Epidemiology:Effects of Cognitive-Behavioral Stress Management on Cortisol Responses - Assignment Example

Introduction: In the present scenario, stress is the inevitable part of life. It could be physiological or psychological. Cortisol is an important hormone, it is not only released during the condition of stress but also in fight or flight responses. This hormone brings various stress-related changes as well. It is evident that body’s relaxation response must be activated to combat stress. The condition of the stress cannot be prolonged as it could be devastating and induce chronic stress worsening cognitive performance, suppressed thyroid function, hyperglycemia, reduction in bone density and muscle tissues, increased blood pressure and lowered immunity, increased abdominal fat and hence invites all linked (Scott, E). Psychological stress brings release of cortisol, a stress hormone that maintains physiological and psychological equilibrium. If cortisol is released in embellished magnitude, it brings harmful effects not only on somatic health but also impairs cognitive functioning. It is apparent that stress-induced variations of hypothalamus-pituitary adrenal (HPA) axis functioning are implicated in the commencement and upholding of both somatic and psychiatric conditions, these and also comparable arbitrations could be used for anticipation and rehabilitation of these deleterious stress effects. The view is the focus of the article, it is the study carried out to examine the long-term effects of cognitive-behavioral stress management (CBSM) training on cortisol stress management in healthy men and women. The article emphasizes the impact of CBSM training to attenuate cortisol stress responses in both men and women. Strength of the Methodology: The article presents a sight that there is a slight variation between the sexes in response to the CBSM training. Any change in the execution of HPA axis activity alters the circadian rhythm of cortisol secretion and also high plasma cortisol levels (Touitou et al). Various laboratory and environmental stressors are linked to HPA axis response causing upper respiratory tract infection (Cohen et al, 2002) and long-term implications on cardiovascular-related incidences and also type 2 diabetes in men (Rosmond et al , 2003) and also incriminated turned down memory performance in women (Seeman et al,1997 or fractures in men and women (Greendale et al, 1999). Approach vs. Research: Knowing these impacts and their devastating consequences the article throws light on the modulation of cortisol levels by conducting randomized controlled trial study. The study also explains an examination of stability over time and generalizability with regards to gender of endocrine effects of CBSM in healthy individuals. Selection of the participants: The subjects taken in this study were three hundred and fifteen, II year psychology students, with due care to reduce individual differences and any external academic stressors. After the primitive screening, selection criterion and questionnaire provided, only 83 subjects were left for the analysis. These participants were randomly selected and assigned in eight groups as per the CBSM group sessions with restricted N=12. Of these groups 1-4 were under the treatment (N=42) and rest 5-8 were categorized as control groups (N=41). Strength of the methodology: The article has the advantage of selecting the participants for both control and treated groups of negligible demographic variables (including age, gender, habitual smoking, use of oral contraceptives and body mass). Data collection and information to the participants: Groups for CBSM met on two alternate Saturdays or Sundays and in total N=11 received 10h CBSM conducts as per the norms by the two clinical psychologists. The article focused on four cognitive-behavioral stress-reducing techniques namely, cognitive restructuring, problem-solving, self-instruction, progressive muscle relaxation. It also mentions about the training manual and flash cards describing CBSM technique, but the readers of this cannot get the benefit of the knowledge and amendments in CBSM technique adopted in this study they will have to refer the previous article (Gaab et al, 2003). Biochemical analysis of saliva samples were performed with Salivette (Sarstedt, Rommelsdorf, Germany), samples were stored at -20° C and saliva-free cortisol was analyzed with chemiluminescence immunoassay with precision to minimize error and statistical analysis was done using ANOVA and ANCOVA tests. The methodology adopted for the analysis of samples were very tedious and time consuming and highly error prone as there are chances of mixing of results. The treatment was performed for four months and all the subjects underwent a standardized psychological stress test (Trier Social Stress Test, TSST, Kirschbaum et al, 1993). In this study, TSST was performed for treated CBSM group every 2-week period whereas for the controls it is for 4-week period. Data Analysis: Some of the participants were not able to undergo TSST, the article states that the subjects not performing the TSST did not differ in the baseline variables from the performers. Thirty nine subjects under the category of CBSM and 37 subjects of control group performed the TSST. The article states that CBSM treatment was given to controls also. This is a good measurement so as to provide the benefit of the study to all the participants. Psychological stress test was also performed where hob interview and also arithmetic tasks were given in front of the committee. The analysis of the study was done with the saliva samples collected immediately before and one, 10, 20, 30, 45, 60 mins after TSST. It is said that the TSST was performed in a separate room than CBSM. It is good practice to have a separate environment for the quality analysis and participants will not be diverted to any other situation(s). The results signify that baseline cortisol levels were not different but differ significantly in their endocrine stress response over time. Subjects in the CBSM group show an attenuated salivary cortisol response as compared to controls. The study has additional grouping variable of gender, gender has significantly interacted with group effects on cortisol response over time, and moreover use of oral contraceptives were treated as an additional grouping variable in females. Discussion: The study is conducted to examine the stability and the generalizability of CBSM effect on cortisol stress responses in healthy subjects, the results indicate that the attenuation of cortisol stress responses just after 2-weeks of CBSM training (Gaab et al, 2003) the same can be observed after 4 months in both men and women, with a smaller magnitude in women than men. The findings of the study indicate that subjects in the CBSM group showed a diminished cognitive stress appraisal in the TSST. The study articulates the fact that primary appraisal had a stronger impact on cortisol stress responses than secondary appraisal. The article mentions about the threat predominance and also decrease in HPA axis stress responses but the methodology is not clear. The study also finds that there is a decline in the ability to retrieve and implement CBSM training. The study is totally based on saliva cortisol as an indicator or endocrine stress reactivity which is closely associated with plasma cortisol and ACTH levels but blood samples can also be tested for the confirmation of results, BFS (Benefit Finding Scale) and POMS (Profile of Mood States) (Dean, G et al ,2000) are not mentioned. Weakness of the methodology: The article does not imply about the fact that the participant were provided the same kind of external environment as well, if they are living with the family, hostel, and the means of transport or any kind of financial , emotional conditions the participants are provided as these are the conditions inducing release of cortisol. The study analyzes the psychometric measures with Primary Appraisal Secondary Appraisal Scale (PASA). It this study the items for Primary and Secondary Appraisals are not clear. The article says there are 16 situation-specific items but only 4 items (challenge, threat, self-concept of own competence and control expectancy) for PA and 2 for SA have been depicted. The study provide the basis that primary scales can be summed up to a general stress index and can be calculated as Stress Index= PA- SA. A layman cannot derive much benefit to de-stress himself by reading this article. There are various other methods to keep the cortisol levels under control, self-hypnosis, exercise, yoga, listening to music, breathing exercises, meditation, journaling and outings and changes in lifestyle or place of work. The level of cortisol varies between the individuals which is not stated in the study as every individual react to different level and with different outlook to stress and hence the release of cortisol may vary (Scott, E). Thus further studies can be conducted using this article as a base line for evaluation and to frame the hypothesis and more innovations can be added. References: 1. Touitou, Y., Bogdan, A., Levi, F., Benavides, M., Auzeby, A. 1996. Disruption of the circadian patterns of serum cortisol in breast and ovarian cancer patients: relationships with tumour marker antigens. Br J Cancer, 74, pp, 1248–52. 2. Elizabeth, S. 2008. Cortisol and Stress: How to Stay Healthy: Cortisol and Your Body About.com, Updated: February 5, 2008 Health's Disease and Condition content is reviewed by the Medical Review Board 3. Cruess, D.G., Antoni, M.H., McGregor, B.A., Kilbourn, K. M., Boyers, A.E., Alferi, S.M., Carver, C.S., Kumar, M. 2000. Cognitive-Behavioral Stress Management Reduces Serum Cortisol By Enhancing Benefit Finding Among Women Being Treated for Early Stage Breast Cancer. Psychosomatic Medicine, 62, pp, 304-308. 4. Gaab, J., Blattler, N., Menzi, T., Pabst, B., Stoyer, S., Ehlert, U. 2003. Randomized controlled evaluation of the effects of cognitive-behavioral stress management on cortisol responses to acute stress in healthy subjects. Psychoneuroendocrinology, 28, pp, 767–779. 5. Cohen, S., Hamrick, N., Rodriguez, M.S., Feldman, P.J., Rabin, B.S., Manuck, S.B. 2002. Reactivity and vulnerability to stress-associated risk for upper respiratory illness. Psychosom. Med, 64, pp 302–310. 6. Kirschbaum, C., Kudielka, B.M., Gaab, J., Schommer, N.C., Hellhammer, D.H. 1999. Impact of gender, menstrual cycle phase, and oral contraceptives on the activity of the hypothalamus-pituitary-adrenal axis. Psychosom. Med, 61, pp, 154-162. 7. Rosmond, R., Wallerius, S., Wanger, P., Martin, L., Holm, G., Bjorntorp, P. 2003. A 5-year follow-up study of disease incidence in men with an abnormal hormone pattern. J. Intern. Med. 254, pp, 386–390. 8. Seeman, T.E., McEwen, B.S., Singer, B.H., Albert, M.S., Rowe, J.W. 1997. Increase in urinary cortisol excretion and memory declines: MacArthur studies of successful aging. J Clin Endocrinol. Metab, 82, pp, 2458–2465. Part 2 Aim: the article presented with critical analysis in part 1 does not come up with authentic cognitive measures to be taken to overcome the stress and lower the cortisol level. Introduction: The shortcomings of the Part 1 are suggestive for alternative methods to combat stress and related disorders. These methods are measures to minimize the cortisol levels, self-hypnosis, exercise, yoga, listening to music, breathing exercises, meditation, journaling and outings and changes in lifestyle or place of work. Relaxation response (RR) is said to be the best method to root out stress. Mind-body practices to educe the relaxation response are used worldwide to prevent and treat disease. RR counteracts the stress response exhibiting a distinct pattern of physiology and transcriptional profile (Dusek,). The results obtained from the studies made clear that psychosocial stress discernible system-wide perturbations of cellular processes. This enhances oxidative stress and promotes a pro-inflammatory milieu (Irie, 2002, Yamaguchi, 2002, Zheng, 2007). Selection of the participant: The article selects the elderly population to further illustrate upon the fact that chronic psychosocial stress has been associated with enhanced process of aging at the cellular level. It is evident that, shortened telomeres, low telomerase activity, decreased anti-oxidant capacity and increased oxidative stress are correlated with increased psychosocial stress (Epel, 2004). It is demonstrated that with increased vulnerability to a variety of disease states (Epel, 2006). Data collection: The article emphasize that RR is clinically effective for improving symptoms in a variety of stress-related disorders encompassing cardiovascular, autoimmune and other inflammatory conditions and pain (Astin, 2003). The article hypothesized that RR elicitation is related with systemic gene expression changes in molecular and biochemical pathways involved in cellular metabolism, oxidative phosphorylation/generation of reactive oxygen species. RR also plays an imperative role in responding to oxidative stress. The main emphasis is laid on the fact that these changes to some degree serve to revolutionize the negative impact of stress. Data Analysis: Genome-wide evaluation of PBL GEP gives an approach to examine the transcriptional changes that are involved in elicitation of the RR. An alteration in the gene expression is reported in terms of GEP of RR practitioners suggesting a superior capability to respond to oxidative stress and the associated cellular damage. Genes including COX7B, UQCRB and CASP2 alter in opposite direction as compared to that in the stress response (Morita, 2005; Zieker, 2007). This is the first study of its kind to prospectively evaluate GEP changes in individuals before and after a short-term (8 week) RR training which consequently enables an appreciation of the parallel GEP changes that occur with short- and/or long-term RR practice. Discussion: The future aspects of this study could define the therapeutic value and required duration of RR training to counter stress-related disorders. "Consistent and constitutive changes in gene expression resulting from RR may relate to long term physiological effects," and that "this study may stimulate new investigations into applying transcriptional profiling for accurately measuring RR and stress related responses in multiple disease settings." The study showed that the relaxation response changed the expression of genes involved with inflammation, programmed cell death and the handling of free radicals. The free radicals are normal byproducts of metabolism body neutralize to facilitate stoppage of cellular and tissue damages. Changes induced by the activation of genes have previously been seen in conditions such as post-traumatic stress disorder; the study also states that the relaxation-response-associated changes were the opposite of stress-associated changes. Meditation not only keeps the mind calm and peaceful but also generates positive feeling and sense of being good and healthy. It is the simplest technique to control stress, to reduce anxiety and improve cardiovascular health and to achieve relaxation. It is therefore called the “relaxation response”. This was pioneered by Harvard physician and therapist Herbert Benson in the 1970s in US. RR has gained tremendous support of the physicians and therapist all over the world as it has given relief in dreaded diseases like cancer and AIDS (Stoppler). The relaxation response (RR) antagonize the “adrenaline rush” mentioned in part 1. RR is a state of deep relaxation which normalizes breathing, blood flow, blood pressure and metabolism. Daily practice of adopting such means brings enhanced mood, decrease in blood pressure and hence reduction in stress (Stoppler). The methodology is most simple to adopt. The technique encompass sitting quietly with closed eyes for 10 to 20 minutes with silent repetition of a word, sound or phrase. In this process muscles are relaxed and intruding worries and thoughts are ignored and focus is made solely on the sound surround (Stoppler). References: 1. Astin, J.A., Shapiro, S.L., Eisenberg, D.M., Forys, K.L. 2003. Mind-body medicine: state of the science, implications for practice. J Am Board Fam Pract, 16, pp, 131–147. 2. Dusek, J.A., Chang, B.H., Zaki, J., Lazar, S., Deykin, A. 2006. Association between oxygen consumption and nitric oxide production during the relaxation response. Med Sci Monit, 12, pp, CR1–10. 3. Epel, E.S, Blackburn, E.H., Lin, J., Dhabhar, F.S., Adler, N.E. 2004. Accelerated telomere shortening in response to life stress. Proc Natl Acad Sci U S A , 101, pp, 17312–17315. 4. Epel, E.S., Lin, J., Wilhelm, F.,H., Wolkowitz, O.,M., Cawthon, R. 2006. Cell aging in relation to stress arousal and cardiovascular disease risk factors. Psychoneuroendocrinology, 31, pp, 277–287. 5. Irie, M., Asami, S., Nagata, S., Miyata, M., Kasai, H. 2002. Psychological mediation of a type of oxidative DNA damage, 8-hydroxydeoxyguanosine, in peripheral blood leukocytes of non-smoking and non-drinking workers. Psychother Psychosom , 71, pp, 90–96. 6. Li, Q.Z., Li, P., Garcia, G.E., Johnson, R.J., Feng, L. 2005. Genomic profiling of neutrophil transcripts in Asian Qigong practitioners: a pilot study in gene regulation by mind-body interaction. J Altern Complement Med, 11, pp, 29–39. 7. Morita, K., Saito, T., Ohta, M., Ohmori, T., Kawai, K. 2005. Expression analysis of psychological stress-associated genes in peripheral blood leukocytes. Neurosci Lett , 381, pp, 57–62. 8. Stoppler, M., Meditation Reduces Stress and Improves Health, http://www.medicinenet.com/script/main/art.asp?articlekey=46268 [Accessed on 14th April 2008] 9. Yamaguchi, T., Shioji, I., Sugimoto, A., Yamaoka, M., 2002. Psychological stress increases bilirubin metabolites in human urine. Biochem Biophys Res Commun , 293, pp, 517–520. 10. Zheng, K.C., Ariizumi, M. 2007. Modulations of immune functions and oxidative status induced by noise stress. J Occup Health, 49, pp, 32–38. 11. Zieker, J., Zieker, D., Jatzko, A., Dietzsch, J., Nieselt, K. 2007. Differential gene expression in peripheral blood of patients suffering from post-traumatic stress disorder. Mol Psychiatry, 12, pp, 116–118. Aim: the article presented with critical analysis in part 1 does not come up with authentic cognitive measures to be taken to overcome the stress and lower the cortisol level. Introduction: Stress-management interventions reduce anxiety, depression, distress and fatigue and improve quality of life, immunological, hormonal, cortisol and other behavioral outcomes like fatigue (Scott-Sheldon, Kalichman, S., C., Carey, M., P., Fielder, R., L., 2008). Apart from RR there are various other methods available to support the critical analysis of part 1. It is manifested that stress gives birth to anxiety and this relates to various other diseases including cardiovascular diseases, diabetes and also prolongs the recovery time of the disease. Research is constantly being performed to overcome the stress and related symptoms through yoga. It is therefore concluded that stress management is more imperative than the treatment of the diseases. Stress not only prolongs the illness but also release stressors to alter the psychological and physiological metabolic cycles. It is imperative to manage stress. Stress management interventions for HIV+ adults improved mental health, quality of life, and fatigue but did not improve stress, immunological, or hormonal outcomes (Scott-Sheldon, Kalichman, S., C., Carey, M., P., Fielder, R., L., 2008). One of the ways in which we respond to stress is through our fight-or-flight response. This is an amalgamation of the activation of our sympathetic nervous system and specific hormonal pathways which result in the release of cortisol from the adrenal glands, is often used to measure the stress response as seen in part 1. If factors inducing stress are prolonged then it culminates into chronic stress, this is disastrous. Stress hormones including cortisol decrease the responsiveness of our immune system (as seen in part 1). They also increase blood sugar levels as well as blood pressure and heart rate, helpful in a crisis, but they are deleterious in long-term health and wellbeing. A deep understanding of various diseases laid the fact that stress aggravates the disease progression. The epidemiology of the disease also indicates that reduction in situation in and around patient helps in faster recovery from illness (Scott-Sheldon, Kalichman, S., C., Carey, M., P., Fielder, R., L., 2008,). It is therefore recommended that methods like meditation and yoga must be practiced to reduce the physical effects of stress on the body, and has even been found to lower cortisol levels. A feeling of positivity is generated in people practicing Yoga, as it provides complete peacefulness of body and mind, helping one to relax and manage stress and anxiety. The methodology adopted, encompasses styles of Yoga, forms and intensities and is good choice for stress management and can improve physical, psychological and spiritual well-being (Mayo Yoga). Regardless of which type of yoga an individual practice, even spending time sitting quietly, breathing deeply gives relaxation and comfort. It is crucial to control breathing as a part of yoga; it signifies vital energy of the body. By controlling breathing, body gains control over mind and thoughts and promote stress management and relaxation. Yoga provides loud breaths as air moves inside the body, it fills the lungs providing good amount of oxygen and thereby exchanging oxygen with carbon-di-oxide and therefore more oxygen is carried by the blood to each cell of the body. This help to reduce stress and resolve a variety of health related problems like headache, insomnia, back pain, burnout, weight gain, anger and substance abuse (Mayo Yoga). Yoga, therefore helps in drawing focus from busy, chaotic day relaxes the body throughout poses demanding balance and concentration. Yoga provides overall relief to the body: 1. It increases flexibility of the body as it demands increased range of motion and hence helps in physical endeavors to carryout day-to-day activities of life (Mayo Yoga). 2. It helps to manage chronic health conditions like asthma, carpal tunnel syndrome, depression, low back pain, multiple sclerosis, osteoarthritis of the knees or memory problems, heart disease and high blood pressure. Yoga, + vegetarian diet+ aerobic exercise + medication = reduced cardiovascular disease rates and blood pressure levels. It is emphasized that it is not the substitute of medications (Mayo Yoga). 3. Other features encompass weight reduction, balance of the body, to cope with the cancer and Alzheimer’s caregivers stress and fatigue (Mayo Yoga). Considering all these facts to combat diseases and stress an understanding is developed that Stress Management Intervention (SMI) is one the nonpharmacological approach to evaluate Hypertension Prevention (TOHP-I) and also that SMI lowers diastolic blood pressure (BP) in healthy men and women between age 30 to 54 years with diastolic BP 80–89 mm Hg (Batey, 2000). Methodology adopted consists of randomization of SMI for 242 and 320 participants an “assessment only” for SMI Control. The participants were trained for four relaxation methods/ techniques to reduce stress reactions, cognitive approaches, communication skills, time management, and anger management within a general problem-solving format. These individuals are observed for BP, psychosocial measures, and urinary samples from both SMI and SMI Control participants (Batey, 2000). Results depict a significant 1.36 mm Hg (p = 0.01) reduction in diastolic BP relative to SMI Controls at the end of the trial for SMI participants who completed 61% or more of intervention session (Batey, 2000). It is also evident that antidepressant medication and stress management therapy are each discreetly effective in treating chronic tension-type headaches (Holroyd, 2001). Conclusion: Thus, it is evident that work issues, difficulties, challenges, obstacles, deadlines, papers, tests, athletic events, performances, family problems, and tragic events are only a few of the situations and all the other factors instigating stress. Sometimes even joyous events like holidays, weddings and new additions to a family can also exacerbate stress. Therefore methods like meditation (RR) and yoga must be promoted to combat stress so as to avoid the progression of diseases. Reference: 1. Batey, D., 2000. Stress Management Intervention for Primary Prevention of Hypertension Detailed Results from Phase I of Trials of Hypertension Prevention (TOHP-I), Annals of Epidemiology, Vol 10(1), pp, 45-58. 2. Scott-Sheldon, Kalichman, S., C., Carey, M., P., Fielder, R., L., 2008. Stress Management Interventions for HIV+ Adults: A Meta-Analysis of Randomized Controlled Trials, 1989 to 2006. Health Psychol.Author manuscript; 28(2), pp,114-8. 3. Holroyd, K. A., O’Donnell, F. J., Stensland, M., Lipchik, G.L., Cordingley, G.E., Carlson, B.W., 2001. Management of Chronic Tension-Type Headache With Tricyclic Antidepressant Medication, Stress Management Therapy, and Their Combination. JAMA, 285(17), pp, 2208-2215. 4. Mayo Yoga: Improve your stress management and relaxation skills. Stress Management http://www.mayoclinic.com/health/yoga/cm00004 Read More