levels were increased by stressors in persons with either high or low state anxiety as well as in persons with high trait anxiety.42)
Berg et al. examined differences in the amounts of hormones between VDT workers with skin symptoms and those without symptoms.48) As a result, they reported that the levels of thyroxin and prolactin were significantly higher in workers with skin symptoms than in those without the
symptoms. Furthermore, they found that the levels of testosterone were lower in VDT workers with skin symptoms, when they were working.
2. Immunological Responses. There has been an increasing number of studies concerning the relationship between stress and immunological indices with the development of neuropsychoim munology. Representative studies include the following.
Kiecolt-Glaser and Glaser et al. reported a series of studies concerning stress that was caused by an upcoming examination and affected immuno competence.49-53) It was reported that the num ber of total T lymphocytes, helper T cells, and suppressor T cells and the helper-suppressor cell ratio were significantly decreased by stress due to the examination. It was also reported that the number of NK cells, NK cell activities49,51,53) and lysis of target cells by NK cells as well as anti-Leu-7+ were decreased by stressors.51) Fur thermore, lymphocyte stimulation responses to PHA and Con-A were decreased by stress, and activities of leukocyte migration-inhibition factor (LIF)52) and the production of interferons by lymphocytes stimulated by Con-A51,52) were in hibited during the examination. The antibody titers to EB virus were increased by stress due to examination.52) As a whole, it is suggested that immunocompetence is inhibited by stress.
The relationship of stress and anxiety to im munoglobulin and complements was examined. It was reported that IgG increased as work stress increased.54) Teshima et al. reported that IgG was decreased by stressors in persons with high state anxiety, whereas it was increased in persons with low trait anxiety.42) They also reported that IgA was in creased by stressors in persons with both high and low state anxiety, as well as in persons with both high and low trait anxiety.42) Among complements, CH50 was decerased by stressors in persons with both high and low state anxiety, as well as in persons with both high and low trait anxiety.42) The same was true of C4,42) while C3 was decreased by stressors in persons with low trait anxiety.42)
The relationships between chronic stress and immunocompetence as well as the effects of acute stressors on immunocompetence were reported. According to the study concerning family care givers for Alzheimer's disease patients under chronic stress for many years, the caregivers had
significantly lower percentages of total T lympho cytes and helper T cells than did control subjects, as well as significantly lower helper-suppressor cell ratios; care givers also had significantly higher antibody titers to EB virus than control subjects.55) It is suggested that immunocompet ence is also inhibited by chronic stress.
There are some studies which examined the relationship between marital status and immuno competence. It was reported that the number of helper T cells was significantly higher in married women than in divorced women, and that the number of NK cells was significantly higher in married women than in divorced women.56) A mong married men, lower quality of marital life was associated with a poorer response to EB virus antibody, as well as lower helper-suppressor ratios.57) It was also reported that lymphocyte
stimulation responses to PHA and Con-A were decreased among persons with poorer marital quality and separated couples.56,58,59)
3. Other Physiological Reactions. Adsett et al. examined changes in coronary blood flow, blood pressure, cardiac output and peripheral resistance before and during stressful interviews.60) As a result, interviews which aroused feelings of anger were associated with significant increases in coronary blood flow, systolic and diastolic blood pressure and peripheral resistance, whereas inter views which aroused feelings of anxiety were associated with increased coronary blood flow, cardiac output and systolic blood pressure.
A study was made, indicaitng that stress due to complicated machine operation was a significant predictor of increased diastolic blood pressure in blue-collar workers.61)
Kiecolt-Glaser et al. reported differences in DNA repair in lymphocytes between high and low-distressed individuals.62) The high-distress subgroup had significantly poorer DNA repair in lymphocytes exposed to X-irradiation than low distress subjects. Furthermore, they found that lymphocytes obtained from psychiatric patients had significantly poorer DNA repair than lympho cytes from nonpsychiatric control subjects.
Kawakami et al. examined the relationship between work stress and hemoglobin A1c (HbA1c), which is an index of blood sugar levels.61) As a result, job dissatisfaction was found to correlate significantly with the level of HbA1c in white collar workers.
Visual Reaction Test (VRT) was developed by Saito as a new measure of stress.63)
4. Psychological Reactions. Psychiatric symp toms such as depression and anxiety and job satisfaction are used as indices of psychological stress reactions. Popular questionnaires for the assessment of stress reaction are as follows: Cornell Medical Index (CMI),64) General Health Questionnaire (GHQ),65) Zung Self-Rating De pression Scale (SDS),66) The Todai Health Index (THI),67) Minnesota Multiphasic Personality In ventory (MMPI),68) Beck Depression Inventory (BDI),69) The Center for Epidemiologic Studies Depression Scale (CES-D),70) and Manifest Anx iety Scale (MAS).71) Psychological stress reac tions were assessed by these questionnaires so far. In recent years, structured psychiatric interviews such as the Structured Clinical Interview for DSM-III-R (SCID)72) have also been used as indices for stress reactions.
Nomura et al. developed a stress checklist (SCL-86), which assesses both stressors and stress reactions.73) It consists of 112 items including stress, behavior, psychological, and somatic items. The instruments which measure stress, in par ticular, anxiety and hostility through analysis of frequency modulations in human voices include the Free Association Test (FAT)74-76) and Psycho logical Stress Evaluator (PSE).77-83) The FAT, an indicator of stress in psychotherapy patients, is a widely used psychometric technique for assessing anxiety and hostility in children and adults. It is time consuming and requires the use of highly trained personnel. Validity of the PSE was examined by many researchers.
5. Behavioral Reactions. Popular behavioral stress reactions are increased frequency of medical consultation, absence, decreases in working activ ities and changes in health practices such as increases in smoking and drinking.41) For ex ample, it was reported that job dissatisfaction was significantly correlated with the medical consulta tion rate in blue collar workers.61)
STRESS ASSESSMENT BY A SINGLE QUESTION
We assessed perceived stress with the single question: "Are you feeling a lot of stress?" It is unclear whether this measures a stressor or stress reaction; it is considered to assess both
comprehensively.
In 1989, about 6,000 employees of a camera manufacturing company in Osaka were surveyed using a self-administered questionnaire; further analysis was focused on 2,575 male workers aged
20 to 59 years. Qusetionnaires were completed for all items by 2,132 male workers (82.8%); these workers comprised the subject population of the present study.
The grade of mental health status was measured by the 28-item version of the General Health Questionnaire (GHQ-28).65) GHQ-28 provides four subscales, measuring somatic symptoms, anxiety and insomnia, social dysfunction and severe depression. The higher the score on the GHQ-28, the worse was the mental health status.
We examined the relationship of perceived stress to the total score and subscores on the GHQ-28. As a result, the total score and sub scores of the GHQ-28 were significantly higher in the group with higher perceived stress than in those with lower perceived stress (p<0.05, respec tively; Fig. 1).84)
RELATIONSHIPS OF STRESS TO LIFESTYLES AND PERSONALITY
Demographic factors such as gender and age, social support, personality traits, coping behavior and lifestyles are known to be modifiers of stress.
We examined the relationship of perceived stress assessed by the single question to lifestyle and personality traits.
The subject population was the same as that cited above. First, we examined the relationship of perceived stress to 16 lifestyle factors including smoking, drinking, physical exercise, hours of sleep, regularity of life, hobbies and so on. As a result, the frequencies of persons with time pressure, poor somatic conditions, dissatisfaction with daily life, long working hours, irregular habits and short sleeping hours were significantly higher in the group with high perceived stress
than in the groups with lower stress84) (Table 1). Secondly, we examined the relationships be tween perceived stress and personality traits determined by 10 factors extracted from the Ego gram in Transactional Analysis. As a result, perfectionist and nervous traits were found to be strongly associated with perceived stress84) (Table 2). These findings suggest that subjective factors
Fig. 1. Relationship between perceived stress and mental health status measured by the GHQ-28 in
2,115 male factory workers.
such as time pressure, somatic conditions and personality are more closely associated with perceived stress in workers than visible lifestyle factors such as smoking and drinking.
CONCLUSION
We reviewed the literature on stressors and stress reactions, and thereafter introduced the findings of our study on the relationship of stress to lifestyles and personality. It is suggested that we need to assess subjective aspects as well as
Table 1. Relationship between perceived stress and lifestyle factors in 2115 male factory workers. a)
a) Number of subjects in parentheses .b) Number of persons who drank more than five cups of coffee or tea in a day. * p<0.01, ** p<0.0001.
Table 2. Relationships between perceived stress and personality traits in 2115 male factory workers.#
#Number of subjects in parentheses. * p<0.05, ** p<0.005, *** p<0.001. using objective indices such as data from bio
chemical examinations, to measure the level of stress and promote mental health.
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Reprints requests to Department of Hygiene and Preventive Medicine, Osaka University School of Medicine, Yamada-Oka, Suita, Osaka, 565 Japan (K. Morimoto)
英文論文 の和文要 旨
QUANTITATIVE ASSESSMENT OF STRESSORS AND STRESS REACTION: A REVIEW
Satoko EZOE and Kanehisa MORIMOTO...397
ス トレ ッサ ーお よび ス トレス反 応の 定量 的 評価:総 説 江 副智 子,森 本兼 曩 Selyeに よって ス トレス学説 が 唱 え られ て 以来,さ ま ざまな角 度 か らス トレス研 究 が行 わ れて きた.ス トレス は,身 体 疾患 お よび精 神疾 患 の重 要 な危 険 因子 で あ る と と もに,免 疫 能 な どの生体 の防御 力 に も深 く関連 し,さ らに転勤 率 な どの社 会 行動 面 に も影 響 を 及 ぼ す.衛 生 学,公 衆 衛生 学 の分 野 で も,近 年 ス トレス は重 要課 題 と な って お り,特 に職 域 を 中心 と して さま ざ まな調査 が 実 施 され て きた.本 論文 で は,従 来 行 われ て きたス トレス 評 価法 を,国 内外 の文 献 を整 理 し,ス トレ ッサ ー評 価 と ス トレス反 応評 価 に分 け て概 説す る.ま ず,ス トレ ッサ ー評価 の質 問票 の うち,信 頼 性 お よび妥 当性 が検 討 され てい る もの につ いて 概説 し,さ らに,障 害 者 の家族 や 入 院患者,看 護 学生 な どの特定 の集 団を対 象 と した 質 問票 を紹 介 した.次 に,職 場 に おけ るス トレス要 因を, 1) 仕事 に固 有 の要 因, 2)組 織 にお け る役割, 3)昇 進 ・ 降格, 4)職 場 の人 間 関係, 5)組 織 の構 造 と風 土,お よび6)そ の他,に 分類 して概 説 した.ス トレス反 応 に つ いては, 1)ホ ルモ ン の 反 応, 2)免 疫 学的 反 応, 3)そ の他 の生理 的 反応, 4)心 理 的反 応,お よび5) 行動 的反 応 に分類 し,ス トレス と血 液 生化 学 的指 標 との 関 係に関 す る研究 結 果や ス トレス反 応 の測 定 方法 を 紹介 した.ホ ル モ ンの反 応 につ いて は,ス トレス と血 漿 お よ び尿 中 ア ドレナ リン,血 漿 ノル ア ドレナ リン,血 漿 お よ び尿 中 コル チ ゾール,血 漿 ヒス タ ミン,サ イ ロキ シ ン, プロ ラ クチ ンお よび テ ス トス テ ロ ンな ど との関 係が 調ベ られ てい る.免 疫 学 的反 応 につ い て は,急 性 お よび 慢性 の ス トレス とTリ ン パ 球 数, NK細 胞活 性, PHAや Con-Aに 対 す るTリ ンパ球 の反 応, EBウ イル ス に対す る抗 体価, IgAやIgGな どの免 疫 グロ ブ リン,補 体 な どとの関 係 を調 ベ た研 究結 果 を紹 介 した.そ の 他 の生理 的反 応 として は,冠 血 流量,血 圧 な どの血行 動 態的 指 標, リンパ球 のDNA修 復,ヘ モ グ ロビ ンA1cな ど とス ト レス との関 係 に関 す る研究 を紹 介 した.心 理 的反 応 に 関 して は,代 表 的 な 質問 紙票 を 列挙 す る と ともに,声 の録 音 に よ りス トレス,特 に不 安 と敵 意 を評 価ず る方 法 を紹 介 した.行 動 的反 応 につ いて は,そ の指 標 とな る もの に つ いて 簡単 に 触れ た.最 後 に,わ れ われ が 行 った,単 一 の質 問 に よるス トレス の包括 的評 価 方法 を 紹 介 し,勤 労 者 を対 象 に,そ の質 問 に よる 自覚的 ス トレス と,精 神 健 康 調査 票28項 目版(GHQ-28)に よる精 神 的健 康 度,喫 煙 ・飲 酒 ・睡 眠 ・運 動 ・生活 規 則 性な どの ライ フ スタ イ ル,お よび交 流 分析 の エ ゴ グ ラムか ら抽 出 した性 格 要 因 との 関係 を調 べ,そ の 結果 につ い て 述 ベ た.そ れ に よ り,自 覚 的 ス トレスが 多 いほ ど,精 神 的健 康 度 が悪 く, ライ フス タイ ルの 中で は,特 に多 忙感,体 調 悪 化,長 時 間労 働,生 活 へ の不 満,生 活 お よび食 事 の不 規 則,短 時 間睡 眠 を訴 え る者 の割 合 が,ス トレス の多 い群 で有 意 に 高い.ことが わか った.ま た,性 格 要 因 の中 では,完 全 主 義 と神経 質 の者 が,ス トレスを 多 く感 じて い る こ とが 明 らか に な った.以 上 の こ とか ら,人 々の ス トレス 度を 把 握 し,メ ン タルヘ ル スの保 持 ・増 進 を図 るため に は,血 液生 化 学的 検査 値 な ど の客観 的 な指 標 を 目安 にす る こ と に加 え て,本 人 の主 観 を も とらえ て,多 元 的 に ア プ ロー チす る必要 が あ る と思わ れ る. 著者 へ の通 信先:森 本 兼 曩, 〒565 吹 田市 山 田丘2-2 大 阪大 学 医学 部環 境 医学 教 室
