QUANTITATIVE ASSESSMENT OF STRESSORS AND STRESS …

Jpn J Ind Health, 1994; 36: 397-405

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 theoretical model of occupational stressors were surveyed and factors in work stress were listed. Then, we reviewed 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 Egogram 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 sensitivity and specificity were 0.89 and 0.74, respectively.3)

It was reported that the Work Stress Assessment (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 testretest 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

Received for publication, February 28, 1994

398 Jpn J Ind Health, Vol. 36, 1994

ically Ill or Handicapped Members (ORS),10) Hospital Stress Rating Scale (HSRS)11) for in

patients, Speech-Language Pathologist Stress Inventory (SLPSI),12) The Nurse Stress Checklist,13) Clinical Stress Questionnaire (CSQ)14) for nursing students, Undergraduates Stress Questonnaire

(USQ)15) and Prenatal Social Environment Inventory16) 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 Employment Quality Survey,21) Job Characteristics Inventory,22) the Questionnaire of Perceived Work Environment,23) the Questionnaire of Job Diagnostic Survey24) and Work Environment Scale.25) Kawakami et al. selected 22 items for psychological 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 intrinsic 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 prevalence 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. Furthermore, Cooper and Marshall33) have concluded that less physical occupations, such as professional, managerial and clerical, are more prone to occupational stress associated with role conflict.

3. Career development. Career development refers to "the impact of overpromotion, underpromotion, status incongruence, lack of job security, thwarted ambition. .."33) Conditions related to career development are associated with dissatisfaction with life, low self-esteem and physical 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 satisfaction. 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 cigarettes smoked.

5. Organizational structure and climate. Or

ganizational structure and climate include factors such as office politics, lack of effective consultation, lack of participation in the decision-making process, and restrictions on behavior.33,39) According to Margolis et al.40) and French and Caplan,35) greater participation led to improved performance, lower staff turnover, higher productivity and lower levels of physical and mental illness.

6. Other factors. Added to the above factors which Davidson and Cooper listed, lack of technical utilization, conflicts between job and other activities and technological development are known to be factors related to occupational stress.41)

S. Ezoe and K. Morimoto: Quantitative Assessment of Stressors and Stress Reaction : A Review 399

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 examination 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 immunocompetence.49-53) It was reported that the number 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) Furthermore, 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 inhibited 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 immunoglobulin 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 lymphocytes 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 immunocompetence is also inhibited by chronic stress.

There are some studies which examined the relationship between marital status and immunocompetence. 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) Among 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 interviews 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 lowdistress subjects. Furthermore, they found that lymphocytes obtained from psychiatric patients had significantly poorer DNA repair than lymphocytes 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 symptoms 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 Inventory (MMPI),68) Beck Depression Inventory

(BDI),69) The Center for Epidemiologic Studies Depression Scale (CES-D),70) and Manifest Anxiety Scale (MAS).71) Psychological stress reactions 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 particular, 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 activities and changes in health practices such as

increases in smoking and drinking.41) For example, it was reported that job dissatisfaction was significantly correlated with the medical consultation 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

S. Ezoe and K. Morimoto: Quantitative Assessment of Stressors and Stress Reaction: A Review 401

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 subscores of the GHQ-28 were significantly higher in the group with higher perceived stress than in those with lower perceived stress (p<0.05, respectively; 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 between 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 biochemical 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)

産業医学 36巻, Jpn J Ind Health, Vol. 36, 1994 A123

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

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