psychology case study on stress

Stress: A Case Study

Read the story of a women who thought she was having a heart attack, but was instead diagnosed with panic disorder, panic attacks.

Although on the surface everything seemed fine, she felt that, "the wheels on my tricycle are about to fall off. I'm a mess." Over the past several months she had attacks of shortness of breath, heart palpitations, chest pains, dizziness, and tingling sensations in her fingers and toes. Filled with a sense of impending doom, she would become anxious to the point of panic. Every day she awoke with a dreaded feeling that an attack might strike without reason or warning.

On two occasions, she rushed to a nearby hospital emergency room fearing she was having a heart attack. The first episode followed an argument with her boyfriend about the future of their relationship. After studying her electrocardiogram, the emergency room doctor told her she was "just hyperventilating" and showed her how to breathe into a paper bag to handle the situation in the future. She felt foolish and went home embarrassed, angry and confused. She remained convinced that she had almost had a heart attack.

Her next severe attack occurred after a fight at work with her boss over a new marketing campaign. This time she insisted that she be hospitalized overnight for extensive diagnostic tests and that her internist be consulted. The results were the same--no heart attack. Her internist prescribed a tranquilizer to calm her down.

Convinced now that her own doctor was wrong, she sought the advice of a cardiologist, who conducted another battery of tests, again with no physical findings. The doctor concluded that stress was the primary cause of the panic attacks and "heart attack" symptoms. The doctor referred her to psychologist specializing in stress.

During her first visit, professionals administered stress tests and explained how stress could cause her physical symptoms. At her next visit, utilizing the tests results, they described to her the sources and nature of her health problems. The tests revealed that she was highly susceptible to stress, that she was enduring enormous stress from her family, her personal life, and her job, and that she was experiencing a number of stress-related symptoms in her emotional, sympathetic nervous, muscular and endocrine systems. She wasn't sleeping or eating well, didn't exercise, abused caffeine and alcohol, and lived on the edge financially.

The stress testing crystallized how susceptible she was to stress, what was causing her stress, and how stress was expressing itself in her "heart attack" and other symptoms. This newly found knowledge eliminated a lot of her confusion and separated her concerns into simpler, more manageable problems.

She realized that she was feeling tremendous pressure from her boyfriend, as well as her mother to settle down and get married; yet, she didn't feel ready. At the same time, work was overwhelming her as a new marketing campaign began. Any serious emotional incident--a quarrel with her boyfriend or her boss--sent her over the edge. Her body's response was hyperventilation, palpitations, chest pain, dizziness, anxiety, and a dreadful sense of doom. Stress, in short, was destroying her life.

Adapted from The Stress Solution by Lyle H. Miller, Ph.D., and Alma Dell Smith, Ph.D.

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APA Reference Staff, H. (2007, February 18). Stress: A Case Study, HealthyPlace. Retrieved on 2024, March 17 from https://www.healthyplace.com/anxiety-panic/articles/stress-a-case-study

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• Research Article
• Open access
• Published: 06 April 2021

Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19

• Szabolcs Garbóczy 1 , 2 ,
• Anita Szemán-Nagy 3 ,
• Mohamed S. Ahmad 4 ,
• Szilvia Harsányi 1 ,
• Dorottya Ocsenás 5 , 6 ,
• Viktor Rekenyi 4 ,
• Ala’a B. Al-Tammemi 1 , 7 &
• László Róbert Kolozsvári   ORCID: orcid.org/0000-0001-9426-0898 1 , 7  

BMC Psychology volume  9 , Article number:  53 ( 2021 ) Cite this article

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Metrics details

In the case of people who carry an increased number of anxiety traits and maladaptive coping strategies, psychosocial stressors may further increase the level of perceived stress they experience. In our research study, we aimed to examine the levels of perceived stress and health anxiety as well as coping styles among university students amid the COVID-19 pandemic.

A cross-sectional study was conducted using an online-based survey at the University of Debrecen during the official lockdown in Hungary when dormitories were closed, and teaching was conducted remotely. Our questionnaire solicited data using three assessment tools, namely, the Perceived Stress Scale (PSS), the Ways of Coping Questionnaire (WCQ), and the Short Health Anxiety Inventory (SHAI).

A total of 1320 students have participated in our study and 31 non-eligible responses were excluded. Among the remaining 1289 participants, 948 (73.5%) and 341 (26.5%) were Hungarian and international students, respectively. Female students predominated the overall sample with 920 participants (71.4%). In general, there was a statistically significant positive relationship between perceived stress and health anxiety. Health anxiety and perceived stress levels were significantly higher among international students compared to domestic ones. Regarding coping, wishful thinking was associated with higher levels of stress and anxiety among international students, while being a goal-oriented person acted the opposite way. Among the domestic students, cognitive restructuring as a coping strategy was associated with lower levels of stress and anxiety. Concerning health anxiety, female students (domestic and international) had significantly higher levels of health anxiety compared to males. Moreover, female students had significantly higher levels of perceived stress compared to males in the international group, however, there was no significant difference in perceived stress between males and females in the domestic group.

The elevated perceived stress levels during major life events can be further deepened by disengagement from home (being away/abroad from country or family) and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping methods, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety could be mitigated.

Peer Review reports

Introduction

On March 4, 2020, the first cases of coronavirus disease were declared in Hungary. One week later, the World Health Organization (WHO) declared COVID-19 as a global pandemic [ 1 ]. The Hungarian government ordered a ban on outdoor public events with more than 500 people and indoor events with more than 100 participants to reduce contact between people [ 2 ]. On March 27, the government imposed a nationwide lockdown for two weeks effective from March 28, to mitigate the spread of the pandemic. Except for food stores, drug stores, pharmacies, and petrol stations, all other shops and educational institutions remained closed. On April 16, a week-long extension was further announced [ 3 ].

The COVID-19 pandemic with its high morbidity and mortality has already afflicted the psychological and physical wellbeing of humans worldwide [ 4 , 5 , 6 , 7 , 8 , 9 ]. During major life events, people may have to deal with more stress. Stress can negatively affect the population’s well-being or function when they construe the situation as stressful and they cannot handle the environmental stimuli [ 10 ]. Various inter-related and inter-linked concepts are present in such situations including stress, anxiety, and coping. According to the literature, perceived stress can lead to higher levels of anxiety and lower levels of health-related quality of life [ 11 ]. Another study found significant and consistent associations between coping strategies and the dimensions of health anxiety [ 12 ].

Health anxiety is one of the most common types of anxiety and it describes how people think and behave toward their health and how they perceive any health-related concerns or threats. Health anxiety is increasingly conceptualized as existing on a spectrum [ 13 , 14 ], and as an adaptive signal that helps to develop survival-oriented behaviors. It also occurs in almost everyone’s life to a certain degree and can be rather deleterious when it is excessive [ 13 , 14 ]. Illness anxiety or hypochondriasis is on the high end of the spectrum and it affects someone’s life when it interferes with daily life by making people misinterpret the somatic sensations, leading them to think that they have an underlying condition [ 14 ].

According to the American Psychiatric Association—Diagnostic and Statistical Manual of Mental Disorders (fifth edition), Illness anxiety disorder is described as a preoccupation with acquiring or having a serious illness, and it reflects the high spectrum of health anxiety [ 15 ]. Somatic symptoms are not present or if they are, then only mild in intensity. The preoccupation is disproportionate or excessive if there is a high risk of developing a medical condition (e.g., family history) or the patient has another medical condition. Excessive health-related behaviors can be observed (e.g., checking body for signs of illness) and individuals can show maladaptive avoidance as well by avoiding hospitals and doctor appointments [ 15 ].

Health anxiety is indeed an important topic as both its increase and decrease can progress to problems [ 14 ]. Looking at health anxiety as a wide spectrum, it can be high or low [ 16 ]. While people with a higher degree of worry and checking behaviors may cause some burden on healthcare facilities by visiting them too many times (e.g., frequent unnecessary visits), other individuals may not seek medical help at healthcare units to avoid catching up infections for instance. A lower degree of health anxiety can lead to low compliance with imposed regulations made to control a pandemic [ 17 ].

The COVID-19 pandemic as a major event in almost everyone’s life has posed a great impact on the population’s perceived stress level. Several studies about the relation between coping and response to epidemics in recent and previous outbreaks found higher perceived stress levels among people [ 18 , 19 , 20 , 21 ]. Being a woman, low income, and living with other people all were associated with higher stress levels [ 18 ]. Protective factors like being emotionally more stable, having self-control, adaptive coping strategies, and internal locus of control were also addressed [ 19 , 20 ]. The findings indicated that the COVID-19 crisis is perceived as a stressful event. The perceived stress was higher amongst people than it was in situations with no emergency. Nervousness, stress, and loss of control of one’s life are the factors that are most connected to perceived stress levels which leads to the suggestion that unpredictability and uncontrollability take an important part in perceived stress during a crisis [ 19 , 20 ].

Moreover, certain coping styles (e.g., having a positive attitude) were associated with less psychological distress experiences but avoidance strategies were more likely to cause higher levels of stress [ 21 ]. According to Lazarus (1999), individuals differ in their perception of stress if the stress response is viewed as the interaction between the environment and humans [ 22 ]. An Individual can experience two kinds of evaluation processes, one to appraise the external stressors and personal stake, and the other one to appraise personal resources that can be used to cope with stressors [ 22 , 23 ]. If there is an imbalance between these two evaluation processes, then stress occurs, because the personal resources are not enough to cope with the stressor’s demands [ 23 ].

During stressful life events, it is important to pay attention to the increasing levels of health anxiety and to the kind of coping mechanisms that are potential factors to mitigate the effects of high anxiety. The transactional model of stress by Lazarus and Folkman (1987) provides an insight into these kinds of factors [ 24 ]. Lazarus and Folkman theorized two types of coping responses: emotion-focused coping, and problem-focused coping. Emotion-focused coping strategies (e.g., distancing, acceptance of responsibility, positive reappraisal) might be used when the source of stress is not embedded in the person’s control and these strategies aim to manage the individual’s emotional response to a threat. Also, emotion-focused coping strategies are directed at managing emotional distress [ 24 ]. On the other hand, problem-focused coping strategies (e.g., confrontive coping, seeking social support, planful problem-solving) help an individual to be able to endure and/or minimize the threat, targeting the causes of stress in practical ways [ 24 ]. It was also addressed that emotion-focused coping mechanisms were used more in situations appraised as requiring acceptance, whereas problem-focused forms of coping were used more in encounters assessed as changeable [ 24 ].

A recent study in Hunan province in China found that the most effective factor in coping with stress among medical staff was the knowledge of their family’s well-being [ 25 ]. Although there have been several studies about the mental health of hospital workers during the COVID-19 pandemic or other epidemics (e.g., SARS, MERS) [ 26 , 27 , 28 , 29 ], only a few studies from recent literature assessed the general population’s coping strategies. According to Gerhold (2020) [ 30 ], older people perceived a lower risk of COVID-19 than younger people. Also, women have expressed more worries about the disease than men did. Coping strategies were highly problem-focused and most of the participants reported that they listen to professionals’ advice and tried to remain calm [ 30 ]. In the same study, most responders perceived the COVID-19 pandemic as a global catastrophe that will severely affect a lot of people. On the other hand, they perceived the pandemic as a controllable risk that can be reduced. Dealing with macrosocial stressors takes faith in politics and in those people, who work with COVID-19 on the frontline.

Mental disorders are found prevalent among college students and their onset occurs mostly before entry to college [ 31 ]. The diagnosis and timely interventions at an early stage of illness are essential to improve psychosocial functioning and treatment outcomes [ 31 ]. According to research that was conducted at the University of Debrecen in Hungary a few years ago, the students were found to have high levels of stress and the rate of the participants with impacted mental health was alarming [ 32 ]. With an unprecedented stressful event like the COVID-19 crisis, changes to the mental health status of people, including students, are expected.

Aims of the study

In our present study, we aimed at assessing the levels of health anxiety, perceived stress, and coping styles among university students amidst the COVID-19 lockdown in Hungary, using three validated assessment tools for each domain.

Methods and materials

Study design and setting.

This study utilized a cross-sectional design, using online self-administered questionnaires that were created and designed in Google Forms® (A web-based survey tool). Data collection was carried out in the period April 30, 2020, and May 15, 2020, which represents one of the most stressful periods during the early stage of the COVID-19 pandemic in Hungary when the official curfew/lockdown was declared along with the closure of dormitories and shifting to online remote teaching. The first cases of COVID-19 were declared in Hungary on March 4, 2020. On April 30, 2020, there were 2775 confirmed cases, 312 deaths, and 581 recoveries. As of May 15, 2020, the number of confirmed cases, deaths, and recovered persons was 3417, 442, and 1287, respectively.

Our study was conducted at the University of Debrecen, which is one of the largest higher education institutions in Hungary. The University is located in the city of Debrecen, the second-largest city in Hungary. Debrecen city is considered the educational and cultural hub of Eastern Hungary. As of October 2019, around 28,593 students were enrolled in various study programs at the University of Debrecen, of whom, 6,297 were international students [ 33 ]. The university offers various degree courses in Hungarian and English languages.

Study participants and sampling

The target population of our study was students at the University of Debrecen. Students were approached through social media platforms (e.g., Facebook®) and the official student administration system at the University of Debrecen (Neptun). The invitation link to our survey was sent to students on the web-based platforms described earlier. By using the Neptun system, we theoretically assumed that our survey questionnaire has reached all students at the University. The students who were interested and willing to participate in the study could fill out our questionnaire anonymously during the determined study period; thus, employing a convenience sampling approach. All students at the University of Debrecen whose age was 18 years or older and who were in Hungary during the outbreak had the eligibility to participate in our study whether undergraduates or postgraduates.

Study instruments

In our present study, the survey has solicited information about the sociodemographic profile of participants including age (in years), gender (female vs male), study program (health-related vs non-health related), and whether the student stayed in Hungary or traveled abroad during the period of conducting our survey in the outbreak. Our survey has also adopted three international scales to collect data about health anxiety, coping styles, and perceived stress during the pandemic crisis. As the language of instruction for international students at the University of Debrecen is English, and English fluency is one of the criteria for international students’ admission at the University of Debrecen, the international students were asked to fill out the English version of the survey and the scales. On the other hand, the Hungarian students were asked to fill out the Hungarian version of the survey and the validated Hungarian scales. Also, we provided contact information for psychological support when needed. Students who felt that they needed some help and psychological counseling could use the contact information of our peer supporters. Four International students have used this opportunity and were referred to a higher level of care. The original scales and their validated Hungarian versions are described in the following sections.

Perceived Stress Scale (PSS)

The Perceived Stress Scale (PSS) measures the level of stress in the general population who have at least completed a junior high school [ 34 ]. In the PSS, the respondents had to report how often certain things occurred like nervousness; loss of control; feeling of upset; piling up difficulties that cannot be handled; or on the contrary how often the students felt they were able to handle situations; and were on top of things. For the International students, we used the 10-item PSS (English version). The statements’ responses were scored on a 5-point Likert scale (from 0 = never to 4 = very often) as per the scale’s guide. Also, in the 10-item PSS, four positive items were reversely scored (e.g. felt confident about someone’s ability to handle personal problems) [ 34 ]. The PSS has satisfactory psychometric properties with a Cronbach’s alpha of 0.78, and this English version was used for international students in our study.

For the Hungarian students, we used the Hungarian version of the PSS, which has 14 statements that cover the same aspects of stress described earlier. In this version of the PSS, the responses were evaluated on a 5-point Likert scale (0–4) to mark how typical a particular behavior was for a respondent in the last month [ 35 ]. The Hungarian version of the PSS was psychometrically validated in 2006. In the validation study, the Hungarian 14-item PSS has shown satisfactory internal consistency with a Cronbach’s alpha of 0.88 [ 35 ].

Ways of Coping Questionnaire (WCQ)

The second scale we used was the 26-Item Ways of Coping Questionnaire (WCQ) which was developed by Sørlie and Sexton [ 36 ]. For the international students, we used the validated English version of the 26-Item WCQ that distinguished five different factors, including Wishful thinking (hoped for a miracle, day-dreamed for a better time), Goal-oriented (tried to analyze the problem, concentrated on what to do), Seeking support (talked to someone, got professional help), Thinking it over (drew on past experiences, realized other solutions), and Avoidance (refused to think about it, minimized seriousness of it). The WCQ examined how often the respondents used certain coping mechanisms, eg: hoped for a miracle, fantasized, prepared for the worst, analyzed the problem, talked to someone, or on the opposite did not talk to anyone, drew conclusions from past things, came up with several solutions for a problem or contained their feelings. As per the 26-item WCQ, responses were scored on a 4-point Likert scale (from 0 = “does not apply and/or not used” to 3 = “used a great deal”). This scale has satisfactory psychometric properties with Cronbach's alpha for the factors ranged from 0.74 to 0.81[ 36 ].

For the Hungarian students, we used the Hungarian 16-Item WCQ, which was validated in 2008 [ 37 ]. In the Hungarian WCQ, four dimensions were identified, which were cognitive restructuring/adaptation (every cloud has a silver lining), Stress reduction (by eating; drinking; smoking), Problem analysis (I tried to analyze the problem), and Helplessness/Passive coping (I prayed; used drugs) [ 37 ]. The Cronbach’s alpha values for the Hungarian WCQ’s dimensions were in the range of 0.30–0.74 [ 37 ].

Short Health Anxiety Inventory (SHAI)

The third scale adopted was the 18-Items Short Health Anxiety Inventory (SHAI). Overall, the SHAI has two subscales. The first subscale comprised of 14 items that examined to what degree the respondents were worried about their health in the past six months; how often they noticed physical pain/ache or sensations; how worried they were about a serious illness; how much they felt at risk for a serious illness; how much attention was drawn to bodily sensations; what their environment said, how much they deal with their health. The second subscale of SHAI comprised of 4 items (negative consequences if the illness occurs) that enquired how the respondents would feel if they were diagnosed with a serious illness, whether they would be able to enjoy things; would they trust modern medicine to heal them; how many aspects of their life it would affect; how much they could preserve their dignity despite the illness [ 38 ]. One of four possible statements (scored from 0 to 3) must be chosen. Alberts et al. (2013) [ 39 ] found the mean SHAI value to be 12.41 (± 6.81) in a non-clinical sample. The original 18-item SHAI has Cronbach’s alpha values in the range of 0.74–0.96 [ 39 ]. For the Hungarian students, the Hungarian version of the SHAI was used. The Hungarian version of SHAI was validated in 2011 [ 40 ]. The scoring differs from the English version in that the four statements were scored from 1 to 4, but the statements themselves were the same. In the Hungarian validation study, it was found that the SHAI mean score in a non-clinical sample (university students) was 33.02 points (± 6.28) and the Cronbach's alpha of the test was 0.83 [ 40 ].

Data analyses

Data were extracted from Google Forms® as an Excel sheet for quality check and coding then we used SPSS® (v.25) and RStudio statistical software packages to analyze the data. Descriptive and summary statistics were presented as appropriate. To assess the difference between groups/categories of anxiety, stress, and coping styles, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution and for post hoc tests, we used the Mann–Whitney test. Also, we used Spearman’s rank correlation to assess the relationship between health anxiety and perceived stress within the international group and the Hungarian group. Comparison between international and domestic groups and different genders in terms of health anxiety and perceived stress levels were also conducted using the Mann–Whitney test. Binary logistic regression analysis was also employed to examine the associations between different coping styles/ strategies (treated as independent variables) and both, health anxiety level and perceived stress level (treated as outcome variables) using median splits. A p-value less than 5% was implemented for statistical significance.

Ethical considerations

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey. There were no rewards/incentives for completing the survey.

Sociodemographic characteristics of respondents

A total of 1320 students have responded to our survey. Six responses were eliminated due to incompleteness and an additional 25 responses were also excluded as the students filled out the survey from abroad (International students who were outside Hungary during the period of conducting our study). After exclusion of the described non-eligible responses (a total of 31 responses), the remaining 1289 valid responses were included in our analysis. Out of 1289 participants (100%), 73.5% were Hungarian students and around 26.5% were international students. Overall, female students have predominated the sample (n = 920, 71.4%). The median age (Interquartile range) among Hungarian students was 22 years (5) and for the international students was 22 years (4). Out of the total sample, most of the Hungarian students were enrolled in non-health-related programs (n = 690, 53.5%), while most of the international students were enrolled in health-related programs (n = 213, 16.5%). Table 1 demonstrates the sociodemographic profile of participants (Hungarian vs International).

Perceived stress, anxiety, and coping styles

For greater clarity of statistical analysis and interpretation, we created preferences regarding coping mechanisms. That is, we made the categories based on which coping factor (in the international sample) or dimension (in the Hungarian sample) the given person reached the highest scores, so it can be said that it is the person's preferred coping strategy. The four coping strategies among international students were goal-oriented, thinking it over, wishful thinking, and avoidance, while among the Hungarian students were cognitive restructuring, problem analysis, stress reduction, and passive coping.

The 26-item WCQ [ 31 ] contains a seeking support subscale which is missing from the Hungarian 16-item WCQ [ 32 ]; therefore, the seeking support subscale was excluded from our analysis. Moreover, because the PSS contained a different number of items in English and Hungarian versions (10 items vs 14 items), we looked at the average score of the answers so that we could compare international and domestic students.

In the evaluation of SHAI, the scoring of the two questionnaires are different. For the sake of comparability between the two samples, the international points were corrected to the Hungarian, adding plus one to the value of each answer. This may be the reason why we obtained higher results compared to international standards.

Among the international students, the mean score (± standard deviation) of perceived stress among male students was 2.11(± 0.86) compared to female students 2.51 (± 0.78), while the mean score (± standard deviation) of health anxiety was 34.12 (± 7.88) and 36.31 (± 7.75) among males and females, respectively. Table 2 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among international students.

In the Hungarian sample, the mean score (± standard deviation) of perceived stress among male students was 2.06 (± 0.84) compared to female students 2.18 (± 0.83), while the mean score (± standard deviation) of health anxiety was 33.40 (± 7.63) and 35.05 (± 7.39) among males and females, respectively. Table 3 shows more details regarding the perceived stress scores and health anxiety scores stratified by coping strategies among Hungarian students.

Concerning coping styles among international students, the statements with the highest-ranked responses were “wished the situation would go away or somehow be finished” and “Had fantasies or wishes about how things might turn out” and both fall into the wishful thinking coping. Among the Hungarian students, the statements with the highest-ranked responses were “I tried to analyze the problem to understand better” (falls into problem analysis coping) and “I thought every cloud has a silver lining, I tried to perceive things cheerfully” (falls into cognitive restructuring coping).

On the other hand, the statements with the least-ranked responses among the international students belonged to the Avoidance coping. Among the Hungarians, it was Passive coping “I tried to take sedatives or medications” and Stress reduction “I staked everything upon a single cast, I started to do something risky” to have the lowest-ranked responses. Table 4 shows a comparison of different coping strategies among international and Hungarian students.

To test the difference between coping strategies, we used the non-parametric Kruskal–Wallis test, since the variables did not have a normal distribution. For post hoc tests, we used Mann–Whitney tests with lowered significance levels ( p  = 0.0083). Among Hungarian students, there were significant differences between the groups in stress ( χ 2 (3) = 212.01; p < 0.001) and health anxiety ( χ 2 (3) = 80.32; p  < 0.001). In the post hoc tests, there were significant differences everywhere ( p  < 0.001) except between stress reduction and passive coping ( p  = 0.089) and between problem analysis and passive coping ( p  = 0.034). Considering the health anxiety, the results were very similar. There were significant differences between all groups ( p  < 0.001), except between stress reduction and passive coping ( p  = 0.347) and between problem analysis and passive coping ( p  = 0.205). See Figs.  1 and 2 for the Hungarian students.

Perceived stress differences between coping strategies among the Hungarian students

Health anxiety differences between coping strategies among the Hungarian students

Among the international students, the results were similar. According to the Kruskal–Wallis test, there were significant differences in stress ( χ 2 (3) = 73.26; p  < 0.001) and health anxiety ( χ 2 (3) = 42.60; p  < 0.001) between various coping strategies. The post hoc tests showed that there were differences between the perceived stress level and coping strategies everywhere ( p  < 0.005) except and between avoidance and thinking it over ( p  = 0.640). Concerning health anxiety, there were significant differences between wishful thinking and goal-oriented ( p  < 0.001), between wishful thinking and avoidance ( p  = 0.001), and between goal-oriented and avoidance ( p  = 0.285). There were no significant differences between wishful thinking and thinking it over ( p  = 0.069), between goal-oriented and thinking it over ( p  = 0.069), and between avoidance and thinking it over ( p  = 0.131). See Figs.  3 and 4 .

Perceived stress differences between coping strategies among the international students

Health anxiety differences between coping strategies among the international students

The relationship between coping strategies with health anxiety and perceived stress levels among the international students

We applied logistic regression analyses for the variables to see which of the coping strategies has a significant effect on SHAI and PSS results. In the first model (model a), with the health anxiety as an outcome dummy variable (with median split; median: 35), only two coping strategies had a statistically significant relationship with health anxiety level, including wishful thinking (as a risk factor) and goal-oriented (as a protective factor).

In the second model (model b), with the perceived stress as an outcome dummy variable (with median split; median: 2.40), three coping strategies were found to have a statistically significant association with the level of perceived stress, including wishful thinking (as a risk factor), while goal-oriented and thinking it over as protective factors. See Table 5 .

The relationship between coping strategies with health anxiety and perceived stress levels among domestic students

By employing logistic regression analysis, with the health anxiety as an outcome dummy variable (with median split; median: 33.5) (model a), three coping strategies had a statistically significant relationship with health anxiety level among domestic students, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor).

Similarly, with the perceived stress as an outcome dummy variable (with median split; median: 2.1429) (model b), three coping strategies had a statistically significant relationship with perceived stress level, including stress reduction and problem analysis (as risk factors), while cognitive restructuring (as a protective factor). See Table 6 .

Comparisons between domestic and international students

We compared health anxiety and perceived stress levels of the Hungarian and international students’ groups using the Mann–Whitney test. In the case of health anxiety, the results showed that there were significant differences between the two groups ( W  = 149,431; p  = 0.038) and international students’ levels were higher. Also, there was a significant difference in the perceived stress level between the two groups ( W  = 141,024; p  < 0.001), and the international students have increased stress levels compared to the Hungarian ones.

Comparisons between genders within students’ groups (International vs Hungarian)

Firstly, we compared the international men’s and women’s health anxiety and stress levels using the Mann–Whitney test. The results showed that the international women’s health anxiety ( W  = 11,810; p  = 0.012) and perceived stress ( W  = 10,371; p  < 0.001) levels were both significantly higher than international men’s values. However, in the Hungarian sample, women’s health anxiety was significantly higher than men’s ( W  = 69,643; p  < 0.001), but there was no significant difference in perceived stress levels among between Hungarian women and men ( W  = 75,644.5; p  = 0.064).

Relationship between health anxiety and perceived stress

We correlated the general health anxiety and perceived stress using Spearman’s rank correlation. There was a significant moderate positive relationship between the two variables ( p  < 0.001; ρ  = 0.446). Within the Hungarian students, there was a significant correlation between health anxiety and perceived stress ( p  < 0.001; ρ  = 0.433), similarly among international students as well ( p  < 0.001; ρ  = 0.465).

In our study, we found that individuals who were characterized by a preference for certain coping strategies reported significantly higher perceived stress and/or health anxiety than those who used other coping methods. These correlations can be found in both the Hungarian and international students. In the light of our results, we can say that 48.4% of the international students used wishful thinking as their preferred coping method while around 43% of the Hungarian students used primarily cognitive restructuring to overcome their problems.

Regulation of emotion refers to “the processes whereby individuals monitor, evaluate, and modify their emotions in an effort to control which emotions they have, when they have them, and how they experience and express those emotions” [ 41 ]. There is an overlap between emotion-focused coping and emotion regulation strategies, but there are also differences. The overlap between the two concepts can be noticed in the fact that emotion-focused coping strategies have an emotional regulatory role, and emotion regulation strategies may “tax the individual’s resources” as the emotion-focused coping strategies do [ 23 , 42 ]. However, in emotion-focused coping strategies, non-emotional tools can also be used to achieve non-emotional goals, while emotion regulation strategies may be used for maintaining or reinforcing positive emotions [ 42 ].

Based on the cognitive-behavioral model of health anxiety, emotion-regulating strategies can regulate the physiological, cognitive, and behavioral consequences of a fear response to some degree, even when the person encounters the conditioned stimulus again [ 12 , 43 ]. In the long run, regular use of these dysfunctional emotion control strategies may manifest as functional impairment, which may be associated with anxiety disorders. A detailed study that examined health anxiety in the view of the cognitive-behavioral model found that, regardless of the effect of depression, there are significant and consistent correlations between certain dimensions of health anxiety and dysfunctional coping and emotional regulation strategies [ 12 ].

Similar to our current study, other studies have found that health anxiety was positively correlated with maladaptive emotion regulation and negatively with adaptive emotion regulation [ 44 ], and in the case of state anxiety that emotion-focused coping strategies proved to be less effective in reducing stress, while active coping leads to a sense of subjective well-being [ 17 , 27 , 45 , 46 , 47 ]

SHAI values were found to be high in other studies during the pandemic, and the SHAI results of the international students in our study were found to be even slightly higher compared to those studies [ 44 , 48 ]. Besides, anxiety values for women were found to be higher than for men in several studies [ 44 , 48 , 49 , 50 ]. This was similar to what we found among the international students but not among the Hungarian ones. We can speculate that the ability to contact someone, the closeness of family and beloved ones, familiarity with the living environment, and maybe less online search about the coronavirus news could be factors counting towards that finding among Hungarian students. Also, most international students were enrolled in health-related study programs and his might have affected how they perceived stress/anxiety and their preferred coping strategies as well. Literature found that students of medical disciplines could have obstacles in achieving a healthy coping strategy to deal with stress and anxiety despite their profound medical knowledge compared to non-health-related students [ 51 , 52 ]. Literature also stressed the immense need for training programs to help students of medical disciplines in adopting coping skills and stress-reducing strategies [ 51 ].

The findings of our study may be a starting point for the exploration of the linkage between perceived stress, health anxiety, and coping strategies when people are not in their domestic context. People who are away from their home and friends in a relatively alien environment may tend to use coping mechanisms other than the adequate ones, which in turn can lead to increased levels of perceived stress.

Furthermore, our results seem to support the knowledge that deep-rooted health anxiety is difficult to change because it is closely related to certain coping mechanisms. It was also addressed in the literature that personality traits may have a significant influence on the coping strategy used by a person [ 53 ], revealing sophisticated and challenging links to be considered especially during training programs on effective coping and management skills. On the other hand, perceived stress which has risen significantly above the average level in the current pandemic, can be most effectively targeted by the well-formulated recommendations and advice of major international health organizations if people successfully adhere to them (e.g. physical activity; proper and adequate sleep; healthy eating; avoiding alcohol; meditation; caring for others; relationships maintenance, and using credible information resources about the pandemic, etc.) [ 1 , 54 ]. Furthermore, there may be additional positive effects of these recommendations when published in different languages or languages that are spoken by a wide range of nationalities. Besides, cognitive behavioral therapy techniques, some of which are available online during the current pandemic crisis, can further reduce anxiety. Also, if someone does not feel safe or fear prevails, there are helplines to get in touch with professionals, and this applies to the University of Debrecen in Hungary, and to a certain extent internationally.

Naturally, our study had certain limitations that should be acknowledged and considered. The temporality of events could not be assessed as we employed a cross-sectional study design, that is, we did not have information on the previous conditions of the participants which means that it is possible that some of these conditions existed in the past, while others de facto occurred with COVID-19 crisis. The survey questionnaires were completed by those who felt interested and involved, i.e., a convenience sampling technique was used, this impairs the representativeness of the sample (in terms of sociodemographic variables) and the generalizability of our results. Also, the type of recruitment (including social media) as well as the online nature of the study, probably appealed more to people with an affinity with this kind of instrument. Besides, each questionnaire represented self-reported states; thus, over-reporting or under-reporting could be present. It is also important to note that international students were answering the survey questionnaire in a language that might not have been their mother language. Nevertheless, English fluency is a prerequisite to enroll in a study program at the University of Debrecen for international students. As the options for gender were only male/female in our survey questionnaire, we might have missed the views of students who do not identify themselves according to these gender categories. Also, no data on medical history/current medical status were collected. Lastly, we had to make minor changes to the used scales in the different languages for comparability.

The COVID-19 pandemic crisis has imposed a significant burden on the physical and psychological wellbeing of humans. Crises like the current pandemic can trigger unprecedented emotional and behavioral responses among individuals to adapt or cope with the situation. The elevated perceived stress levels during major life events can be further deepened by disengagement from home and by using inadequate coping strategies. By following and adhering to the international recommendations, adopting proper coping strategies, and equipping oneself with the required coping and stress management skills, the associated high levels of perceived stress and anxiety might be mitigated.

Availability of data and materials

The datasets generated and/or analyzed during the current study are not publicly available due to compliance with institutional guidelines but they are available from the corresponding author (LRK) on a reasonable request.

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

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Acknowledgments

We would like to provide our extreme thanks and appreciation to all students who participated in our study. ABA is currently supported by the Tempus Public Foundation’s scholarship at the University of Debrecen.

This research project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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Szabolcs Garbóczy, Szilvia Harsányi, Ala’a B. Al-Tammemi & László Róbert Kolozsvári

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Anita Szemán-Nagy

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Mohamed S. Ahmad & Viktor Rekenyi

Department of Social and Work Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

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All authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK have worked on the study design, text writing, revising, and editing of the manuscript. DO, SG, and VR have done data management and extraction, data analysis. Drafting and interpretation of the manuscript were made in close collaboration by all authors SG, ASN, MSA, SH, DO, VR, ABA, and LRK. All authors read and approved the final manuscript.

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Garbóczy, S., Szemán-Nagy, A., Ahmad, M.S. et al. Health anxiety, perceived stress, and coping styles in the shadow of the COVID-19. BMC Psychol 9 , 53 (2021). https://doi.org/10.1186/s40359-021-00560-3

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Cognitive-Behavioral Treatments for Anxiety and Stress-Related Disorders

• Joshua E. Curtiss , Ph.D. ,
• Daniella S. Levine , B.A. ,
• Ilana Ander , B.A. ,
• Amanda W. Baker , Ph.D.

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Cognitive-behavioral therapy (CBT) is a first-line, empirically supported intervention for anxiety disorders. CBT refers to a family of techniques that are designed to target maladaptive thoughts and behaviors that maintain anxiety over time. Several individual CBT protocols have been developed for individual presentations of anxiety. The article describes common and unique components of CBT interventions for the treatment of patients with anxiety and related disorders (i.e., panic disorder, social anxiety disorder, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder, prolonged grief). Recent strategies for enhancing the efficacy of CBT protocols are highlighted as well.

Anxiety disorders are among the most prevalent of mental disorders and are associated with high societal burden ( 1 ). One of the most well-researched and efficacious treatments for anxiety disorders is cognitive-behavioral therapy (CBT). At its core, CBT refers to a family of interventions and techniques that promote more adaptive thinking and behaviors in an effort to ameliorate distressing emotional experiences ( 2 ). CBT differs from other therapeutic orientations in that it is highly structured and often manualized. CBT sessions often occur weekly for a limited period (e.g., 12–16 weeks), and a small number of booster sessions are sometimes offered subsequently to reinforce independent use of skills. A cognitive-behavioral conceptualization of anxiety disorders includes identification of dysfunctional thinking patterns, distressing feelings or physiological experiences, and unproductive behaviors. When each of these three components interact and mutually reinforce one another, distressing and impairing levels of anxiety can be maintained over time. Although there are several CBT interventions for different types of anxiety, some common techniques and treatment goals form the basis of the CBT philosophy.

Cognitive Interventions

One of the primary CBT strategies is cognitive intervention. In brief, CBT holds that one’s emotional experience is dictated by one’s interpretation of the events and circumstances surrounding that experience ( 2 , 3 ). Anxiety disorders are associated with negatively biased cognitive distortions (e.g., “I think it’s 100% likely I will lose my job, and no one will ever hire me again”). The objective of cognitive interventions is to facilitate more adaptive thinking through cognitive restructuring and behavioral experiments. Cognitive restructuring promotes more adaptive and realistic interpretations of events by identifying the presence of thinking traps. These cognitive traps are patterns of biased thinking that contribute to overly negative appraisals. For example, “black-and-white thinking” describes the interpretation of circumstances as either all good or all bad, without recognition of interpretations between these two extremes, and “overgeneralization” describes the making of sweeping judgments on the basis of limited experiences). Through identification of thinking traps, cognitive restructuring can be used to promote more balanced thinking, encouraging patients to consider alternative interpretations of circumstances that are more helpful and less biased by anxiety (e.g., “Maybe thinking the chance of losing my job is 100% is overestimating the likelihood that it will actually happen. And, it’s not a forgone conclusion that even if I lose my job, I will never find another one for the rest of my life.”). Similarly, behavioral experiments can be used to facilitate cognitive change. Behavioral experiments involve encouraging patients to empirically test maladaptive beliefs to determine whether there is evidence supporting extreme thinking. For example, if a patient believes that he/she/they is romantically undesirable and that asking someone on a date will cause the other person to react with disgust and disdain, then the patient would be encouraged to test this belief by asking someone on a date. Some combination of cognitive restructuring and behavioral experiments are often implemented in CBT across all anxiety disorders.

Behavioral Interventions

There are several behavioral strategies in CBT for anxiety disorders, yet the central behavioral strategy is exposure therapy. Exposure techniques rely on learning theory to explain how prolonged fear is maintained over time. Specifically, heightened anxiety and fear prompt individuals to avoid experiences, events, and thoughts that they believe will lead to catastrophic outcomes. Continued avoidance of feared stimuli and events contributes to the maintenance of prolonged anxiety. Consistent with the premises underlying extinction learning, exposure exercises are designed to encourage a patient to confront a feared situation without engaging in avoidance or subtle safety behaviors (i.e., doing something to make an anxiety-inducing situation less distressing). After repeated exposures to a feared situation (e.g., heights) without engaging in avoidance or safety behaviors (e.g., closing one’s eyes to avoid looking down), the patient will learn that such a situation is less likely to be associated with disastrous outcomes, and new experiences of safety will be reinforced. Similar to the behavioral experiments described in the cognitive intervention section above, which test whether a faulty thought is true or false, exposure exercises offer the opportunity for patients to test their negative beliefs about the likelihood of a bad outcome by exposing themselves to whatever situations they have been avoiding. Thus, cognitive approaches and exposure exercises are complementary techniques that can benefit individuals with anxiety disorders. In the following sections, different aspects of CBT will be explored and emphasized insofar as they relate to specific presentations of anxiety.

CBT for Specific Disorders

Panic disorder.

Panic disorder, as defined by the DSM-5 , is characterized by recurrent, unexpected panic attacks accompanied by worry and behavioral changes in relation to future attacks. Panic attacks are marked by acute, intense discomfort, with symptoms including heart palpitations, sweating, and shortness of breath. Individuals with panic disorder exhibit cognitive and behavioral symptoms, such as catastrophic misinterpretations of their symptoms as dangerous (e.g., “my heart pounding means I will have a heart attack”) and avoidance of situations or sensations that induce panic ( 4 ). Cognitive-behavioral treatments thus target these symptoms. For example, cognitive restructuring is used to help patients reinterpret their maladaptive thoughts surrounding panic (e.g., “if I get dizzy, I will go crazy”) to be more flexible (e.g., “if I get dizzy, it may just mean that I spun around too fast”). Behavioral treatments for panic include exposure to the situations (i.e., in-vivo exposure, which might include driving in traffic or riding the subway) and bodily sensations (i.e., interoceptive exposure, which would include physical exercises to bring on physical symptoms) that trigger panic in order to reduce the fear and anticipatory anxiety that maintain the symptoms. The aim of these exposures is to illustrate that the situations and sensations are benign and not indicative of danger.

Generalized Anxiety Disorder

Generalized anxiety disorder (GAD) is characterized by excessive and uncontrollable worry about several life domains (e.g., finances, health, career, the future in general). Treatment for GAD involves a wholesale approach to target excessive worry with a combination of cognitive and behavioral strategies ( 5 ). Although cognitive restructuring exercises are indeed emphasized throughout the treatment to target dysfunctional thoughts, usually further cognitive treatments are included to address worry behavior in addition to thought content. Individuals with GAD rarely achieve complete remission after restructuring only one of their negative thoughts. The CBT conceptualization of worry describes worry as a mental behavior or process, characterized by repetitive negative thinking about catastrophic future outcomes. To target worrying as a process, cognitive techniques, such as mindfulness, are emphasized. Rather than targeting the content of worry (e.g., “I think I will definitely lose my job if I do not prepare for this meeting”), mindfulness exercises target the worry behavior by promoting the opposite of repetitive negative thinking (i.e., nonjudgmental and nonreactive present moment awareness), thereby facilitating greater psychological distance from negative thoughts. Exposure therapy is often implemented as imaginal exposures for GAD, because individuals with GAD rarely have an external object that is feared. Such imaginal exposures will encourage patients with GAD to write a detailed narrative of their worst-case scenario or catastrophic outcome and then imagine themselves undergoing such an experience without avoiding their emotions. Cognitive restructuring and imaginal exposure exercises can benefit patients with GAD by targeting their tendency to give catastrophic interpretations to their worries, whereas mindfulness can be helpful in targeting worry as a mental behavior itself ( 5 ).

Social Anxiety Disorder

Social anxiety disorder involves a fear of negative evaluation in social situations and is accompanied by anxiety and avoidance of interpersonal interactions and performance in front of others. The primary treatment approach for social anxiety disorder consists of exposure exercises to feared social situations ( 6 ). Cognitive restructuring is used in conjunction with exposure exercises to reinforce the new learning and shift in perspective occurring through exposure therapy. Typically, exposure exercises for social anxiety disorder come in two stages ( 6 ). The first stage of exposures often targets patients’ overestimation that something bad will happen during a social interaction. For instance, patients with this disorder may fear that they will make many verbal faux pas (e.g., saying “uh” more than 30 times) during a conversation. An exposure exercise may consist of recording the patient having a 2-minute conversation and listening to the recording afterward to see whether the feared outcome actually occurred. The second stage of exposure exercises (i.e., social cost exposures) consists of having patients directly making their worst-case social anxiety scenario come true to determine how bad and intolerable it actually is. Such a social cost exposure might involve encouraging a patient to embarrass her- or himself on purpose by singing “Twinkle, Twinkle Little Star” in a crowded public street. After fully confronting a social situation that the patient predicted would be very embarrassing, the patient can then determine whether such a situation is as devastating and intolerable as predicted. After repeated social cost exposures, patients with social anxiety disorder experience less anxiety in embarrassing social situations and are more willing to adopt less catastrophic beliefs about the meaning of making mistakes in social situations.

Obsessive-Compulsive Disorder

Obsessive-compulsive disorder (OCD) is characterized by obsessions (i.e., unwanted thoughts or images that are intrusive in nature) and compulsions (i.e., actions or mental behaviors that are performed in a rule-like manner to neutralize the obsession). A CBT conceptualization of OCD considers compulsions as a form of emotional avoidance. Although both cognitive interventions and exposure exercises are helpful for individuals with OCD, the latter are often emphasized. The gold-standard CBT treatment for OCD is exposure and ritual prevention therapy ( 7 ). The primary idea underlying exposure and ritual prevention is to expose individuals with OCD to the feared circumstance associated with the obsession and prevent them from performing the compulsive ritual that gives them comfort through avoidance. For example, patients who experience frequent obsessions about whether their doors are locked or their appliances are off (e.g., “If my door is unlocked, then my house might be robbed or something bad might happen.”) will often feel compelled to perform a compulsion (e.g., ritualistic checking) to avoid the likelihood of having their obsession come true. Exposure and ritual prevention would be used to expose such patients to a feared situation, such as leaving their door unlocked on purpose, and resisting the compulsion to check the door or to lock it. During these exposures, the patients would be asked to embrace the uncertainty surrounding the possibility of the feared outcome coming true (i.e., someone entering the house). Repeated sessions of exposure and ritual prevention will facilitate corrective learning about the likelihood that feared outcomes will occur.

Posttraumatic Stress Disorder

As defined by the DSM-5 , posttraumatic stress disorder (PTSD) can arise after a traumatic event in which an individual directly experiences, witnesses, or learns about the actual or threatened death, serious injury, or sexual violence toward a loved one. After the traumatic stressor event, an individual with PTSD may experience intrusion symptoms (e.g., upsetting dreams or flashbacks of the event), avoidance of reminders of the event, changes in cognitions and affect (e.g., distorted beliefs about oneself, others, and the world), and changes in physiological arousal (e.g., jumpiness, irritability) ( 4 ). Gold-standard treatments for PTSD involve targeting the cognitive and behavioral symptoms that maintain the disorder ( 8 ). PTSD treatments target negative changes in cognition by restructuring the thoughts and beliefs surrounding the traumatic event. For example, evidence-based treatments alter persistent negative beliefs about the world (e.g., “I was assaulted; therefore, the world is dangerous”) to be more flexible (e.g., “even though I was assaulted, there are safe places for me to be”). In challenging these beliefs, the patient may be better able to foster flexible thinking, positive affect, trust, and control in their lives. PTSD treatments are also designed to help patients confront the upsetting memories and situations associated with the traumatic event. Through in-vivo exposures (i.e., approaching situations that are reminders of the trauma) and imaginal exposures (i.e., confronting upsetting memories of the trauma), the patient can begin to behaviorally approach, rather than avoid, reminders of the event to overcome their fears of the trauma and the associated symptoms.

Prolonged Grief Disorder

After losing a loved one, many individuals experience grief symptoms, such as thoughts (e.g., memories of the deceased, memories of the death), emotions (e.g., yearning, emotional pain), and behaviors (e.g., social withdrawal, avoidance of reminders). For most bereaved individuals, these symptoms decrease over time; however, some individuals experience a debilitating syndrome of persistent grief called prolonged grief disorder. This disorder is a direct consequence of the loss, thereby differentiating it from depression and PTSD. Evidence-based and efficacious treatment options for prolonged grief disorder draw from interpersonal therapy, CBT, and motivational interviewing, with additional psychoeducation components ( 9 ). These treatments aim to facilitate the natural bereavement process as individuals accept and integrate the loss. Strategies can be either loss-related or restoration-related. Specific loss-related strategies that draw from CBT include imaginal and situational revisiting (e.g., retelling the story of the loss, going to places that have been avoided since the loss) and a grief monitoring diary. Restoration-related strategies include short- and long-term planning, self-assessment and self-regulation, and rebuilding interpersonal connections.

Transdiagnostic Approaches to CBT for Anxiety Disorders

Throughout the past several decades, there has been a proliferation of CBT approaches that have been individualized to specific anxiety disorder presentations (e.g., panic disorder, specific phobias, social anxiety disorder). Each disorder-specific treatment manual is written to consider unique applications of CBT strategies for the presenting disorder. However, in recent years, there has been increased interest in considering transdiagnostic approaches to the treatment of anxiety and related disorders ( 10 ). The commonalities among individual anxiety disorders and the high levels of comorbidity have contributed to the rationale for a unified CBT approach that can target transdiagnostic mechanisms underlying all anxiety disorders. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) has been the most studied transdiagnostic treatment for anxiety disorders, and recent evidence ( 10 ) corroborates the equivalent efficacy of the UP relative to disorder-specific treatment protocols for individual anxiety disorders.

The UP consists of five core modules that target transdiagnostic mechanisms of emotional disorders, particularly neuroticism and emotional avoidance, underlying all anxiety disorders. Specifically, the modules are mindfulness of emotions, cognitive flexibility, identifying and preventing patterns of emotion avoidance, increasing tolerance of emotion-related physical sensations, and interoceptive and situational emotion-focused exposures ( 10 ). Each module may be used flexibly for individual patients. The first two modules are more cognitive in nature, whereas the latter modules are more behavioral and emphasize the treatment of avoidance. The first module emphasizes mindfulness of emotions, which consists of allowing oneself to fully and nonjudgmentally experience emotions and allow them to come and go while remaining focused on the present. The second module fosters cognitive flexibility by identifying thinking traps that lead to overly negative thoughts and interpretations and by teaching restructuring strategies to generate alternative interpretations of circumstances that are less biased and more adaptive. The third module promotes the identification of emotion-driven behaviors (i.e., actions that a given emotion compels a person to do, such as avoidance behaviors in response to fear) and the adoption of alternative actions (i.e., behaviors that are different from or the opposite of the emotion-driven behavior). For example, if social anxiety prompts an individual to avoid eye contact as an emotion-driven behavior, then an alternative action would be to intentionally maintain eye contact with another speaker to counteract this subtle form of avoidance. The final two modules consist of exposure exercises to develop better tolerance of unwanted physical symptoms produced by anxiety (e.g., increased heart rate) and to reduce fear in anxiety-provoking situations.

Because the UP contains many of the core components of disorder-specific protocols and has demonstrated equivalent efficacy, such a treatment approach may reduce the need for excessive reliance on disorder-specific protocols ( 10 ). Furthermore, the UP can be extended to other emotional disorders, such as depression.

Complementary Approaches for CBT

Mindfulness.

Mindfulness-based interventions function both as transdiagnostic adjunctive treatments to CBT for patients with anxiety and stress disorders as well as stand-alone treatments. Mindfulness is the practice of nonjudgmental awareness of the present moment experience. The aim of these interventions is to reduce emotional dysregulation and reactivity to stressors. Common mindfulness-based interventions include manualized group skills training programs called mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy ( 11 ). MBSR involves eight, 2–2.5-hour sessions with an instructor, in conjunction with a daylong retreat, weekly homework assignments, and practice sessions. Modules are designed to train participants in mindful meditation, interpersonal communication, sustained attention, and recognition of automatic stress reactivity. Mindfulness-based cognitive therapy has a structure similar to MBSR but includes cognitive therapy techniques to train participants to recognize and disengage from negative automatic thought patterns ( 12 ). These interventions omit aspects of traditional CBT (e.g., cognitive restructuring). Mindfulness-based interventions have been explored as both brief and Internet-delivered interventions and have been integrated into other evidence-based practices (e.g., dialectical behavior therapy and acceptance and commitment therapy).

Pharmacotherapy

There has been much interest in determining whether combination strategies of CBT and pharmacotherapy yield greater efficacy than either one alone for individuals with anxiety disorders. A comprehensive meta-analysis ( 13 ) examining this combination strategy suggested that adding pharmacotherapy to CBT may produce short-term benefit, yet such improvements diminished during 6-month follow-up. This combination strategy was more efficacious for individuals with panic disorder or GAD than for individuals with other presentations of anxiety. Moreover, the meta-analysis ( 13 ) indicated that the effect size for CBT combined with benzodiazepines was significantly greater than that for CBT combined with serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants. Another important consideration for pharmacotherapy in the treatment of individuals with anxiety disorders is to ensure that anxiolytic medications, such as benzodiazepines, are administered carefully in the context of exposure therapy. Anxiolytic medications taken to temporarily reduce anxiety may undermine quality exposure therapy sessions by preventing patients from fully learning whether they can tolerate fear without resorting to avoidance behaviors. Thus, although pharmacotherapy appears to improve outcomes in combination with CBT for patients with anxiety disorders, further research is needed to determine the durability of these effects.

D-Cycloserine in Conjunction With Exposures

One approach for improving patient outcomes is to target the extinction learning process underlying exposure exercises. There has been recent interest in cognitive enhancers, such as d-cycloserine (DCS) or methylene blue, as pharmacological adjuncts to exposure therapy ( 14 , 15 ). In preclinical studies, DCS has demonstrated evidence as a cognitive enhancer, consolidating new learning during extinction training. Specifically, the efficacy associated with DCS depends on the efficacy of the exposure exercise. For instance, during a successful exposure exercise, in which anxiety levels decrease substantially, the administration of DCS may confer additional benefit by consolidating this learning. However, if an exposure exercise was unsuccessful and fear levels never decreased, then DCS might consolidate the fear memory, thereby exacerbating the severity of the anxiety disorder ( 14 ). Recently, however, there has been evidence ( 16 ) suggesting that the efficacy of cognitive enhancers, such as DCS, has been declining, possibly because of changes in dose and dose timing. More research needs to be undertaken to understand under what circumstances (e.g., length of exposure session, amount of fear reduction, timing of dose) DCS would offer the greatest therapeutic effect in conjunction with exposure therapy.

Novel Delivery Methods

Internet-delivered CBT (I-CBT) is an alternative modality for the delivery of CBT for patients with anxiety and related disorders. I-CBT is a scalable alternative to in-person treatment, with the Internet used as an accessible and cost-effective method of delivery for evidence-based treatment. In I-CBT, CBT modules are delivered via computer or an application on a mobile device, with the support of a therapist or through a self-guided system. I-CBT has been shown ( 17 – 19 ) to be superior to waitlist and placebo conditions in the treatment of adults with a range of anxiety and trauma disorders, including anxiety and PTSD. Results ( 18 ) have indicated that I-CBT is similarly effective at reducing panic disorder symptoms as face-to-face CBT. The results of another trial ( 20 ) have indicated that I-CBT is also effective at reducing symptoms of OCD and social anxiety disorder.

In addition to Internet and mobile application platforms for CBT, virtual reality technology offers novel avenues to access cognitive-behavioral interventions ( 21 ). One key advantage is that recent advances in the sensory vividness of virtual reality platforms have facilitated more meaningful exposure exercises. For example, virtual reality flight simulators can be leveraged to expose a patient with flight phobia to several flight conditions with enhanced sensory detail (e.g., sounds of liftoff or landing, vibrations, images of clouds through a window, images of in-cabin atmosphere). This technology could obviate the need to purchase several expensive flights to participate in exposure exercises, thereby permitting more frequent exposure opportunities.

Conclusions

CBT is an effective, gold-standard treatment for anxiety and stress-related disorders. CBT uses specific techniques to target unhelpful thoughts, feelings, and behaviors shown to generate and maintain anxiety. CBT can be used as a stand-alone treatment, may be combined with standard medications for the treatment of patients with anxiety disorders (e.g., selective serotonin reuptake inhibitors), or used with novel interventions (e.g., mindfulness). Furthermore, this treatment is flexible in terms of who may benefit from it. Overall, whenever a patient is experiencing some form of emotional psychopathology (e.g., an anxiety or depression disorder) or distressing emotions that do not meet disorder threshold but cause distress or interference in daily activities, referral to a CBT provider is indicated to pursue a course of treatment to actively address such symptoms and problems.

The authors report no financial relationships with commercial interests.

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Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program

• Original Paper
• Published: 28 November 2020
• Volume 30 , pages 431–446, ( 2021 )

Cite this article

• Deborah L. Schussler   ORCID: orcid.org/0000-0001-5970-4326 1 ,
• Yoonkyung Oh 2 ,
• Julia Mahfouz 3 ,
• Joseph Levitan 4 ,
• Jennifer L. Frank 1 ,
• Patricia C. Broderick 1 ,
• Joy L. Mitra 1 ,
• Elaine Berrena 1 ,
• Kimberly Kohler 1 &
• Mark T. Greenberg 1  

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Research on mindfulness-based programs (MBPs) for adolescents suggests improvements in stress, emotion regulation, and ability to perform some cognitive tasks. However, there is little research examining the contextual factors impacting why specific students experience particular changes and the process by which these changes occur. Responding to the NIH call for “n-of-1 studies” that examine how individuals respond to interventions, we conducted a systematic case study, following an intervention trial (Learning to BREATHE), to investigate how individual students experienced an MBP. Specifically, we examined how students’ participation impacted their perceived stress and well-being and why students chose to implement practices in their daily lives. Students in health classes at two diverse high schools completed quantitative self-report measures (pre-, post-, follow-up), qualitative interviews, and open-ended survey questions. We analyzed self-report data to examine whether and to what extent student performance on measures of psychological functioning, stress, attention, and well-being changed before and after participation in an MBP. We analyzed qualitative data to investigate contextual information about why those changes may have occurred and why individuals chose to adopt or disregard mindfulness practices outside the classroom. Results suggest that, particularly for high-risk adolescents and those who integrated program practices into their daily lives, the intervention impacted internalizing symptoms, stress management, mindfulness, and emotion regulation. Mindful breathing was found to be a feasible practice easily incorporated into school routines. Contextual factors impacted practice uptake and program outcomes. Implications for practitioners aiming to help high school students manage stress are discussed.

Systematic case study provides nuanced data about how individuals respond to a mindfulness-based program (MBP).

High-risk adolescents received the most benefit from MBP participation.

Students who practiced were more likely to experience change across outcomes.

The MBP most impacted the way students responded to stress.

Mindful breathing may be the most accessible practice for students.

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Author Contributions

All authors contributed to the study conception and design. Qualitative data collection and analysis were performed by D.L.S., J.M., and J.L. Quantitative analysis was performed by Y.O., while J.L.M., E.B., and K.K. led the quantitative data collection. The first draft of the manuscript was written by D.L.S. and Y.O., and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

The project described was supported by Award Number R305A140113 from the Institute of Education Sciences (IES). The content is solely the responsibility of the authors and does not necessarily represent the official views of the Institute of Education Sciences or the U.S. Department of Education.

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Schussler, D.L., Oh, Y., Mahfouz, J. et al. Stress and Well-Being: A Systematic Case Study of Adolescents’ Experiences in a Mindfulness-Based Program. J Child Fam Stud 30 , 431–446 (2021). https://doi.org/10.1007/s10826-020-01864-5

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Understanding the Far-Reaching Effects of Stress

Research on health and coping effects from stress, trauma, and abuse..

Posted February 20, 2024 | Reviewed by Michelle Quirk

• What Is Stress?
• Find counselling to overcome stress
• Up to 70 percent of diseases may be related to stress.
• Childhood maltreatment can lead to thinking and coping that inhibit resilience.
• Chronic stressors disrupt activation of the body's systems that restore homeostasis.

The term " stress " has become so ubiquitous that it may pose a challenge if people are asked to define it. Because stress is so widespread, individuals may also be desensitized to the terminology and not fully comprehend the gravity of its consequences. However, stress is serious, as up to 70 percent of diseases are related to stress.

Types of Stress

While stress can be acute (more immediate and shorter-term) or chronic (lasting months to years), it can also be compounded by events that occurred in the past (distant stress). This is where terms like "triggered" can arise, as a current event may mimic a past stressor event or trauma. Stress can also be categorized into encounter stress, anticipatory stress, and situational stress.

Here is an example of encounter stress and some of the body’s physiological responses. Imagine a young college student walking alone to their car late at night. Suddenly, a large person with a dark mask begins to approach. Fearing for their life, their hypothalamus-pituitary-adrenocortical (HPA) and sympathetic-adrenal-medullary (SAM) pathways are immediately activated, secreting heightened amounts of the glucocorticoid cortisol that enacts the fight-or-flight response, allowing them to run or fight for their life. The digestive system is halted so that blood can rush to the limbs to facilitate fighting or running.

Returning to the concept of distant stressors, now imagine the young student is actually walking with a friend, close to sunset, and the parking lot is filled with other students. The approaching person is a fellow classmate. However, in this scenario, the student has had a prior assault, and the approaching friend is wearing similar clothes to the student’s former assailant. In this case, the distant stressor, or triggered traumatic memory , may activate the same physiological response as the original dangerous assault.

Moreover, if the young student had a history of childhood maltreatment on top of the assault, the student’s stress response would likely be heightened in an array of normal situations that don’t even mimic the assault. This is because chronic stressors and traumas disrupt the activation of the parasympathetic nervous system and vagal brake that restores the body to homeostasis, leaving the body vulnerable to an array of diseases and chronic health conditions.

Childhood Abuse

Childhood maltreatment not only sets up physiological roadblocks but can also lead to thinking and coping that inhibit resilience . Duprey et al. (2021) researched the effects of childhood emotional abuse and found that individuals with a history of childhood emotional abuse were more likely to internalize issues; have higher levels of hopelessness, withdrawal, and maladaptive cognitive schemas; and were more at risk for substance abuse disorders.

Meanwhile, Yan (2016) found that abuse survivors had heightened sympathetic hyperactivity, hypertension, depression , and anxiety . The increased inflammatory responses and oxidative stress also led to chronic inflammatory diseases, T-cell increases, autoimmune responses, dietary preference alterations, altered weight, and disruptions to the gut microbiome .

Complex Solutions

Complex stress cases benefit from complex solutions. While medical treatments to treat disease and mental health therapies like cognitive-behavioral therapy could help, having a more systemic approach that helps the person retrain and manage their stress response while finding ways to increase relaxation times and cultivate healthy sleep, diet , and exercise would appear to be more favorable than a prescription for an antidepressant .

Interestingly, Bisson et al. (2020) conducted a systematic review of meta-analyses of some of the most promising alternative treatments that showed evidence-based measures. Yoga appeared to show positive results, and the variety of yoga (from slower Yin to more cardio [and adrenaline-releasing] Ashtanga), combined with philosophical principles for living, could help abuse survivors work through posttraumatic stress disorder ( PTSD ) while gaining philosophical insights that could help amend some cognitive distortions. The authors also found promising results with acupuncture and transcranial magnetic stimulation (TMS), which were reported to be more favorable than health education . Finally, it would be imperative that the person be assessed for substance issues and offered recovery treatment, as many of these interventions could be nullified by substance abuse.

Bisson, J. I., van Gelderen, M., Roberts, N. P., & Lewis, C. (2020). Non-pharmacological and non-psychological approaches to the treatment of PTSD: Results of a systematic review and meta-analyses. European Journal of Psychotraumatology , 11 (1), 1795361.

Duprey, E. B., Oshri, A., Liu, S., Kogan, S. M., & Caughy, M. O. (2021). Physiological Stress Response Reactivity Mediates the Link Between Emotional Abuse and Youth Internalizing Problems. Child Psychiatry and Human Development , 52 (3), 450–463. https://doi.org/10.1007/s10578-020-01033-1

Yan, Q. (2016). Psychoneuroimmunology: Systems Biology Approaches to Mind-Body Medicine. New York, NY: Springer Publishing.

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Revealing the Hidden Consequences: Real-life Case Studies in Stress and Anxiety

In today's fast-paced world, stress and anxiety are part and parcel of everyday life. While they are natural reactions to challenging circumstances, persistent, poorly managed stress can result in serious health outcomes. The stress behind the development of these illnesses is often not seen or well-treated since it is invisible and doesn't show up on x-rays or lab tests.

Case Study 1: The Physical Toll of Chronic Stress and Anxiety

John, a middle-aged executive, experienced chronic stress due to work and family pressure, leading to a range of health issues. Having never learned good stress management skills, John overate, drank too much coffee in the daytime and alcohol in the evening, and made no time for exercise or relaxation in his overbusy days. 

He didn’t complain or even recognize how stressed he was since all his colleagues and friends seemed to be dealing with the same issues.  He didn't recognize the signs of stress but over a few years accumulated a number of medical diagnoses and medications to go with them.

• Eating on the run and too much coffee and alcohol gave him chronic heartburn, diagnosed as “GERD” (GastroEsophageal Reflux Disease) and treated with omeprazole and antacids
• John developed high blood pressure and high cholesterol, putting him at high risk for heart disease and stroke, so was given blood pressure medications and statin medication
• His increasingly poor sleep was treated with Trazodone, a medication that knocked him out but left him feeling groggy and starting his day with 2 or 3 large cups of coffee
• As he became increasingly exhausted and using more alcohol, he got crankier and more irritable, early signs of depression in men. His doctor started him on an antidepressant which helped his mood, but didn't help him change his lifestyle which was at the root of all these “diagnoses.”

Case Study 2: Mental and Emotional Consequences

Susan, a school teacher, faced constant anxiety due to high workload and financial problems. This prolonged exposure to unmanaged stress and anxiety led to:

• Emotional Burnout: Over time, Susan experienced emotional exhaustion leading to feelings of detachment, a condition often referred to as burnout.
• Cognitive Difficulties: Chronic stress and burnout affected her ability to concentrate, plan, and make good decisions.
• Depression: Eventually, persistent stress and anxiety triggered the onset of depression in Susan

Case Study 3: The Social Impact

Emma, a college student suffering from chronic stress, worry, and anxiety, exhibited changes in her social behavior:

• Isolation: She started withdrawing from her friends and social activities, leading to feelings of loneliness and even more stress.
• Conflict: Her stress made her irritable, leading to increased conflict in her personal relationships, worsening her isolation and loneliness.

Identifying these signs of too much stress is the first step towards recovery. None of these people had an illness or disease – they were overstressed and didn't have the tools or support to help them manage it.  There are many techniques and tools that can help to keep stress and anxiety at manageable levels:

• Mindfulness and Meditation: Techniques like these helped John stay focused on the present moment, reducing his stress levels.
• Physical Activity: Regular exercise assisted Susan in reducing her stress. It served as a natural mood enhancer and distracted her from constant worry.
• Balanced Diet: Emma found that a healthy diet helped combat her stress. Certain foods even assisted in reducing stress, such as those rich in omega-3 fatty acids and vitamin C.
• Guided Imagery: Upon recognizing the detrimental effects of stress and anxiety on their daily lives, John, Susan, and Emma decided to learn how to reduce stress and manage it better when it couldn’t be avoided.  Either on their own or with the urging of a therapist, they discovered relaxation and guided imagery. The skills and practices they learned became a keystone of their healthy lifestyle, playing a significant role in alleviating their stress and anxiety and guiding them towards recovery.

Recognizing the signs of excessive stress and anxiety is the first step towards effectively managing them. Learning good elf-care stress and anxiety reduction skills is the second step. If you’re too overwhelmed or mired down in the stress, professional help you dig out of it. Remember, seeking help and making strides towards a healthier life is absolutely okay. Living a life free from the burden of constant worry is your right. The journey to that life begins now.

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ORIGINAL RESEARCH article

Studying daily fluctuations of emotional effort among nurses of intensive care units: the establishment of latent profiles and its relationship with daily secondary traumatic stress and vitality.

• 1 Faculty of Education and Psychology, Universidad Francisco de Vitoria, Madrid, Spain
• 2 Department of Biological and Health Sciences, European University of Madrid, Madrid, Spain
• 3 Faculty of Psychology, Autonomous University of Madrid, Madrid, Spain

Introduction: Nursing professionals working in Intensive Care Units (ICU) face significant challenges that can result in secondary traumatic stress (STS). These challenges stem from witnessing patients’ suffering and managing difficult tasks (i.e. communication with patients’ relatives). Furthermore, these professionals encounter emotional demands, such as emotional effort, which is the dissonance between the emotion felt and the emotion that should be expressed to meet work expectations. Consequently, we aimed to investigate whether different profiles exist concerning nurses’ levels of emotional effort over a five-day period and whether these profiles are related to daily STS and vitality.

Methods: The sample comprised 44 nursing professionals from ICUs in Spanish hospitals. They were assessed daily, using a package of questionnaires twice per day for five working days: a) immediately after their shift and b) at a later time after working.

Results: The findings revealed three distinct profiles based on emotional effort levels: high (Profile 1), moderate (Profile 2), and low (Profile 3). These profiles were found to be negative predictors for both daily shattered assumptions and symptomatology.

Discussion: This study underscores the importance of assessing daily emotional demands in an ICU setting. Such assessments are crucial for establishing preventive measures to help nursing professionals manage lower-level emotional demands.

Introduction

Nursing professionals working in Intensive Care Units (ICU) are known to face various psychosocial risks ( Nikbakht Nasrabadi et al., 2022 ). Working in an ICU entails working under pressure and tough stressors, which may lead to an increase in emotional exhaustion among healthcare professionals ( Ballester-Arnal et al., 2016 ). Additionally, this could result in negative consequences related to trauma in the medium and long-term ( Ariapooran et al., 2022 ). Specifically, the prevalence of secondary traumatic stress (STS) among nurses ranges from 7 to 67.64%, depending on the country and specific population studied ( Partlak Günüşen et al., 2019 ). In Spain, studies conducted after the COVID-19 outbreak revealed alarming rates of STS, with 38% of nurses experiencing moderate or severe symptoms, consequently affecting their mental health ( Martin-Rodriguez et al., 2022 ). Although no specific studies have updated the prevalence of STS among nurses, Luceño-Moreno et al. (2020) sampled 1,442 healthcare professionals and found that 56.6% suffered from posttraumatic stress. The prolonged strain and work stress experienced by these professionals may increase intention to quit their jobs, with a worldwide turnover rate of 27% ( Xu et al., 2023 ). Thus, studying the occurrence of STS in nurses is undeniably relevant to provide a comprehensive understanding of their mental health and well-being.

Nurses are constantly in direct contact with patients, families, and other healthcare professionals, requiring effective communication skills ( Foglia et al., 2010 ). Furthermore, the pandemic outbreak has increased patient load ( Nikbakht Nasrabadi et al., 2022 ), increasing the scarcity of job resources and imposing several limitations on overcoming these difficulties ( Blanco-Donoso et al., 2021 ; Moreno-Jiménez et al., 2021 ). This situation is further exacerbated by a decrease in the number of skilled nurses available to meet the growing demand ( Nikbakht Nasrabadi et al., 2022 ). Similarly, Foglia et al. (2010) highlighted the need for nurses to simultaneously deal with technological and human skills. They are not only responsible for providing medical care, but also for communicating effectively and providing emotional support. These factors impose a difficult situation linked to the shortage of nursing professionals ( Tolksdorf et al., 2022 ). These demands increase nurses’ emotional effort and are strongly related to psychosocial risks ( Delgado et al., 2017 ).

Emotional effort in nurses working in ICU

The emotional effort of nursing constitutes an emotional demand resulting from managing communication and relationships with families, patients, and colleagues ( Delgado et al., 2017 ). Thus, nursing involves not only highly qualified skills related to caring for patients by using technology and appropriate knowledge, but also emotional skills to identify and regulate others’ emotions ( Alonazi, 2020 ). Based on the work of Delgado et al. (2017) , they discussed emotional labor to refer to this emotional demand in the work setting. Delgado et al. (2017) distinguished two types of emotional regulation: (a) deep acting, as a way of identifying and properly regulating one’s emotions, and (b) surface acting, because the emotions that need to be displayed to meet workplace rules do not match the emotions felt. The latter has the same meaning and characteristics as emotional effort ( Quiñones-García et al., 2013 ), and has been strongly related to emotional exhaustion, burnout, and negative health consequences ( Schmidt and Diestel, 2014 ). Hereafter, we refer to emotional effort to highlight the dissonance between meeting the rules of emotional expression and the emotions felt, as stated by surface acting.

As mentioned above, the direct relationship between emotional effort and exhaustion has been previously studied ( Martínez-Iñigo et al., 2007 ). Prolonged emotional demands that require work in an ICU are strongly related to work-related stress ( Zaghini et al., 2020 ), which could lead to emotional exhaustion ( Bakker and Demerouti, 2017 ). However, few studies have focused on vitality as the opposite of emotional exhaustion ( Bakker et al., 2023 ). Studies have shown that emotional demands can lead to positive outcomes when professionals possess proper emotion regulation strategies as emotional demands are more challenging than hindrances ( Donoso et al., 2015 ). These facts could lead to feeling more vigorous at work, instead of being exhausted. Thus, we considered it highly interesting to test this hypothesis in an ICU.

The ICU context is also associated with the likelihood of developing other psychosocial risks such as STS ( Van Mol et al., 2015 ; Barleycorn, 2019 ) due to the traumatic stimuli that nursing professionals must deal with. Shoji et al. (2015) found that burnout comes first as prolonged exposure to job-related stressors, whereas in the medium term, the likelihood of the appearance of STS in specific contexts is high as a result of specific stressors, such as the cycle of death and suffering, the contagion of patients and relatives, life-death decisions, and time pressure for attending patients. Thus, burnout and STS could be two different negative outcomes that are likely to appear in emotionally demanding contexts; however, few studies have focused on how STS develops ( Moreno-Jiménez et al., 2022 ). To explain how this specific work context could lead to STS, we based our work on the conservation of resources theory (CoR; Hobfoll, 2001 ).

According to the CoR theory, demanding work settings can result in energy loss, similar to the concept of emotional exhaustion proposed by the Job Demands-Resources Model ( Bakker et al., 2004 ). The emotional demands faced by nursing professionals can contribute to energy loss by depleting the resources required to cope with these demands ( Le Blanc et al., 2001 ). This energy loss can occur across various work environments where an imbalance exists between demands and available resources ( Demerouti et al., 2001 ). However, when this general energy loss occurs due to the depletion of a broad range of resources, it increases the likelihood of experiencing specific negative consequences owing to prolonged exposure to particular demands ( Hobfoll, 2011 ). In the context of this study, the specific demands related to ICU may lead to STS ( Van Mol et al., 2015 ).

Emotional effort and secondary traumatic stress in nurses

Secondary traumatic stress refers to the natural response experienced by professionals through helping and caring for patients or victims of traumatic situations ( Figley, 1999 ). Thus, advances in trauma research reveal that professionals in ICU are constantly exposed to traumatic stimuli, such as the cycle of death and suffering, communicating bad news to families, and high-pressure decision-making, among other stressors ( Foglia et al., 2010 ). These stressors profoundly impact on the mental health of healthcare professionals. The COVID-19 outbreak has further intensified the traumatic stressors that could occur in an ICU, such as fear of contagion and close contact with death ( Lázaro-Pérez et al., 2020 ). Recent studies have revealed that the prevalence of STS among ICU professionals is as high as 62% in some countries such as Iran ( Ariapooran et al., 2022 ).

Advancements in studies on STS have revealed the importance of distinguishing among the three dimensions of this syndrome ( Meda et al., 2011 ; Moreno-Jiménez et al., 2020 ), moving beyond the classical model proposed by Figley (1999) . These dimensions provide a deeper understanding of the three levels of affection that could occur when referring to a trauma, as the traumatic stressors do not affect every professional in the same way, and can vary depending on individual and job resources ( Donoso et al., 2015 ; Van Mol et al., 2015 ). The three dimensions are emotional, cognitive, and symptomatology.

The emotional dimension refers to compassion fatigue, which is similar to burnout among nurses ( Steinheiser, 2018 ). Compassion fatigue appears as the stress of caring for others ( Jakimowicz et al., 2018 ) and the depletion of empathetic skills as a result of chronic exposure to others’ suffering and a lack of self-care measures ( Peters, 2018 ). Peters (2018) supported the idea that emotional exhaustion is a consequence of compassion fatigue. Thus, we hypothesized that the emotional demand for emotional effort could have a direct and positive relationship with the development of compassion fatigue, similar to emotional exhaustion.

The cognitive dimension, known as shattered assumptions, refers to the disruption of professionals’ beliefs due to prolonged exposure to traumatic events that challenge their worldview ( Janoff-Bulmann, 1992 ). Individuals typically hold positive beliefs about the world and themselves, but when these assumptions are undermined, it can lead to a sense of derailment ( Joseph, 2018 ). In the context of ICU, the dissonance between the emotions felt due to exposure to patients’ suffering and the emotions that they need to express to deal with other tasks (i.e., communicating with physicians) may contribute to this derailment. Emotional dissonance is intimately related to cognitive dissonance regarding identity, which could facilitate these shattered assumptions in the ICU context. Moreover, studies have revealed that emotional dissonance activates a regulation pattern that can lead to surface acting, which involves suppressing genuine emotions and exerting emotional effort ( Sommerfeldt and Kent, 2020 ). Thus, we hypothesized that the demand for emotional effort in ICU could be positively related to shattered assumptions.

Finally, the symptomatology dimension is as associated with symptoms related to Posttraumatic-Stress Disorder, including intrusion, avoidance, and arousal/anxiety in response to feared stimuli ( Lee et al., 2018 ). This dimension includes behaviors (e.g., avoiding trauma-related tasks), cognitions (e.g., ruminating about delivering bad news to relatives), and emotions (e.g., anxiety related to memories of deceased patients) directly related to exposure to specific traumatic stressors ( Moreno-Jiménez et al., 2020 ). Previous studies suggest that symptomatology appears in the short-term due to the direct impact of stressors without the use of personal resources to mitigate the effects. This constitutes the core principle of the Job Demands-Resource Theory ( Bakker et al., 2004 ), where a general loss of energy occurs when demands exceed available resources. However, if exposure to stressors continues, it could lead to specific trauma symptomatology following the CoR theory ( Hobfoll, 2001 , 2011 ). We hypothesized that this dimension represents a short-term symptom of energy loss in overcoming emotional effort and the need to maintain a high-quality job performance ( Amarnani et al., 2019 ).

The present study

Considering the above, we aim to investigate whether emotional effort experienced in an ICU context constitutes an emotional demand that could lead to the three dimensions of STS and diminish vitality. We propose a diary methodology as a novel approach to test the effect of working hours on the well-being of nursing professionals, testing spillover effects to examine the impact of work on how they feel at the end of the day ( Ohly et al., 2010 ). Moreover, most diary studies have focused on establishing predictive models of daily variables and outcomes ( Xanthopoulou et al., 2012 ; Bakker and Albrecht, 2018 ; Benson and Bruner, 2018 ; Cambier et al., 2019 ), but few have focused on the fluctuations of these demands and their predictive value for outcomes. Broadly speaking, employing latent profile analysis using longitudinal data allows us to identify unobserved groupings that capture temporal trends throughout the week ( Brondino et al., 2020 ). Through this diary methodology, we seek to study different profiles of emotional effort to observe the fluctuations in this emotional demand and its impact on nurses’ well-being. The daily information provides an in-depth exploration into the phenomenological process that occurs during a week in the working life of a nurse. Furthermore, we aim to test whether these different profiles predict the different dimensions of STS and vitality.

Thus, we formulated the following hypotheses:

H1 : Different profiles of the level of daily emotional effort will be identified over five consecutive days.

H2 : High-level emotional effort profiles predict higher levels of daily (a) compassion fatigue, (b) shattered assumptions, and (c) symptomatology compared with low-level emotional effort profiles.

H3 : High-level emotional effort profiles predict lower levels of daily vitality compared to low-level emotional effort profiles.

Materials and methods

Design and procedure.

This study employed a diary approach using repeated measures for five consecutive days twice per day. The sample was recruited using the snowball technique by contacting the main supervisors of the ICU in three different hospitals. Once we established contact with the hospital, a clinical session was provided to explain the main goal of the study. They were then given a package that included: (a) a letter describing the goal of the study and confirming anonymity and confidentiality; (b) instructions regarding questionnaire completion; and (c) the daily questionnaires. They were asked to complete the questionnaire twice daily for five consecutive working days. The assessments were as follows: (1) at work, before leaving the workplace, and (2) at home, when time had passed after work, either before going to sleep for nurses on morning shifts or the next morning for those on afternoon shifts. This procedure allowed us to control for the shift variable and collect data, leaving enough space between working and recovery times to examine the impact of working hours when nurses are involved in other activities. Moreover, this time lapse between the predictor and outcomes prevented us from committing response tendencies and common method biases, as suggested by other studies ( Podsakoff et al., 2003 ). As this study consisted of a diary study, including a total of 44 nurses over five days, we counted a total of 220 observations. The University Ethics Committee approved the protocol and assessment (reference number: CEI 71–1,276). This study has not been registered.

The measurements were performed twice a day for five consecutive working days. First, we assessed the following emotional job demands:

Daily emotional effort at work

This variable was assessed using the Emotional Effort Questionnaire ( Quiñones-García et al., 2013 ). This scale evaluates the extent to which professionals find it challenging to comply with workplace rules governing emotional expression, thereby hindering their job performance (e.g., “How often have you felt that meeting the rules of emotional expression directly impacted on your work in other tasks?”). To assess it on a daily basis, the items were rewritten, incorporating the phrase “today at work” at the beginning. It consisted of a 7-item scale with responses ranging from 1 “never” to 5 “always.” The reliability index, measured through Cronbach’s Alpha, averaged 0.86, ranging from 0.84 to 0.87.

Second, we assessed the following outcomes at home:

Daily compassion fatigue

This variable was assessed with the Secondary Traumatic Stress Scale (STSS) using the Spanish version validated by Meda et al. (2011) . To assess it on a daily basis, the items were rewritten, with the word “today” added at the beginning. This scale consists of five items that assess the degree of psychological and mental exhaustion of professionals (e.g., “I feel emotionally without strength”). The 5-item scale response ranged from 1 (“totally disagree”) to 4 (“totally agree”). The reliability index based on Cronbach’s Alpha was good, with an average of 0.82, ranging from.73 to 0.87.

Daily shattered assumptions

This variable was also assessed with the STSS ( Meda et al., 2011 ) using a 4-item scale to specifically evaluate the changes in beliefs that occur due to exposure to traumatic stimuli (e.g., “my work makes me see the world as unfair”). To assess it on a daily basis, the items were rewritten, with the word “today” added at the beginning. The scale response was the same as mentioned above, ranging from 1 (“totally disagree”) to 4 (“totally agree”). We found a good reliability index using Cronbach’s Alpha, with an average of 0.68, ranging from 0.60 to 0.76.

Daily symptomatology

This variable was obtained from the last five items of the STSS scale ( Meda et al., 2011 ). It assesses the degree of symptomatology and individual/social consequences that professionals may suffer due to prolonged exposure to traumatic stimuli (e.g., “I even remember the name of some patients”). To assess it on a daily basis, the items were rewritten, with the word “today” added at the beginning. Responses ranged from 1 (“totally disagree”) to 4 (“totally agree”). We found a good reliability index using Cronbach’s Alpha, with an average of 0.85, ranging from 0.79 and 0.88.

Daily subjective vitality

This variable was assessed using the Spanish version of Ryan and Frederick’s Vitality Scale ( Ryan and Frederick, 1997 ; Rodríguez-Carvajal et al., 2010 ). It consists of seven items that establish the degree to which professionals feel vigorous and alive in different domains (e.g., “I feel such full of energy that seems I am going to explode”). To assess it on a daily basis, the items were rewritten, with the word “today” added at the beginning. A 7-item scale was used to responses, ranging from 1 (“not at all”) to 7 (“very much”). Cronbach’s Alpha was employed to assess reliability, with an average of 0.82, ranging from 0.77 to 0.89.

Participants

As mentioned above, the sample comprised 44 ICU nurses, with 11 males and 33 females. Concerning shifts, 18 were from the morning shift, 14 from the afternoon shift, and 12 from both shifts. The average age was 39.41 years old. The diary study allowed us to capture a total number of 220 daily observations (44 participants × 5 days).

Statistical analysis

First, SPSS was used to obtain descriptive statistics. Subsequently, latent profiles of emotional effort were explored using R Studio and the tidy Latent Profile Analysis (LPA) package, considering the levels of emotional effort recorded over five consecutive days.

LPA is a statistical technique used to identify unobserved subgroups or latent profiles within a population, based on observed variables. Tidy LPA maximizes the log-likelihood function to estimate the parameters of a latent profile model. To achieve this, the package employs an iterative optimization algorithm that seeks to determine the parameter values that yield the highest log-likelihood. By maximizing the log-likelihood, the tidy LPA effectively identifies the optimal configuration of the latent profiles for the given dataset. To avoid local maxima, which can lead to suboptimal results, tidy LPA utilizes multiple random starts during the optimization process. This implies that the algorithm starts the optimization from various initial parameter values, allowing it to explore different regions of the parameter space. By considering multiple starting points, a tidy LPA increases the likelihood of finding the global maximum of the log-likelihood function, thereby reducing the risk of being trapped in the local maxima. By employing this procedure, tidy LPA enhances the robustness and accuracy of the latent profile analysis, ensuring that the estimated profiles are more likely to represent the true underlying structure of the data.

To determine the number of profiles, we considered different indicators ( Nylund et al., 2007 ; Tein et al., 2013 ), including the Bayesian Information Criterion (BIC), Akaike Information Criterion (AIC), and entropy indicator. BIC and AIC should provide low values, whereas entropy should provide values higher than 0.80. We employed a Bootstrap Likelihood Ratio Test (BLRT) to compare the different models.

Finally, to examine whether these latent profiles are associated with outcomes (i.e., daily compassion fatigue, shattered assumptions, symptomatology, and vitality), we employed a hierarchical modeling approach (HLM). Our data presented two levels: level 1 was day-level ( N  = 220 occasions) and level 2 was a person-level measure ( N  = 44 participants) ( Nezlek, 2007 ). The latent profile variable was added at the person-level centered on the grand mean as established by Ohly et al. (2010) . In our model, the outcome variables (i.e., emotional exhaustion and vitality) served as day-level variables, while gender, shift, age, and latent profile were considered person-level variables. The R package was used to perform this multilevel analysis.

Descriptive analysis

Descriptive analyses are shown in Table 1 . As observed, emotional effort had a medium-high score ( M  = 2.88), as well as the three dimensions of STS, with the highest in symptomatology, followed by shattered assumptions. Vitality had a medium-low score ( M  = 3.30). First, we obtained a positive and significant correlation between the three dimensions of STS (i.e., compassion fatigue, shattered assumptions, and symptomatology) and emotional effort. Conversely, this correlation was negative in the case of vitality.

Table 1 . Means, standard deviations, and correlations of the study variables.

Hypothesis testing

Second, to explore the latent profiles of emotional effort, as established in H 1 , we examined the statistics for different profile solutions ( Table 2 ). The three-profile solution emerged as the optimal choice, with the lowest BIC and AIC, and the highest entropy.

Table 2 . Latent profile analysis of emotional effort: criteria values for different profile solutions.

Upon selecting the best profile solution, a plot was obtained to visualize the profiles ( Figure 1 ). The plot illustrates a three-profile solution representing distinct patterns of emotional effort within the study population. Each profile was characterized by different levels of emotional effort, with Profile 1 showing high emotional effort, Profile 2 exhibiting moderate emotional effort, and Profile 3 displaying low emotional effort.

Figure 1 . Latent profile analysis of emotional effort: plot of the three-profile solution.

Latent profiles predicting secondary traumatic stress and vitality

Finally, to check whether these latent profiles are predictors of daily secondary traumatic stress (H 2 ) and daily vitality (H 3 ), we ran a hierarchical linear regression with R to maintain the daily level of the measures (within-person) nested in individuals (between-person level). Table 3 presents the results of these analyses. The results obtained were as follows:

Table 3 . Multilevel estimates for predicting daily outcomes after work ( N  = 44* 5 days = 220 statistical observations).

To test H 2a , we obtained that gender and shift were negative significant predictors of daily compassion fatigue ( E  = −0.396, SE  = 0.178; t  = −2.214; p  < 0.05; and E  = −0.33, SE  = 0.155, t  = −2.131, p  < 0.05, respectively). None of the latent profiles of emotional effort was a significant predictor. The adjusted R-squared value explained 12% of the between-person variance through this predictive model. Additionally, the intercept was 1.76, meaning that this was the average score for daily compassion fatigue with lower levels of demographic variables (men, morning shift, Profile 1 in emotional effort, and average age).

Concerning H 2b , it seems that shift and age were significant predictors of daily shattered assumptions ( E  = −0.123, SE  = 0.054; t  = −2.254; p  < 0.05; and E  = 0.018, SE  = 0.005, t  = 3.733, p  < 0.001, respectively). Moreover, we found the latent profiles to be significant and positive ( E  = 0.492, SE  = 0.115, t  = 4.271, p  < 0.001). The adjusted R-squared value revealed that this model could predict 14% of the total explained between-person variance. Moreover, the intercept was 0.92, meaning that this was the average punctuation in daily shattered assumptions with lower levels of demographic variables (men, morning shift, Profile 1 in emotional effort, and average age).

Concerning H 2c , we found gender and shift to be significant predictors ( E  = 0.571, SE  = 0.115, t  = 2.345, p  < 0.05; E  = −0.155, SE  = 0.064, t  = −2.428, p  < 0.05, respectively). Moreover, latent profiles appeared to be positive and significant predictor ( E  = 0.436, SE  = 0.136, t  = 3.193, p  < 0.01). This model allowed us to explain 10% of the between-person variance. Additionally, the intercept was 1.24, meaning that this was the average punctuation in daily symptomatology when lower levels of demographic variables were established, as previously stated.

Daily vitality

Finally, regarding H 3 , the only predictors that resulted in being significant were shift ( E  = 0.352, SE  = 0.093, t  = 3.777, p  < 0.001) and age ( E  = 0.021, SE  = 0.008, t  = 2.559, p  < 0.05). This model explained a total of 14% between-person variance. Concerning the intercept, the value was 1.87, indicating that this was the average punctuation in daily vitality when the following categories were met: men, morning shift, Profile 1 in emotional effort, and average age.

Additionally, the intercept values were significant in all adjusted models except for the model explaining daily shattered assumptions. The intercepts represent the baseline level of the dependent variable when the predictors included in the model have a value of zero. This means that the expected daily levels of emotional effort ( E  = 3.30, p  < 0.01), compassion fatigue ( E  = 1.70, p  < 0.001), symptomatology ( E  = 1.24, p  < 0.01) and vitality ( E  = 1.87, p  < 0.01) were significantly different from zero, even in the absence of predictor effects.

This study highlights current worldwide phenomena such as psychosocial risks and STS experienced by nursing professionals, especially after the COVID-19 pandemic outbreak. Martin-Rodriguez et al. (2022) argued that almost 40% of nursing professionals present severe or moderate symptoms of this psychosocial risk; thus, special attention should be paid to this problem. Moreover, this study is a step forward in daily studies conducted to date. In this sense, the establishment of a three-profile solution provides valuable information on the daily functioning of emotional patterns among nursing professionals in ICU. In addition, the information provided by the three-profile solution allowed us to speculate about the differences in emotional regulation strategies that could occur during working hours in such emotionally demanding contexts. This provides a necessary background for developing future preventative programs. In addition, this study fills a gap in the effect of daily emotional effort in an emotionally demanding work settings (i.e., ICU) and its relationship with STS and vitality, which has been poorly explored in previous studies. Therefore, we obtained interesting results for both outcomes.

First, daily compassion fatigue was predicted only by sociodemographic variables, with no predictive relationship between emotional effort profiles and this outcome. Despite this, the descriptive analysis revealed a positive and significant relationship between compassion fatigue and emotional effort, but a lack of predictive value regarding emotional effort profiles.

However, we found gender and shift were significant negative predictors of daily compassion fatigue, meaning that compassion fatigue seems to be lower in women than in men, especially in the afternoon shift. These results align with previous studies ( Moreno-Jiménez et al., 2020 ), where gender roles were identified as explaining how men may be less accustomed to managing and dealing with emotions compared to women, posing a risk factor of increased daily compassion fatigue levels ( Eagly and Wood, 2016 ). This lack of expertise in managing emotional events may result in a rapid loss of resources in attempting to cope with these emotions, leading to an increase in compassion fatigue. We suggest two possible explanations for this shift. Morning shifts mark the beginning of relatives’ visits and the information provided by physicians. This point suggests that intense and emotionally charged situations may occur during this time, in contrast to the afternoon shift, with possibly fewer relative visits. However, this result could be a consequence of the assessment time, as afternoon shift nurses assessed their level of STS and vitality after a period of recovery the following morning. This recovery time could lead to a decrease in compassion fatigue levels, as supported by previous studies ( Sonnentag et al., 2008 ). We strongly support the latter explanation, as we obtained the same results in shattered assumptions and symptomatology, with the opposite trend noted for vitality.

Notably, we did not find age to be a significant positive predictor, suggesting that this outcome could possibly be more related to the years spent in ICU rather than age itself. This result is supported by previous studies on healthcare professionals in the ICU, where compassion fatigue is not considered a short-term outcome but a medium-and long-term outcome associated with the time spent in the ICU dealing with specific traumatic tasks and the regulation strategies used ( Moreno-Jiménez et al., 2020 ). This observation allows us to differentiate between compassion fatigue and emotional exhaustion, which often overlap in several studies ( Cieslak et al., 2014 ). In contrast, while emotional exhaustion may appear in the short-term as a result of losing energy to overcome challenges ( Shoji et al., 2015 ), compassion fatigue involves specific resources (i.e., empathy) in certain professionals (i.e., helping professionals), as established by Figley (2002) .

Second, the daily measurement of shattered assumptions yielded similar results for shift and age. It appears that older nursing professionals are more susceptible to experiencing these disruptions in their beliefs, possibly due to changes in values across their lifespan, where the significance of work becomes particularly relevant ( Harris and Tao, 2022 ). Probably younger nurses place a great deal of value on learning and challenging experiences, while they are building the meaning of work and their life, which is a protective factor for burnout and STS ( Harris and Tao, 2022 ). In contrast, older nurses could have a greater impact on their belief in personal invulnerability ( Janoff-Bulmann, 1992 ; Rodríguez-Muñoz et al., 2010 ). It is likely that older nurses may experience more negative consequences, and consequently, stressors may have a stronger impact compared to their younger counterparts. Consequently, beliefs of invulnerability and self-worth could easily be threatened, increasing the likelihood of being shattered.

Moreover, an interesting result emerged from the three-profile solution. Specifically, emotional effort profiles are significant positive predictors, suggesting that the greater the daily emotional effort, the less shattered the assumptions. These results could be explained by the type of emotion/cognitive strategies used to self-regulate emotionally demanding situations. In other words, nursing professionals dealing with greater emotional dissonance between what they feel and what they must express may be less focused on cognitive expectations and unity of their identity. Instead, they seem to prioritize regulating these emotions, following the CoR principles, as a loss of emotional resources occurs during the attempt to balance them ( Hobfoll, 2001 ). Previous studies have identified passion for work as a stable resource to maintain a high-quality job in demanding professions ( van Mol et al., 2018 ; Amarnani et al., 2019 ), particularly in ICU contexts with high demands, leading to lower levels of STS ( Moreno-Jiménez et al., 2022 ). Building on this, nurses with lower emotional effort (Profile 3) may lack the trigger to apply these regulation strategies (i.e., harmonious passion, recovery activities) and could be more vulnerable to experiencing shattered beliefs. In contrast, nursing professionals with high emotional effort (Profile 1) may activate these strategies, allowing them to protect themselves from derailment ( Joseph, 2018 ) and cognitive dissonance ( Sommerfeldt and Kent, 2020 ). Speculating about the use of the strategies activated in Figure 1 , we observed peaks in the levels of emotional effort on days two and three, with nursing professionals in Profile 1 showing the highest levels and those in Profile 3 with the lowest. We observed stabilization over the next two days as a result of the strategies applied. Thus, we hypothesized that on days when nursing professionals experience more emotional effort, they may also display lower levels of shattered assumptions, contrary to established in H 2b .

Third, concerning daily symptomatology, we did not find gender to be a significant predictor, contrary to the results for compassion fatigue. Age could have a greater impact on daily levels of symptomatology than expertise in dealing with emotionally demanding situations and gender differences ( Eagly and Wood, 2016 ). Hence, as occurs in shattered assumptions, older nurses are likely to suffer from symptomatology, possibly linked to this personal vulnerability, not only as a belief but also having physical consequences. Additionally, it is likely that older nurses have more years of experience in the ICU, which means more exposure to stressors and, in turn, higher levels of symptomatology ( Moreno-Jiménez et al., 2020 ). Moreover, as previously mentioned, shift was a significant and negative predictor, possibly due to the timing at which the outcomes were assessed.

Concerning symptomatology, the three profiles were significant and positive predictors, meaning that the higher the profile, the higher the daily symptomatology. In other words, nursing professionals with less emotional effort seemed to possess more daily symptomatology, opposed as stablished in H 2c. This led us to speculate on the symptomatology dimension, which has been proposed in previous studies as a short-term dimension that appears with prolonged exposure to ICU demands ( Moreno-Jiménez et al., 2019 , 2020 ) similar to emotional exhaustion ( Bakker and Demerouti, 2017 ). These findings allow us to hypothesize that even low levels of emotional effort could lead to a high level of symptomatology, possibly related to other variables, such as stressors or rumination about the emotional situations they have to deal with Donahue et al. (2012) . As mentioned above, a low emotional effort profile may not trigger the activation of emotion regulation strategies (i.e., recovery activities when facing emotional demands), leading to greater levels of symptomatology. Nursing professionals in Profile 1 seemed to adapt and properly regulate their daily symptomatology, possibly meaning that other factors in high-emotional effort profiles mitigate this as a consequence of being obliged to protect themselves.

Finally, the vitality dimension was not significantly related to any of the three emotional effort profiles, thus we reject our H 3 . Emotional exhaustion seems to be strongly linked to an increase in job demands ( Bakker and Demerouti, 2017 ; Bakker et al., 2023 ) but vitality may be more closely related to personal resources, such as passion for work, rather than job demands. A study by Mudło (2023) supports this statement, as only medical students without passion presented low levels of vitality, whereas students with high levels of passion presented high levels of subjective vitality. Additionally, a study by Carmona-Cobo and Lopez-Zafra (2022) revealed that daily subjective vitality was predicted by daily social support in a sample of nurses. Thus, these findings highlight the strong relationship between vitality and resources rather than demands.

This study had some limitations that should be addressed in future research. First, the assessment of nurses from different shifts could directly impact the results obtained in the three dimensions of STS, as we tried to equalize this assessment using the same criteria (i.e., assessing emotional effort during working time, and STS and vitality after leaving work). This could be responsible for the lower levels of STS and higher vitality in the afternoon shift, as it was assessed the next morning. In further research, it is advisable to increase the sample size and conduct analyses splitting by shifts to clarify these data. Additionally, in order to avoid potential fatigue and professionals’ tiredness, some of the scale used had few items, which could attempt against its reliability. However, we highlighted that the use of a daily approach with five days of assessment at two moments per day allows us to control the response tendencies of participants and have more observations that enable a more comprehensive understanding of the phenomenon studied. Finally, it is important to remark that this study counts on a small sample size due to the difficulties of assessing this specific sample (only nurses) with a wide assessment protocol (five consecutive days) within a specific work setting (intensive care units). It seems undeniably relevant to replicate this study with bigger sample to gain generalization, and to boost the scientific value providing steps forward the preventative models.

Theoretical and practical contributions

Overall, these findings emphasize the theoretical contributions that should lead to practical implications, being highly relevant in ICU contexts, especially regarding the mental health of nursing professionals. As emotional demands such as emotional effort may play a significant role in predicting daily levels of shattered assumptions and symptomatology, more resources should be provided to these professionals to deal with this demand. More job resources, such as coworker and leader support, may diminish this emotional effort and increase daily levels of vitality. This fact may allow the nursing professionals to convert their working hours in a positive experience through the role of vitality. Additionally, the findings revealed that those with high-emotional effort profiles are able to self-regulate and overcome this, but those with low-emotional effort profiles present high levels of STS, making it important to teach strategies to deal with this. These results remark the importance of providing cognitive and emotional strategies to manage with such emotional demands, even from the lowest levels. In this sense, implementing job crafting techniques, as supported by Demerouti et al. (2019) , could be useful in teaching how to identify emotional demands (i.e., bad news communication and communication with relatives), identify personal resources (i.e., social skills and the establishment of a time-out after communicating), and how to apply these personal resources specifically for each demand. For example, to have the ability of applying assertiveness to effectively communicate to the patient’s relatives and stablishing a recovery time after the difficult communication, as a time-out to breath, and either use a relaxion technique or favor a small psychological detachment. Job crafting could be a valuable way to provide self-control in self-regulation skills, especially when demand levels are lower ( Bakker et al., 2023 ).

This study emphasized the impact of daily emotional effort as an emotional demand among nurses in ICU, specifically affecting their beliefs and symptomatology related to trauma. Moreover, this study allowed us to delve into the daily fluctuation of emotional demands, providing information about how they could change over a week and the existence of strategies to regulate them. The lack of regulation strategies to overcome this emotional effort at work could lead to a greater level of negative consequences on a daily basis (i.e., shattered assumptions and symptomatology), even after work, which could increase individuals’ intentions to leave the profession. Additionally, job resources should be considered, including social support, which is related to subjective vitality in prior literature. Vitality is an elemental phenomenon that increases nurses’ well-being.

Data availability statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statement

The studies involving humans were approved by Ethical Committee of Autonomous University of Madrid (reference number CEI 71-1276). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

JM-J: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Validation, Writing – original draft, Writing – review & editing. MR: Conceptualization, Data curation, Formal analysis, Software, Writing – original draft, Writing – review & editing. LB-D: Conceptualization, Funding acquisition, Investigation, Methodology, Resources, Supervision, Validation, Writing – original draft, Writing – review & editing. MH-H: Formal analysis, Methodology, Software, Writing – original draft, Writing – review & editing. EG: Conceptualization, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Writing – review & editing.

The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by the I+D+I National Project of Ministerio de Ciencia e Innovación (PID2019-106368GB-I00)/AEI/10.13039/501100011033 and the project financed by Universidad Francisco de Vitoria (UFV2023-03). Also, the work has been supported by the National Thesis Award Lafourcade-Ponce 2023.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

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Keywords: diary study, emotional effort, secondary traumatic stress, vitality, latent profile

Citation: Moreno-Jiménez JE, Romero M, Blanco-Donoso LM, Hernández-Hurtado M and Garrosa E (2024) Studying daily fluctuations of emotional effort among nurses of intensive care units: the establishment of latent profiles and its relationship with daily secondary traumatic stress and vitality. Front. Psychol . 15:1340740. doi: 10.3389/fpsyg.2024.1340740

Received: 18 November 2023; Accepted: 27 February 2024; Published: 15 March 2024.

Reviewed by:

Copyright © 2024 Moreno-Jiménez, Romero, Blanco-Donoso, Hernández-Hurtado and Garrosa. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Jennifer E. Moreno-Jiménez, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

• Mental Health

Why Zero Stress Shouldn’t Be Your Goal

H ow many times have you heard that squashing stress is crucial for good health? Stress has become such a wellness buzzword that the quest to get rid of it can feel, well, stressful. But stress isn’t always the enemy. In fact, research suggests some is actually good for you , with potential benefits ranging from enhanced brain function to healthier aging .

In recent decades, some people have grown overly fearful of stress, concluding that it's "the most horrible thing that can happen to you," says Daniela Kaufer, a professor of integrative biology at the University of California, Berkeley. But “it’s a much more complex story," she says. "Stress is a vital, required response.”

What is stress, anyway?

For one thing, it’s ubiquitous: research suggests people feel at least some stress on up to 90% of their days. But what’s actually going on in your body when you’re dealing with family drama or work deadlines?

In a high-stakes situation, your brain directs the adrenal glands to release hormones including adrenaline, causing physiological changes throughout the body that lead to the sweaty palms, fast breathing, and racing heart many people experience when they’re under pressure. The body also releases oxytocin , or the "bonding hormone," during times of stress.

When stress festers for a long time, unaddressed, it’s linked to mental and physical health issues, even raising your risk for chronic conditions like heart disease . But in an immediate sense, a stress response is vital. It can help you power through a hard time or even escape physical danger. And, when acute stress is managed well, it can set you up for better health and well-being in the future.

How stress improves health

In toxicology, there’s a phenomenon known as “hormesis,” which describes substances that are beneficial at low doses but dangerous at high doses. Assaf Oshri, an associate professor of human development and family science at the University of Georgia, has applied that concept to his research on adversity , demonstrating that it works in largely the same way.

Chronic stress, as well as stress resulting from highly traumatic experiences, can be damaging—but moderate amounts of stress can benefit the body and mind, improving cognitive function and boosting resilience , according to Oshri's work. In studies on rats , Kaufer has also demonstrated that acute stress may help the brain work better and prime animals for better reactions next time they encounter stressors.

“ Resilience is a process. It’s not a trait,” Oshri says. “It emerges from your interactions with the environment.” If people aren’t exposed to any stress, he says, they may not build up that resilience muscle. If they’re exposed to too much—or to particularly traumatic forms, like abuse or discrimination—their well-being may suffer. But there seems to be a sweet spot in between, where stress fortifies psychological health and helps people bounce back from difficult situations. (Exactly where that sweet spot is may vary from person to person, Oshri says.)

Even physical health can benefit from some level of stress. Exercising is, at its core, a process of putting stress on the body so it can grow stronger. And some studies also show that short-term stress exposure boosts immune function.

How you deal with stress matters

It’s not just the amount of pressure you’re under that influences well-being; it’s also how you respond to it. Studies have shown that people who believe they can learn and grow from hard experiences fare better during challenging times, as opposed to those who view stressors as completely negative.

Still, it’s okay—even healthy—to be a little rattled by life’s curveballs. A 2024 study found that there’s a “Goldilocks zone” when it comes to emotional responses to stress. People who tend to have either extremely strong or extremely weak reactions to challenging situations are at increased risk of poor health and well-being, explains co-author Jonathan Rush, an assistant professor of psychology at the University of Victoria in Canada. People in the middle, who respond a little but not too much, tend to be healthiest, he says.

“One of the main purposes of having emotions is that they alert us to things in our environment” so we can deal with them appropriately, Rush says. Blocking out your emotions entirely is akin to ignoring a leaky faucet in your bathroom: “eventually,” Rush says, “you’re going to have a flood in your home.”

Mindfulness practices like yoga and meditation can help people cultivate a balance between going off and shutting down in the face of stress, Rush says. Mindfulness isn’t about ignoring negative feelings, but rather acknowledging them so you can manage them in healthier ways, he explains.

Leaning on loved ones during tough times is important too, Kaufer adds, since social support can serve as a buffer against the negative effects of stress and trauma. And if you can, she says, remind yourself that stress is a difficult but necessary part of life.

“You can’t choose exactly what happens to you, but you can choose your response in the moment,” Kaufer says. “Having the idea that you can overcome things, you can grow from things, whatever happens you will have a path forward”—that’s what matters most.

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Study tracks shifts in student mental health during college

Dartmouth study followed 200 students all four years, including through the pandemic.

A four-year study by Dartmouth researchers captures the most in-depth data yet on how college students' self-esteem and mental health fluctuates during their four years in academia, identifying key populations and stressors that the researchers say administrators could target to improve student well-being.

The study also provides among the first real-time accounts of how the coronavirus pandemic affected students' behavior and mental health. The stress and uncertainty of COVID-19 resulted in long-lasting behavioral changes that persisted as a "new normal" even as the pandemic diminished, including feeling more stressed, less socially engaged, and sleeping more.

The researchers tracked more than 200 Dartmouth undergraduates in the classes of 2021 and 2022 for all four years of college. Students volunteered to let a specially developed app called StudentLife tap into the sensors that are built into smartphones. The app cataloged their daily physical and social activity, how long they slept, their location and travel, the time they spent on their phone, and how often they listened to music or videos. Students also filled out weekly behavioral surveys, and selected students gave post-study interviews.

The study -- which is the longest mobile-sensing study ever conducted -- is published in the Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies . The researchers will present it at the Association of Computing Machinery's UbiComp/ISWC 2024 conference in Melbourne, Australia, in October. The team made their anonymized data set publicly available -- including self-reports, surveys, and phone-sensing and brain-imaging data -- to help advance research into the mental health of students during their college years.

Andrew Campbell, the paper's senior author and Dartmouth's Albert Bradley 1915 Third Century Professor of Computer Science, said that the study's extensive data reinforces the importance of college and university administrators across the country being more attuned to how and when students' mental well-being changes during the school year.

"For the first time, we've produced granular data about the ebb and flow of student mental health. It's incredibly dynamic -- there's nothing that's steady state through the term, let alone through the year," he said. "These sorts of tools will have a tremendous impact on projecting forward and developing much more data-driven ways to intervene and respond exactly when students need it most."

First-year and female students are especially at risk for high anxiety and low self-esteem, the study finds. Among first-year students, self-esteem dropped to its lowest point in the first weeks of their transition from high school to college but rose steadily every semester until it was about 10% higher by graduation.

"We can see that students came out of high school with a certain level of self-esteem that dropped off to the lowest point of the four years. Some said they started to experience 'imposter syndrome' from being around other high-performing students," Campbell said. "As the years progress, though, we can draw a straight line from low to high as their self-esteem improves. I think we would see a similar trend class over class. To me, that's a very positive thing."

Female students -- who made up 60% of study participants -- experienced on average 5% greater stress levels and 10% lower self-esteem than male students. More significantly, the data show that female students tended to be less active, with male students walking 37% more often.

Sophomores were 40% more socially active compared to their first year, the researchers report. But these students also reported feeling 13% more stressed than during their first year as their workload increased, they felt pressure to socialize, or as first-year social groups dispersed.

One student in a sorority recalled that having pre-arranged activities "kind of adds stress as I feel like I should be having fun because everyone tells me that it is fun." Another student noted that after the first year," students have more access to the whole campus and that is when you start feeling excluded from things."

In a novel finding, the researchers identify an "anticipatory stress spike" of 17% experienced in the last two weeks of summer break. While still lower than mid-academic year stress, the spike was consistent across different summers.

In post-study interviews, some students pointed to returning to campus early for team sports. Others specified reconnecting with family and high school friends during their first summer home, saying they felt "a sense of leaving behind the comfort and familiarity of these long-standing friendships" as the break ended, the researchers report.

"This is a foundational study," said Subigya Nepal, first author of the study and a PhD candidate in Campbell's research group. "It has more real-time granular data than anything we or anyone else has provided before. We don't know yet how it will translate to campuses nationwide, but it can be a template for getting the conversation going."

The depth and accuracy of the study data suggest that mobile-sensing software could eventually give universities the ability to create proactive mental-health policies specific to certain student populations and times of year, Campbell said.

For example, a paper Campbell's research group published in 2022 based on StudentLife data showed that first-generation students experienced lower self-esteem and higher levels of depression than other students throughout their four years of college.

"We will be able to look at campus in much more nuanced ways than waiting for the results of an annual mental health study and then developing policy," Campbell said. "We know that Dartmouth is a small and very tight-knit campus community. But if we applied these same methods to a college with similar attributes, I believe we would find very similar trends."

Weathering the pandemic

When students returned home at the start of the coronavirus pandemic, the researchers found that self-esteem actually increased during the pandemic by 5% overall and by another 6% afterward when life returned closer to what it was before. One student suggested in their interview that getting older came with more confidence. Others indicated that being home led to them spending more time with friends talking on the phone, on social media, or streaming movies together.

The data show that phone usage -- measured by the duration a phone was unlocked -- indeed increased by nearly 33 minutes, or 19%, during the pandemic, while time spent in physical activity dropped by 52 minutes, or 27%. By 2022, phone usage fell from its pandemic peak to just above pre-pandemic levels, while engagement in physical activity had recovered to exceed the pre-pandemic period by three minutes.

Despite reporting higher self-esteem, students' feelings of stress increased by more than 10% during the pandemic. Since the pandemic, stress fell by less than 2% of its pandemic peak, indicating that the experience had a lasting impact on student well-being, the researchers report.

In early 2021, as students returned to campus, the reunion with friends and community was tempered by an overwhelming concern of the still-rampant coronavirus. "There was the first outbreak in winter 2021 and that was terrifying," one student recalls. Another student adds: "You could be put into isolation for a long time even if you did not have COVID. Everyone was afraid to contact-trace anyone else in case they got mad at each other."

Female students were especially concerned about the coronavirus, on average 13% more than male students. "Even though the girls might have been hanging out with each other more, they are more aware of the impact," one female student reported. "I actually had COVID and exposed some friends of mine. All the girls that I told tested as they were worried. They were continually checking up to make sure that they did not have it and take it home to their family."

Students still learning remotely had social levels 16% higher than students on campus, who engaged in activity an average of 10% less often than when they were learning from home. However, on-campus students used their phones 47% more often. When interviewed after the study, these students reported spending extended periods of time video-calling or streaming movies with friends and family.

Social activity and engagement had not yet returned to pre-pandemic levels by the end of the study in June 2022, recovering by a little less than 3% after a nearly 10% drop during the pandemic. Similarly, the pandemic seems to have made students stick closer to home, with their distance traveled cut by nearly half during the pandemic and holding at that level in the time since.

Campbell and several of his fellow researchers are now developing a smartphone app known as MoodCapture that uses artificial intelligence paired with facial-image processing software to reliably detect the onset of depression before the user even knows something is wrong.

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Story Source:

Materials provided by Dartmouth College . Original written by Morgan Kelly. Note: Content may be edited for style and length.

Journal Reference :

• Subigya Nepal, Wenjun Liu, Arvind Pillai, Weichen Wang, Vlado Vojdanovski, Jeremy F. Huckins, Courtney Rogers, Meghan L. Meyer, Andrew T. Campbell. Capturing the College Experience . Proceedings of the ACM on Interactive, Mobile, Wearable and Ubiquitous Technologies , 2024; 8 (1): 1 DOI: 10.1145/3643501

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Strange & offbeat.

Occupation as therapy for trauma recovery: a case study

Affiliation.

• 1 New York Institute of Technology, Occupational Therapy Department, School of Health Professions, Northern Boulevard, P.O. Box 8000, Old Westbury, NY 11568-8000, USA. [email protected]
• PMID: 21248422
• DOI: 10.3233/WOR-2011-1106

In this case study, a young women who has chronic verbal, emotional, and physical abuse and was exposed to repetitive adult acts of abuse as a child initially presented with Posttraumatic Stress Disorder (PTSD) marked by constriction and disconnection, which resulted in her feeling passive and tortured. As part of her occupational therapy intervention, based on the occupational adaptation, psychoanalytic, and recovery frames of reference, she was able to use her skills as a musician and lyricist to work through her trauma by performing heavy metal music. She used work to express emotions and tell and retell her story to audiences eager to hear her. Work helped her develop an identity that allowed her to be active in the world and reach out to others through her music. This case study focuses on the intervention - how music and occupation functioned as a foundation for relieving her PTSD.

Publication types

• Case Reports
• Adaptation, Psychological*
• Child Abuse / psychology*
• Occupational Therapy / methods*
• Stress Disorders, Post-Traumatic / psychology*
• Stress Disorders, Post-Traumatic / therapy*
• Young Adult

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What Is a Case Study?

Weighing the pros and cons of this method of research

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

Cara Lustik is a fact-checker and copywriter.

Verywell / Colleen Tighe

• Pros and Cons

What Types of Case Studies Are Out There?

Where do you find data for a case study, how do i write a psychology case study.

A case study is an in-depth study of one person, group, or event. In a case study, nearly every aspect of the subject's life and history is analyzed to seek patterns and causes of behavior. Case studies can be used in many different fields, including psychology, medicine, education, anthropology, political science, and social work.

The point of a case study is to learn as much as possible about an individual or group so that the information can be generalized to many others. Unfortunately, case studies tend to be highly subjective, and it is sometimes difficult to generalize results to a larger population.

While case studies focus on a single individual or group, they follow a format similar to other types of psychology writing. If you are writing a case study, we got you—here are some rules of APA format to reference.  

At a Glance

A case study, or an in-depth study of a person, group, or event, can be a useful research tool when used wisely. In many cases, case studies are best used in situations where it would be difficult or impossible for you to conduct an experiment. They are helpful for looking at unique situations and allow researchers to gather a lot of˜ information about a specific individual or group of people. However, it's important to be cautious of any bias we draw from them as they are highly subjective.

What Are the Benefits and Limitations of Case Studies?

A case study can have its strengths and weaknesses. Researchers must consider these pros and cons before deciding if this type of study is appropriate for their needs.

One of the greatest advantages of a case study is that it allows researchers to investigate things that are often difficult or impossible to replicate in a lab. Some other benefits of a case study:

• Allows researchers to capture information on the 'how,' 'what,' and 'why,' of something that's implemented
• Gives researchers the chance to collect information on why one strategy might be chosen over another
• Permits researchers to develop hypotheses that can be explored in experimental research

On the other hand, a case study can have some drawbacks:

• It cannot necessarily be generalized to the larger population
• Cannot demonstrate cause and effect
• It may not be scientifically rigorous
• It can lead to bias

Researchers may choose to perform a case study if they want to explore a unique or recently discovered phenomenon. Through their insights, researchers develop additional ideas and study questions that might be explored in future studies.

It's important to remember that the insights from case studies cannot be used to determine cause-and-effect relationships between variables. However, case studies may be used to develop hypotheses that can then be addressed in experimental research.

Case Study Examples

There have been a number of notable case studies in the history of psychology. Much of  Freud's work and theories were developed through individual case studies. Some great examples of case studies in psychology include:

• Anna O : Anna O. was a pseudonym of a woman named Bertha Pappenheim, a patient of a physician named Josef Breuer. While she was never a patient of Freud's, Freud and Breuer discussed her case extensively. The woman was experiencing symptoms of a condition that was then known as hysteria and found that talking about her problems helped relieve her symptoms. Her case played an important part in the development of talk therapy as an approach to mental health treatment.
• Phineas Gage : Phineas Gage was a railroad employee who experienced a terrible accident in which an explosion sent a metal rod through his skull, damaging important portions of his brain. Gage recovered from his accident but was left with serious changes in both personality and behavior.
• Genie : Genie was a young girl subjected to horrific abuse and isolation. The case study of Genie allowed researchers to study whether language learning was possible, even after missing critical periods for language development. Her case also served as an example of how scientific research may interfere with treatment and lead to further abuse of vulnerable individuals.

Such cases demonstrate how case research can be used to study things that researchers could not replicate in experimental settings. In Genie's case, her horrific abuse denied her the opportunity to learn a language at critical points in her development.

This is clearly not something researchers could ethically replicate, but conducting a case study on Genie allowed researchers to study phenomena that are otherwise impossible to reproduce.

There are a few different types of case studies that psychologists and other researchers might use:

• Collective case studies : These involve studying a group of individuals. Researchers might study a group of people in a certain setting or look at an entire community. For example, psychologists might explore how access to resources in a community has affected the collective mental well-being of those who live there.
• Descriptive case studies : These involve starting with a descriptive theory. The subjects are then observed, and the information gathered is compared to the pre-existing theory.
• Explanatory case studies : These   are often used to do causal investigations. In other words, researchers are interested in looking at factors that may have caused certain things to occur.
• Exploratory case studies : These are sometimes used as a prelude to further, more in-depth research. This allows researchers to gather more information before developing their research questions and hypotheses .
• Instrumental case studies : These occur when the individual or group allows researchers to understand more than what is initially obvious to observers.
• Intrinsic case studies : This type of case study is when the researcher has a personal interest in the case. Jean Piaget's observations of his own children are good examples of how an intrinsic case study can contribute to the development of a psychological theory.

The three main case study types often used are intrinsic, instrumental, and collective. Intrinsic case studies are useful for learning about unique cases. Instrumental case studies help look at an individual to learn more about a broader issue. A collective case study can be useful for looking at several cases simultaneously.

The type of case study that psychology researchers use depends on the unique characteristics of the situation and the case itself.

There are a number of different sources and methods that researchers can use to gather information about an individual or group. Six major sources that have been identified by researchers are:

• Archival records : Census records, survey records, and name lists are examples of archival records.
• Direct observation : This strategy involves observing the subject, often in a natural setting . While an individual observer is sometimes used, it is more common to utilize a group of observers.
• Documents : Letters, newspaper articles, administrative records, etc., are the types of documents often used as sources.
• Interviews : Interviews are one of the most important methods for gathering information in case studies. An interview can involve structured survey questions or more open-ended questions.
• Participant observation : When the researcher serves as a participant in events and observes the actions and outcomes, it is called participant observation.
• Physical artifacts : Tools, objects, instruments, and other artifacts are often observed during a direct observation of the subject.

If you have been directed to write a case study for a psychology course, be sure to check with your instructor for any specific guidelines you need to follow. If you are writing your case study for a professional publication, check with the publisher for their specific guidelines for submitting a case study.

Here is a general outline of what should be included in a case study.

Section 1: A Case History

This section will have the following structure and content:

Background information : The first section of your paper will present your client's background. Include factors such as age, gender, work, health status, family mental health history, family and social relationships, drug and alcohol history, life difficulties, goals, and coping skills and weaknesses.

Description of the presenting problem : In the next section of your case study, you will describe the problem or symptoms that the client presented with.

Describe any physical, emotional, or sensory symptoms reported by the client. Thoughts, feelings, and perceptions related to the symptoms should also be noted. Any screening or diagnostic assessments that are used should also be described in detail and all scores reported.

Your diagnosis : Provide your diagnosis and give the appropriate Diagnostic and Statistical Manual code. Explain how you reached your diagnosis, how the client's symptoms fit the diagnostic criteria for the disorder(s), or any possible difficulties in reaching a diagnosis.

Section 2: Treatment Plan

This portion of the paper will address the chosen treatment for the condition. This might also include the theoretical basis for the chosen treatment or any other evidence that might exist to support why this approach was chosen.

• Cognitive behavioral approach : Explain how a cognitive behavioral therapist would approach treatment. Offer background information on cognitive behavioral therapy and describe the treatment sessions, client response, and outcome of this type of treatment. Make note of any difficulties or successes encountered by your client during treatment.
• Humanistic approach : Describe a humanistic approach that could be used to treat your client, such as client-centered therapy . Provide information on the type of treatment you chose, the client's reaction to the treatment, and the end result of this approach. Explain why the treatment was successful or unsuccessful.
• Psychoanalytic approach : Describe how a psychoanalytic therapist would view the client's problem. Provide some background on the psychoanalytic approach and cite relevant references. Explain how psychoanalytic therapy would be used to treat the client, how the client would respond to therapy, and the effectiveness of this treatment approach.
• Pharmacological approach : If treatment primarily involves the use of medications, explain which medications were used and why. Provide background on the effectiveness of these medications and how monotherapy may compare with an approach that combines medications with therapy or other treatments.

This section of a case study should also include information about the treatment goals, process, and outcomes.

When you are writing a case study, you should also include a section where you discuss the case study itself, including the strengths and limitiations of the study. You should note how the findings of your case study might support previous research. 

In your discussion section, you should also describe some of the implications of your case study. What ideas or findings might require further exploration? How might researchers go about exploring some of these questions in additional studies?

Need More Tips?

Here are a few additional pointers to keep in mind when formatting your case study:

• Never refer to the subject of your case study as "the client." Instead, use their name or a pseudonym.
• Read examples of case studies to gain an idea about the style and format.
• Remember to use APA format when citing references .

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach .  BMC Med Res Methodol . 2011;11:100.

Crowe S, Cresswell K, Robertson A, Huby G, Avery A, Sheikh A. The case study approach . BMC Med Res Methodol . 2011 Jun 27;11:100. doi:10.1186/1471-2288-11-100

Gagnon, Yves-Chantal.  The Case Study as Research Method: A Practical Handbook . Canada, Chicago Review Press Incorporated DBA Independent Pub Group, 2010.

Yin, Robert K. Case Study Research and Applications: Design and Methods . United States, SAGE Publications, 2017.

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

IBDP Psychology

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Self-study assisted cognitive therapy for PTSD: a case study

Research has demonstrated that Cognitive Therapy for PTSD (CT-PTSD), a version of trauma-focused cognitive-behavioural therapy developed by Ehlers and Clark's group (2000), is effective and feasible when offered in weekly and intensive daily formats. It is unknown whether patients with post-traumatic stress disorder (PTSD) could engage in and benefit from self-study assisted cognitive therapy, which would reduce therapist contact time.

This case report aims to illustrate this possibility.

A patient with PTSD and comorbid major depression, who developed these problems following a road traffic accident, was treated in six sessions of cognitive therapy with six self-study modules completed in-between sessions. The patient made a complete recovery on measures of PTSD, anxiety, and depression as assessed by self-report and independent assessment.

Self-study assisted cognitive CT-PTSD reduced the therapist contact time to half of that normally required in standard CT-PTSD. This highlights the potential feasibility and therapeutic benefits of self-study modules in the brief treatment of PTSD. Further research is required to systematically evaluate the acceptability and efficacy of brief self-study assisted CT-PTSD.

Post-traumatic stress disorder (PTSD) is a severe stress reaction that develops in some people after traumatic events, such as accidents, disaster, or physical or sexual violence. It is one of the most common anxiety disorders and is linked to high rates of comorbidity, chronic disability, and long-term health care costs (Kessler, 2000 ). Over the past decades, effective psychological treatments of PTSD have been developed. Trauma-focused cognitive behavioural therapy (CBT) has repeatedly been demonstrated to be effective and is currently recommended as a first-line treatment for PTSD (e.g., American Psychiatric Association, 2004 ; Australian Centre for Posttraumatic Mental Health, 2007 ; Foa, Keane, Friedman, & Cohen, 2005 ; National Institute of Clinical Excellence [NICE], 2005 ; Stein et al., 2009 ; Veterans Health Administration and Department of Defense, 2004 ). Protocols vary but treatment typically consists of between 8 and 12 sessions (Bisson et al., 2007 ). However, in cases with complex comorbidity or multiple traumas, CBT for PTSD can span more than 20 sessions (e.g., Gillespie, Duffy, Hackmann, & Clark, 2002 ). Furthermore, treatment sessions in trauma-focused CBT are longer than the standard 50-min session and usually last about 90 min for sessions when the trauma is being discussed. Thus, although CBT is a short-term treatment, it requires a significant amount of therapist time and many patients with PTSD are currently unable to access CBT as resources are limited and there is a shortage of trained therapists.

This raises the question of whether there are ways to deliver CBT to patients with PTSD in a more economical way. Unfortunately, attempts to treat PTSD by self-help alone have failed (e.g., Ehlers et al., 2003 ). Nevertheless, it may be possible to cover some components of the treatment by self-study modules to save therapist time, while delivering those that require input and support from the therapist in face-to-face sessions. For other anxiety disorders and depression, effective self-study assisted CBT programmes have been developed (e.g., Clark et al., 1999 , Clark et al., 2010 ; Wright et al., 2005 ). These brief treatments are less costly than therapist-only treatments. PTSD has received less attention in this respect, although there is an emerging interest in internet-based treatment of PTSD (e.g., Knaevelsrud & Maercker, 2007 ). This may in part be due to the complexity of the clinical features of PTSD, the high rates of comorbidity, and the well-documented memory and concentration problems linked to the disorder.

The purpose of this report is to illustrate the possibility of treating PTSD in a self-study assisted brief therapy format. The present self-study assisted treatment builds on Cognitive Therapy for PTSD (CT-PTSD), a trauma-focused CBT programme developed by Ehlers, Clark, and colleagues. CT-PTSD is usually delivered in up to 12 weekly sessions and has been demonstrated to be very acceptable to patients and effective in five randomised controlled trials (Duffy, Gillespie, & Clark, 2007 ; Ehlers et al., 2003 ; Ehlers, Clark, Hackmann, McManus, & Fennell, 2005 ; Ehlers et al., in press; Smith et al., 2007 ). An intensive version of this treatment, offered over 5–7 days rather than 12 weeks, has also been shown to be feasible and effective (Ehlers et al., 2010 ).

The CT-PTSD is based on Ehlers and Clark's ( 2000 ) cognitive model of PTSD. This model suggests that people with PTSD perceive a serious current threat that has two sources, excessively negative appraisals (personal meanings) of the trauma and/or its sequelae and characteristics of trauma memories that lead to re-experiencing symptoms. The problem is maintained by cognitive strategies and behaviours (such as thought suppression, rumination, safety-seeking behaviours, and avoidance) that are intended to reduce the sense of current threat, but maintain the problem by preventing change in the appraisals or trauma memory, and/or by increasing symptoms. CT-PTSD targets the three factors specified in the model. For each patient, an individualised version of the model is developed. The maintaining factors are addressed with the procedures described in Appendix A . The relative weight given to different treatment procedures differs from patient to patient depending on the case formulation.

The new self-study assisted version of CT-PTSD treatment has recently been developed by the Wellcome Trust Anxiety Disorders Research Group at King's College London and the Centre for Anxiety Disorders and Trauma, Maudsley Hospital, London (Anke Ehlers, Jennifer Wild, Richard Stott, Nick Grey, Alicia Deale, Rachel Handley, Debbie Cullen, and Idit Albert).

Self-study modules were written to cover aspects of the treatment programme that patients could complete on their own such as information gathering and experiential assignments that do not require the presence of the therapists. The modules are written in accessible, lay language. They differ in length from about 8–25 A4 pages. There are seven core modules designed to be completed by all patients. These focus on:

• normalising symptoms of PTSD, assessing how the patient has coped with the trauma and PTSD symptoms so far (to identify behaviours that maintain the problem) and identifying the patient's treatment goals ( It All Makes Sense module);
• reclaiming your life assignments ( Reclaiming Your Life module);
• identifying hot spots and updating them in memory ( Working on Your Memories and Updating Your Memories modules);
• spotting and overcoming triggers to intrusive memories ( Spotting your Memory Triggers and Beating Your Memory Triggers modules); and
• creating a plan for setbacks ( Creating You Blueprint module).

A range of optional modules are given as needed, depending on the individual case formulation. These focus on different cognitive themes such as appraisals linked to shame, guilt, anger, or overgeneralisation of danger; common maintaining strategies such as rumination or substance use; or common comorbid problems such as grief, sleep difficulties, or depression.

Case presentation

Initial assessment.

Philip, a White 60-year-old British man, had a road traffic accident on the motorway 3 months before presenting for assessment. The driver of an adjacent car fell asleep and drove into Philip's car from the side. His daughter and grandson were sitting in the back seat. Philip's car spun twice. He tried to look around to see if his daughter and grandson were safe, but he was trapped and could not see them. He thought they were flying about in the car like everything else and that they had died. The car eventually landed on its four wheels. Philip described excruciating pain in his back. He thought that he had broken his back. He could not hear his daughter or grandson and believed they must be dead. However, they had survived. His daughter had a broken arm and his grandson was without injury.

When Philip presented for assessment he was having intrusive memories of the accident every day in which he saw the car spinning. He also had intrusive images of what could have happened and pictured his daughter and grandson dead in the backseat. Philip had flashbacks when he drove his car, which happened several times per week, and he felt hot and sweaty in these situations. He also often woke up with nightmares about the accident.

Philip pushed memories of the accident out of his mind, especially at bedtime. He avoided places that reminded him of the trauma, especially motorways and where it happened on the motorway. Whilst he could remember the trauma, he could not remember that the car had rolled twice until he was told by his daughter. Philip had many hyperarousal symptoms. He had difficulty sleeping, felt irritable, had trouble concentrating, and was overly alert.

Philip also developed depression after the accident. He was low in mood, tearful, unmotivated, and preferred to stay indoors rather than engage in his previous activities, such as meeting friends for a drink and going out with his wife once a week for a meal.

Philip met the criteria for PTSD and major depression as set out in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric Association, 1994 ) and assessed with the Structured Clinical Interview for DSM-IV (SCID; First, Spitzer, Gibbon, & Williams, 1995 ). In addition, Philip had chronic back pain from the accident. The pain was a constant reminder of the accident and could trigger intrusive memories and rumination.

Cognitive formulation

In terms of personal meanings of the trauma, objectively Philip knew the accident was not his fault but he felt as though it was. He believed this 60%. He concluded from the accident that he was incapable of keeping his daughter and grandson safe, especially because another (small) accident had happened when his grandson was in his care. He believed this 80%.

Philip's primary symptoms were upsetting, recurrent memories of seeing the car spinning. His memory was unclear about some details, for example, he had only learned from his daughter about the car spinning twice. When the intrusive memories popped up, he imagined his daughter and grandson being dead, and then tried to push thoughts of the accident out of his mind. Thought suppression made his images pop-up more frequently. Pushing them out of his mind at the worst moments also prevented him from updating these moments in memory with the information that in fact his daughter and grandson were alive.

Further maintaining behaviours

In addition to the suppression of trauma memories, Philip used a range of other behaviours that maintained his PTSD. Philip still drove but he avoided going on motorways. When he was required to drive on the motorway, he checked the position and speed of other cars very closely and imagined accidents happening. This maintained his conviction that he had to be especially careful to prevent further accidents and, thus, his anxiety about driving. He ruminated about the accident being his fault and his inability to keep his family safe, which maintained these appraisals and caused him to feel sad. He also avoided seeing his grandson to limit the chances of further accidents and limited how often he saw his daughter because he felt guilty about what had happened. The withdrawal from his family prevented him from finding out that they were safe with him. It also contributed to his low mood and because he felt low, he stopped going out and doing the things he used to enjoy such as eating out once a week with his wife. This further maintained his low mood.

Treatment goals

According to the case formulation, the main treatment goals according to the Ehlers and Clark ( 2000 ) model were:

• To reduce Philip's sense that he was responsible for the accident.
• To change his appraisal that he was incapable of keeping his daughter and grandson safe.
• To reduce intrusive re-experiencing and nightmares by (1) identifying information that puts the threatening meanings of the moments represented in re-experiencing into perspective, and (2) updating these moments in memory with this information.

Maintaining behaviours and cognitive strategies

• Suppression of intrusive memories.
• Rumination about his perceived inability to keep his daughter and grandson safe.
• Avoidance of his daughter and grandson.
• Avoidance of motorways.
• Excessive checking of other traffic when driving.

To build up:

• Activities that were important to Philip before the accident.
• Daily activity, including physical activity, to help with depression and pain.

Treatment plan

According to the initial formulation, the following treatment procedures described in Appendix A appeared especially relevant for Philip:

• Updating the memory for the worst moments of the trauma.
• Reclaiming your life assignments.
• Behavioural experiments to reduce thought suppression, avoidance, and excessive checking.
• Cognitive restructuring of appraisals of being responsible for the accident and incapable of keeping his family safe.

Clinical measures

On the Post-traumatic Stress Diagnostic Scale (PDS; Foa, Cashman, Jaycox, & Perry, 1997 ) Philip scored 29 in the moderate-to-severe range of PTSD symptom severity. On the Impact of Events Scale-Revised (IES-R; Weiss & Marmar, 1997 ), Philip scored 71 in the severe range. On the 9-item Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer, & Williams, 2001 ), Philip scored 15 in the severe range for depression. On a 7-item measure of generalised anxiety (GAD-7; Spitzer, Kroenke, Williams, & Löwe, 2006 ), Philip scored 16 in the severe range. Philip completed these questionnaires at assessment and prior to every weekly treatment session. Two weeks prior to session 1, Philip was assessed by an independent assessor who administered the Clinician-Administered PTSD Scale (CAPS; Blake et al., 1990 ). The total CAPS severity score was 76.

The therapist met briefly with Philip after the independent CAPS assessment to give him the first two core modules ( It All Makes Sense and Reclaiming Your Life ) and asked him to complete them before the first session.

The It All Makes Sense module focuses on normalising the symptoms of PTSD and obtaining information that will help the case formulation and develop treatment goals. It includes patient testimonies of their experience of CT-PTSD . It asks clients to describe their flashbacks as well as feelings and physical responses to reminders of their trauma. It encourages them to note any triggers of their trauma memories and the key emotions linked to their trauma, such as fear and shame, and the thoughts linked to these emotions. It then helps patients to identify their safety-seeking behaviours (Salkovskis, 1991 ). The module explains why PTSD is linked to physiological arousal and guides the patient to elicit the ways in which they cope with their trauma memories, such as through distraction, alcohol, rumination, or suppression. The module includes an example of another client's treatment goals and space for the client to write out their goals for treatment.

The Reclaiming Your Lif e module educates the patient as to how PTSD can cause patients to stop doing activities they used to do. It then encourages patients to identify what they would like to do again in different areas of their life, such as in their free time and in their home and social life. The module then encourages them to complete a weekly plan in which they identify activities they would like to do and aim to try at least one of these before they meet with their therapist. The module includes a troubleshooting section, which normalises and problem solves potential obstacles to completing the planned activities, such as “I don't have any energy for doing anything” and “It will be too traumatic—I won't be able to cope.”

In addition, the therapist gave Philip the Chronic Pain and PTSD module that describes the effects of chronic pain on feelings and behaviours and guides the patient to identify the effects of chronic pain in their life, as well as the effects of PTSD on chronic pain, such as continually reminding the patient of their trauma. The module also explains why it is important to not give up physical activity in response to chronic pain.

Philip arrived at the session having completed all three modules. The therapist reviewed these prior to commencing the 90-min session. Philip had spent 55 min over 2 days completing the It All Makes Sense module. He had spent 200 min over 2 days completing the Reclaiming Your Life module, and this included the time he spent on an activity he had conducted as part of his weekly plan to reclaim his life. He had spent 85 min over 3 days completing Chronic Pain and PTSD .

The therapist's aims for the session were to operationalise Philip's treatment goals in a concrete way, provide a treatment rationale, and to conduct an imaginal reliving of the accident (Foa & Rothbaum, 1998 ) to identify Philip's emotional hot spots; that is, the worst moments of the trauma, their linked emotions, and personal meanings.

The client's operationalised goals were to: First, to feel happy, which would mean that he could go out more, go shopping with his wife, and feel comfortable driving on the motorway. His second goal was to reduce his nightmares so he could sleep through the night and no longer wake up in a cold sweat. His third goal was to think about his accident without getting upset.

The therapist was able to weave the client's goals into the rationale for revisiting and updating his memory of the accident, since it was hypothesised that his sleep would improve and he would come to terms with his trauma following the process of updating his trauma memory. When presenting the rationale, the therapist drew on information the client provided in the module It All Makes Sense , specifically that he pushed the trauma out of his mind. The client was guided to discover that going over his trauma memory in detail would help him to emotionally process it, and transform it into a regular autobiographical memory without unexpected intrusions. The session contained 30 min of imaginal reliving. Philip rated his distress at 90% and the “nowness” (impression that it is happening now rather than being a memory from the past) as 80%. This was followed by asking the client to identify his worst moments, and what went through his mind in these moments during the trauma. Philip identified two hot spots: The car spinning after the impact and then the car landing on its wheels from what appeared like a great height. Both hot spots meant at the time to him that his daughter and grandson may die or had died. This filled him with fear, sadness, and feelings of guilt. The second also meant to him that he may have broken his back.

To conclude the session, the therapist drew out a weekly plan of Reclaiming Your Life homework with Philip and asked him to note his level of satisfaction out of 100% for each activity. This aimed to target inactivity, which maintained his low mood and contributed to his pain. The client was also given a module, Working on Your Memories , which addresses the consequences of suppressing unwanted memories, how to cope with them, clients are asked to write out a narrative of the trauma in the first person present tense, and write out questions to help identify hot spots. The module also includes a patient's example of their written narrative and hot spots.

Philip had spent 65 min completing Working on Your Memories over 3 days. He had also completed his weekly Reclaiming Your Life plan and had rated most activities as being 70% satisfying. The therapist's plan for this session was to review the client's homework, reinforce what he had learned from being active, and elicit new information to update the meanings of his hot spots. Philip had learned that when he was active his mood improved, and this encouraged him to plan more activities. The therapist then focused on one belief linked to both hot spots: that his daughter and grandson had been harmed or died in the accident. The therapist encouraged Philip to think about what he knew now in relation to his daughter and grandson being alive. Philip was asked to think about the times he had seen them since the accident. He recalled that he had seen them a few times and that on one occasion this had been a happy experience. They had surprised him on Father's Day. Philip could visualise their smiling faces, recall their conversations, and could vividly picture his grandson playing with his mini-football. To update the hot spots in memory, Philip was then asked to close his eyes and recall the moment of impact of his accident, recalling what went through his mind and what he knew now. He ran the worst moment on to include the information that this daughter and grandson were safe and he pictured them at his recent Father's Day celebration.

Again, in conclusion to this session, the therapist and Philip agreed on a weekly plan of Reclaiming Your Life activities for him to complete and to note his level of satisfaction for each activity. As Philip had been avoiding seeing his daughter and grandson because he believed they would be unsafe with him, one of his reclaiming his life activities was set up as a behavioural experiment. This experiment had two purposes: to test his belief that they would be harmed in his presence and to encourage him to re-engage in significant activities he had given up since the trauma, which was to see his family more often.

The client was also given the Updating Your Memories module to further focus on information to update his worst moments. This module includes a rationale for looking at hot spots in detail to update them and examples of how other patients have done this. A space is provided for the patient to describe the situation linked to their hot spot, the thoughts that went through their mind, and their meaning at the time ( then ), what they know now , and how they can remind themselves of what they know now .

Philip had spent 70 min completing the Updating Your Memories module. Table 1 shows his hot spots and how he had updated them in the module.

Updating your memories module: Philip's hot spots and how he updated them

Philip had also completed his weekly Reclaiming Your Life plan and had rated most activities as being 80% satisfying. The therapist planned to review the client's homework; address his rumination about what could have happened and about his inability to keep his daughter and grandson safe, which were maintaining Philip's anxiety; and to address his appraisal that he was responsible for the accident.

Philip was continuing to learn from his homework that being active helped to lift his mood. In comparison to his level of activity before therapy, he was also able to see that being inactive kept him feeling low. Philip had completed his behavioural experiment to test his belief that his daughter and grandson were unsafe with him. He had asked them to come over for lunch on the weekend. Nothing had happened to them in his presence and he re-rated his belief that they would be harmed with him from 80 to 20%. In the session, the therapist guided Philip to discover that ruminating about his inability to keep his daughter and grandson safe triggered intrusive memories of his accident and made him feel anxious. He discovered that when he was ruminating, he was not taking in new information that they were in fact well and that there were many times he had been with them and no danger had occurred. Philip now planned to visualise his daughter and grandson at his Father's Day celebration when he noticed he was ruminating, and to focus on the information that they were well and had survived the accident. Philip was then asked to generate reasons for why the accident had happened. He recalled that the main one was that the driver who had hit their car had fallen asleep. This information did not fit with his belief that he was responsible for the accident, which dropped from 60 to 40% with this information. In addition, the session started to address Philip's checking behaviours when driving. Philip understood that constantly checking the position, speed, and so on of other cars may contribute to his concerns about the dangers of driving and he was willing to do a behavioural experiment that involved (1) driving on the motorway while checking, and (2) driving while dropping the checking behaviour to observe the effect on his levels of anxiety/relaxation and his sense that an accident was going to happen. To conclude the session, the therapist again drew out a weekly plan of Reclaiming Your Life activities with Philip to complete in the following week. The behavioural experiment to drive with and without checking behaviour was also noted on this plan.

The module Guilt and Self-Blame was given to the client. This module helps clients to understand why they feel guilty, what thoughts and thinking errors guilt is linked to, and how to let go of guilt. The client is encouraged to consider all possible causes of their trauma and to rate the contribution of these factors to the occurrence of their trauma in a responsibility pie chart. The module has examples of how other patients have completed specific questions.

The client had conducted his behavioural experiment and rated that he felt 80% relaxed when driving without checking compared to 80% anxious when he drove and checked. He agreed to build on this experience and do more driving without checking until the following session. He had also completed his Reclaiming Your Life tasks. He had spent 90 minutes over 4 days working on the Guilt and Self-Blame module. Philip's self-blame about the accident had dropped from 60 to 40% in the previous session and following this module, it dropped to 0%.

The main plan for this session was to continue updating Philip's hot spots by simultaneously bringing the hot spots and the information gathered in therapy to mind that were relevant to their meanings. First, this was that Philip's daughter and grandson had not died as he had feared. A moment when he had seen them just after the accident sitting on a bench talking and smiling reinforced the updated meaning that they were alive, as did the image of them smiling at his Father's Day celebration. Second, the accident was not Philip's fault as it was the other car that had hit theirs. Third, Philip did not break his back and could walk again after the accident. One problem that made it difficult for Philip to update his hot spots was that he had not been able to see his daughter and grandson during these moments. To facilitate access to his knowledge about what had actually happened while focusing on the trauma, the therapist had the client imagine the trauma from a third-person perspective, watching what was happening to him and his family. The client rated this as 75% distressing with a nowness rating of 80%, but this came down to 0% distressing and 10% for nowness when he also visualised his daughter and grandson in imagery first sitting on the bench smiling and then smiling at his Father's Day celebration.

Homework included driving without checking, teaching his other daughter how to drive, and pleasurable activities. The client was asked to read through the Guilt and Self-Blame module again to consolidate learning about being responsible for the accident.

The client felt much improved and his intrusive memories and nightmares had ceased. He had spent 30 min reviewing the Guilt and Self-Blame module, had continued to drive without checking, and reported he had felt 85% relaxed. This session addressed his belief that he was incapable of looking after his grandson because the car accident was the second time there had been an accident of some sort while Jake had been in his care. Another time, he had held Jake and had fallen. Philip realised that he had been with his grandson many times without any accidents happening and that he thus overestimated the likelihood of accidents. He further realised that the car accident had not been his fault and thus was not good evidence for his ability to look after his family. Furthermore, in both cases Jake had not been seriously hurt.

Homework was again to conduct daily activities, which included seeing his daughter and grandson and rate his satisfaction, to continue with his driving, and to complete the module Blueprint .

The Blueprint module reviews what the client has learned in treatment to help with the prevention of any setbacks or relapse. It asks the client to answer key questions about how their problem started, what kept it going, what they learned in therapy, what their unhelpful and now updated thoughts were, how they could build on what they have learned, and how they could address setbacks if they occurred.

This session focused on reviewing and adding to the client's blueprint and troubleshooting any problems that could arise in the 1-month follow-up period. Philip had spent 60 min completing his Blueprint module. For homework, the client was asked to continue driving, doing activities regularly, and to review his blueprint once per month.

Follow-up session

Philip attended a brief follow-up session 1 month after treatment ended. This session contained a probe reliving the accident. Philip's distress and nowness levels were 0%.

Philip's treatment spanned 6 weeks. In his sixth and final session, he scored in the non-clinical range on all symptom measures, PDS: 2, IES-R: 8, PHQ-9: 1, GAD-7: 1. He no longer met criteria for PTSD on the CAPS as assessed by an independent assessor, with a CAPS total score of 4. He no longer met criteria for major depression as assessed by the SCID. At the 1-month follow-up session, he scored 0 on the PDS, IES-R, PHQ-9, and GAD-7. Philip was contacted again 2 months after treatment ended. He maintained his gains and scored in the non-clinical range on all measures, PDS: 4, IES-R: 5, PHQ-9: 4, and GAD-7: 0.

This case report demonstrates the possibility of using self-study modules to reduce face-to-face therapist contact time in CT-PTSD. By session 5, the client had completed six modules and all scores were in the non-clinical range. The total length of time the client had spent completing modules by the end of treatment (session 6) was 660 min or 11 h and the total therapist contact time was 480 min or 8 h, thus saving about 50% of the therapist's time compared to standard CT-PTSD (Ehlers et al., 2005). Encouragingly, the patient maintained his gains at the 1- and 2-month follow-up.

When asked what he found most helpful, the client identified the modules to update his memory and the imagery exercise he had completed with his therapist in which he viewed the trauma from a third-person perspective. Whilst he had found this upsetting at the time, he had been able to emotionally access his fears about losing his daughter and grandson and address them directly with new information. Although he had started updating the worst moments of the memory with the help of the self-study modules, it was the imagery session that made the updating information fully “sink in,” i.e., he could now make the connection between the moments when he believed his daughter and grandson were dead and the moments when he later saw them sitting on the bench alive and smiling. It was after this session that the client's scores fell into the non-clinical range.

Like standard CT-PTSD, the brief self-study assisted treatment was adapted to the individual case formulation. Because of Philip's depression, the therapist took an active role in identifying suitable activities and much emphasis was given in the sessions to the Reclaiming Your Life assignments and increasing activity levels more generally. Satisfaction ratings were included although they are not a standard part of the Reclaiming Your Life assignments to illustrate the link between activity and mood. As pain was a problem for Philip, the Chronic Pain and PTSD module was given before therapy started so that he could use the advice given in the module early on. The usual procedure would be to give only the first two core modules before the first session. As Philip made a speedy recovery and no longer had intrusive memories and nightmares after the successful memory updating procedure, the two core modules on identifying and discriminating triggers were not given. A site visit, which usually puts the final touches on the updating process, was also no longer considered necessary by the therapist given that Philip had made a complete recovery.

What stands out in terms of Philip's contribution to his recovery is that he completed all modules given to him and all other assigned homework, in particular, engaging in daily activities, which improved his mood. It is as yet unknown how important compliance with homework assignments is to the recovery of patients with PTSD in brief CBT. Other patients, especially those with dissociative symptoms or very extensive avoidance, may find it harder to complete the assignments or do them less thoroughly.

In conclusion, this case study demonstrates the possibility of using self-study modules in the treatment of PTSD despite the memory and concentration problems observed in this patient group. Of course, the conclusions that can be drawn from a case study are very limited as it is unknown whether the treatment was causally responsible for Philip's recovery. Longer follow-ups are needed to assess the stability of treatment effects. Thus, further research is required to systematically evaluate the short- and long-term effects and acceptability of self-study assisted CT-PTSD. Furthermore, it is as yet unknown which patients would benefit most from self-study assisted CT-PTSD, and future research will need to investigate possible predictors of poorer treatment response. The treatment requires the patient to read and write and some patients may find this challenging. It is also possible that patients with multiple trauma or multiple comorbid disorders may be slower to respond with this new treatment because the reduced number of sessions gives the therapist less opportunity to address different cognitive themes and additional problems than in regular CT-PTSD. On the other hand, Philip had comorbid conditions and responded well to treatment. Furthermore, there are additional modules that support the work on additional problems such as modules on earlier trauma or loss. A randomised controlled trial evaluating self-study assisted CT-PTSD is currently underway at King's College London.

Acknowledgements

The work described in this paper was supported by Wellcome Trust Grant No. 069777 to Anke Ehlers and David M. Clark. We thank Nick Grey, Richard Stott, Alicia Deale, Rachel Handley, Debbie Cullen, Idit Albert, and Francesca Brady for their collaboration and help. We are grateful to “Philip” (name and details changed to preserve anonymity) for allowing us to describe his treatment.

Appendix A Cognitive therapy for PTSD: summary of treatment procedures

Goal 1: modify excessively negative appraisals of the trauma and its sequelae.

As in other cognitive therapy programs, excessively negative appraisals of trauma sequelae such as the initial PTSD symptoms (e.g., Ehlers, Mayou, & Bryant, 1998 ) and other people's responses after the event (e.g., Dunmore, Clark, & Ehlers, 2001 ) are modified by the provision of information, Socratic questioning, and behavioral experiments. As many patients with PTSD describe a sense of permanent change since the trauma (e.g., Ehlers, Maercker, & Boos, 2000), Reclaiming Your Life assignments are discussed in each session and usually done as homework. Patients are encouraged to “reclaim” their former lives by reinstating significant activities or social contacts they have given up since the trauma.

Changing negative appraisals of the trauma poses a special challenge as much of the patient's evidence for the problematic appraisals stems from what they remember about the trauma. Thus, work on appraisals of the trauma needs to be closely integrated with work on the trauma memory. Disjointed recall of the trauma in PTSD (a) makes it difficult to assess the problematic meanings by just talking about the trauma, and (b) has the effect that insights from cognitive restructuring may not be sufficient to produce a large shift in affect. Ehlers and Clark ( 2000 ) developed a special procedure to shift problematic meanings of the trauma, termed Updating Trauma Memories . This involves

• Identifying the idiosyncratic appraisals of the trauma : To access the problematic idiosyncratic meanings of the trauma, the moments during the trauma that create the greatest distress and sense of “nowness” during recall (hot spots) are identified through imaginal reliving (Foa & Rothbaum, 1998 ) or narrative writing (Blanchard et al., 2003 ; Resick & Schnicke, 1993 ), and discussion of intrusive memories (see Ehlers et al, 2002 ). The personal meaning of these moments is explored in careful questioning.
• Identification of updating information : The next step is to identify information that provides evidence against the idiosyncratic appraisals linked to each hot spot (“updating information”). This may be information from the course of the event that has not been linked to the meaning of the hot spot or a new conclusion the patient has reached in cognitive restructuring. Examples of the former include information that the outcome was better than expected (e.g., patient did not die, is not paralysed); information that explained the patient's or other people's behaviour (e.g., the patient complied with the perpetrator's instructions because he had knife); the realisation that an impression or perception during the trauma was not true (e.g., the perpetrator had a toy gun rather than a real gun); or explanations from experts of what happened (e.g., explanations about medical procedures in the course of the trauma). Examples of the latter are conclusions from the cognitive restructuring of excessively negative appraisals such as “I am a bad person,” “It was my fault,” “My actions were disgraceful,” or “I attract disaster” using cognitive therapy techniques such as Socratic questioning, systematic discussion of evidence for and against the appraisals, behavioural experiments, pie charts, or surveys.
• Active incorporation of the updating information into the hot spots . Once updating information that the patient finds compelling has been identified, it is actively incorporated into the relevant hot spot. Patients are asked to bring the hot spot to their mind (either through reliving or reading the narrative) and to then remind themselves (prompted by the therapist) of the updating information either (a) verbally (e.g., “I know now that …”), (b) by imagery (e.g., visualising how one's wounds have healed; visualising perpetrator in prison; looking at recent photo of the family), (c) by performing movements or actions that are incompatible with the original meaning of this moment (e.g., moving about, jumping up and down for hot spots that involve prediction that the patient will die or be paralysed), or (d) incompatible sensations (e.g., touching a healed arm). To summarise the updating process, a written narrative is created that includes and highlights the new meanings (e.g., “I know now that it was not my fault”).

Goal 2: Reduce Re-experiencing by Elaboration of the Trauma Memories and Discrimination of Triggers

Four main techniques are used to elaborate the trauma memory and reduce re-experiencing: imaginal reliving of the event (Foa & Rothbaum, 1998), writing out a detailed narrative of the event (Blanchard et al., 2003; Resick & Schnicke, 1993), revisiting the site, and discrimination of triggers. Each procedure has advantages and the relevant weight given to them depends on the patient's level of engagement with the trauma memory and the length of the event. Imaginal reliving , in which the patient visualises the event while simultaneously describing what is happening and what he or she is feeling and thinking, is particularly good at facilitating engagement with the memory and retrieval of all aspects of the memory (including emotions and sensory components). Writing a narrative is particularly useful when aspects of what happened or the order of events are unclear. Reconstructing the event with diagrams and models and a visit to the site can be of further assistance in such instances. For patients with very long traumas and those who tend to dissociate when talking about the trauma, writing may also be easier to manage than imaginal reliving. Revisiting the site of the traumatic event is particularly helpful in facilitating the realisation that the event is in the past. When visiting the site, therapist and patient therefore discuss the way the scene is different from the day of the trauma (“Then” versus “Now”). Revisiting the site is also used to complement discussion and obtain new information that helps explain why or how an event occurred.

Building on the observation that trauma memories are disjointed and often lack crucial context information, Ehlers and Clark ( 2000 ) and Ehlers, Hackmann, and Michael ( 2004 ) outlined that memory elaboration needs to link the hot spots of the trauma with new information that updates their meanings. To establish this new link, CT-PTSD uses the Updating Trauma Memories procedure described above.

Discrimination of triggers of re-experiencing symptoms usually involves two stages. First, patient and therapist carefully analyse where and when intrusions occur to identify triggers. This involves some detective work as patients are usually not aware of many of the sensory triggers (e.g., particular colours, sounds, smells, tastes, touch). Systematic observation (by the patient and the therapist) is usually necessary before all triggers are identified. Once triggers have been identified, the next aim is to break the link between the triggers and the trauma memory. This involves several steps in therapy. First, the patient learns to distinguish between “Then” versus “Now” (i.e., the patient learns to focus on how the present triggers and their context “Now” are different from the trauma “Then”). Second, intrusions are intentionally triggered in therapy so that the patient can learn to apply the “Then” versus “Now” discrimination. This is done by bringing triggers into the therapy session. For example, traffic accident survivors may listen to sounds that remind them of the trauma such as sounds of brakes screeching, collisions, glass breaking, or sirens. People who were attacked with a knife may look at a range of metal objects. Survivors of bombings or fires may look at smoke produced by a smoke machine. People who saw a lot of blood during the trauma may look at red fluids. The “Then” versus “Now” discrimination can be facilitated by carrying out actions that were not possible during the trauma (e.g., movements that were not possible in the trauma, touching objects or looking at photos that remind them of their present life). Third, patients apply these strategies in their natural environment. When re-experiencing occurs, they remind themselves that they are responding to a memory, not current reality. They focus their attention on how the present situation is different from the trauma, and may carry out actions that were not possible during the trauma.

If re-experiencing symptoms persist after successful updating of the hot spots and discrimination of triggers, imagery transformation techniques can be useful. The patient transforms the image into a new image that signifies that the trauma is over. The transformed images can provide convincing evidence that the intrusions are a product of the patient's mind rather than representing current reality. Image transformation is also particularly helpful with intrusions that represent images of things that did not really happen during the trauma (usually anticipated bad consequences of the trauma).

Goal 3: Drop Dysfunctional Behaviours and Cognitive Strategies

The first step in addressing behaviours and cognitive strategies that maintain PTSD is usually to discuss the problematic consequences of the strategy. Sometimes these can be demonstrated directly by a behavioural experiment. For example, asking the patient to try hard not to think about a certain image (e.g., black-and-white cat sitting on therapist's shoulder) demonstrates that thought suppression is likely to increase intrusions. In other instances, a discussion of advantages and disadvantages is helpful, for example when addressing rumination. The next step involves dropping or reversing the problematic strategy, usually in a behavioural experiment.

For the abstract or full text in other languages, please see Supplementary files under Reading Tools online

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