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Ismz.chCopyright 2007 by the American Psychological Association Psychoneuroendocrine Effects of Resource-Activating Stress Management Maja Storch, Jens Gaab, Yvonne Ku¨ttel, Ann-Christin Stu¨ssi, and Helmut Fend Objective: The stress-induced release of cortisol has been linked to detrimental health outcomes.
Therefore, strategies to attenuate cortisol stress responses are of interest for prevention and treatment of
stress-related symptoms and problems. Previous studies have found protective effects of cognitive–
behavioral stress management training—which focuses on the modification of stress-inducing cogni-
tions— on cortisol stress responses; however, the effects of resource-oriented interventions on cortisol
stress responses are unknown. Design: The longitudinal effects of resource-oriented stress management
training (Zurich resource model training) on cortisol stress responses and cognitive appraisal of a
standardized psychosocial stress test were evaluated in 54 healthy male participants assigned randomly
to treatment and control groups. The Trier Social Stress Test (TSST; C. Kirschbaum, Wust, &
Strasburger, 1992) was administered to all participants 3 months after the treatment group underwent
stress management training. Main Outcome Measures: Saliva cortisol samples were taken before,
during, and after the TSST, and cognitive stress appraisal was assessed before the test. Results: The
treatment group had significantly attenuated cortisol responses and stress appraisals in comparison to the
control group. The endocrine differences were mediated by differences in cognitive appraisals. Discus-
sion: These results indicate that resource-oriented stress management training effectively reduces
endocrine stress responses to stress in healthy adults.
Keywords: Zurich resource model, stress management training, resource, cortisol Psychosocial stress can be conceptualized as incongruence be- standing release of HPA axis hormones has been shown to have tween the abilities and needs of a person and the environment. At detrimental effects on somatic and emotional well-being (Mc- the individual level, psychosocial stress is the result of a cognitive Ewen, 1998; Seeman, McEwen, Rowe, & Singer, 2001).
appraisal of what is at stake and what can be done about it As to the processes involved in the activation of the HPA axis (Lazarus, 2005; Lazarus & Folkman, 1984). It is assumed that the during stress, it has been shown that besides genetic (Wust et al., result of this subjective appraisal influences the emotional, behav- 2004), endocrine (Kirschbaum, Kudielka, Gaab, Schommer, & ioral, and biological response to stress. People with higher opti- Hellhammer, 1999), and habitual (Kirschbaum, Wust, & Stras- mism scores report fewer sick days and faster recovery after a burger, 1992) factors, situation-specific anticipatory cognitive ap- specific life stress event (Kivima¨ki et al., 2005). The effect of praisal, but not general personality variables, substantially account optimism, in turn, is supposed to be dependent on the person’s for the extent of the biological response in the face of stress (Gaab, belief and/or capacity to manage stress effectively (Penedo et al., Rohleder, Nater, & Ehlert, 2005). This finding is congruent with 2003). As Richman et al. (2005) stated, work in health psychology the results of a recent meta-analysis of 208 studies, which shows has emphasized risk factors more than protective factors when that the perception of threat to the social self is a major situational trigger of an HPA axis activation in response to stress (Dickerson With regard to biological responses to psychosocial stress, hor- mones of the hypothalamus–pituitary–adrenal (HPA) axis have & Kemeny, 2004). Thus, threat to social status, social esteem, been examined extensively. Although the activation of the HPA respect, and/or acceptance that is judged as not controllable by the axis in response to stress and its effects on cardiovascular, im- person leads to a biological stress response. Therefore, from an mune, and metabolic as well as emotional, behavior, and cognitive individual–subjective as well as a situational perspective, interven- processes helps to maintain equilibrium during and after stress tions aiming to influence perceived social threat could be used to (Sapolsky, Romero, & Munck, 2000), extensive and/or long- prevent adverse consequences of biological stress responses.
A number of studies have shown that cognitive– behavioral stress management (CBSM) effectively reduces basal cortisol lev- Maja Storch, Yvonne Ku¨ttel, Ann-Christin Stu¨ssi, and Helmut Fend, els shortly after the intervention in clinical as well as nonclinical Department of Educational Psychology, Institute of Education Sciences, populations (HIV: Antoni et al., 2000, and Cruess et al., 1999; University of Zurich, Zurich, Switzerland; Jens Gaab, Department of breast cancer: Cruess et al., 2000; athletes: Perna, Antoni, Kumar, Clinical Psychology and Psychotherapy, Institute of Psychology, Univer- Cruess, & Schneiderman, 1998). Also, in healthy participants, CBSM was observed to attenuate cortisol responses to a standard- Correspondence concerning this article should be addressed to Maja ized stress test 2 weeks as well as 4 months after training (Gaab et Storch, Department of Educational Psychology, University of Zurich,Freiestrasse 36, 8032, Zurich, Switzerland. E-mail: firstname.lastname@example.org al., 2003; Hammerfald et al., 2006).
PSYCHONEUROENDOCRINE EFFECTS OF STRESS MANAGEMENT All of the interventions mentioned above have in common that they condition receiving ZRM training before the stress test, and aim to address explicit, conscious levels of self-evaluation. Thus, Groups 3 and 4 were assigned to the control condition, receiving individuals reflect on their experiences, evaluate the contents of con- ZRM training after the completion of the stress test. As all four sciousness, and introspect about the causes and meanings of stressful groups did not differ significantly on any of the assessed demo- situations. Dealing with implicit aspects of the self is not the direct graphic or psychometric variables at baseline (data not shown), the focus of these interventions. However, it is important to differentiate respective groups were joined to form a treatment and a control between implicit and explicit self-esteem as distinct constructs, from group for statistical analyses (for comparison between treatment both a psychological and a neural perspective (Cunningham, Johnson, and control group, see Results section and Table 1). Three months Gatenby, Gore, & Banaji, 2003; Greenwald & Farnham, 2000). In this after the treatment group completed ZRM training, all participants regard, it has been assumed that implicit aspects of the self have an took a standardized psychosocial stress test (the TSST; Kirsch- important impact on social cognition and self-evaluation and that this baum, Pirke, & Hellhammer, 1993). To evaluate the effects of the implicit mode of self-evaluation dominates when the capacity to ZRM training on perceived stress levels, the Perceived Stress Scale engage in conscious self-reflection is lacking (for a review, see Devos (PSS) was administered at baseline and after the intervention in the treatment group or before intervention in the control group.
On the basis of these assumptions, Storch and colleagues de- veloped a self-management training that focuses on implicit self- aspects by combining psychoanalytic with cognitive– behavioralmethods (Zurich resource model [ZRM] training; for review, see The TSST has repeatedly been found to induce profound endo- Storch, 2004a, 2004b; Storch & Krause, 2002; see also the Method crine and cardiovascular responses in 70%– 80% of the persons section for details). The goal of ZRM training is to help partici- tested (Kirschbaum et al., 1993). In our study, after a saliva sample pants use personal resources in order to maintain the integrity of was collected for basal levels of free salivary cortisol, the partic- the social self in situations that are otherwise perceived as threat- ipants were given an introduction to the standardized TSST (2 ening the social self. Because resource activation has been dis- min). They then went to a different room, where they were given cussed as a crucial prerequisite for psychotherapeutically induced 10 min to prepare and to complete a questionnaire designed to change (Gassmann & Grawe, 2006; Grawe, 2002), ZRM training assess cognitive appraisal processes (the Primary Appraisal Sec- focuses on the participants’ personal resources rather than prob- ondary Appraisal Scale, or PASA; see below) regarding the stress situations in the TSST. Afterward, the participants returned to the In summary, the majority of studies on the effects of stress TSST room, where they took part in a simulated job interview (5 management training are based on a problem-oriented rather than min) followed by a mental arithmetic task (5 min) in front of an a resource-oriented model. Therefore, the present study set out to audience of two people. To assess salivary cortisol levels, a saliva test the effects of resource-focused intervention focusing on psy- sample was taken immediately before and after the TSST, with chological and biological stress responses during a standardized further samples taken at 10, 20, 30, 45, and 60 min after the TSST.
psychosocial stress test, using a methodological approach similar The TSST was administered between 2 p.m. and 6 p.m. All to that used in previous CBSM studies (Gaab et al., 2003; Ham- participants received 300 ml of a drink with high glucose content to raise blood glucose levels, as low glucose levels have beenshown to blunt stress-induced increases of cortisol (Kirschbaum etal., 1997). Also, participants were asked not to eat in the 2 hr preceding the TSST. The TSST protocol used differs from the protocol used in other TSST studies in terms of the 10 min ofpreparation time before the TSST (and after the introduction), Participants were recruited by e-mail. All students at the Swiss during which the participants in the current study completed the Federal Institute of Technology, Zurich, Switzerland, were sent an e-mail message that contained a link to an Internet site thatdescribed the study in brief. Interested persons had the opportunity to enroll in the study online. Exclusion criteria were assessed usinga screening questionnaire. The exclusion criteria were being fe- All participants attended group-based ZRM training. Groups of male (Kirschbaum et al., 1999) and being a smoker (Kirschbaum 16 participants met separately on two alternate, consecutive week- et al., 1992), both of which are confounding factors that have been ends (Friday to Sunday). Daily sessions lasted from 9 a.m. to shown to affect physiological dependent measures. Also, persons 5 p.m. Eight weeks after the ZRM training, all participants at- were excluded if they reported acute or chronic somatic or psy- tended a booster session that lasted 2 hr. Two experienced ZRM chiatric disorders. All students who were eligible for the study trainers (Yvonne Ku¨ttel and Ann-Christin Stu¨ssi) conducted the obtained a complete description of the study, gave written in- ZRM training sessions according to the ZRM training manual formed consent, and completed a set of questionnaires (see below (Storch, 2004b; Storch & Krause, 2002). The ZRM training is for details), which allowed us to obtain comprehensive descrip- manualized and is equally suitable for work with individuals and tions of relevant sample characteristics. Of 165 students who enrolled, 66 returned the screening questionnaire. Of these, 64 The purpose of the ZRM training is to foster personal resources students fulfilled participation criteria. Because the optimal group in successfully coordinating personal needs with the urges of the size for the ZRM trainings is 15–17, participants were randomized environment. In this regard, personal resources are defined as in four groups: Groups 1 and 2 were assigned to the treatment personal means that, when activated, put the person in the state Table 1Psychometric Characteristics of All Participants at Baseline FKK ϭ Questionnaire for Competence and Control Orientations; MESA ϭ Measure for Assessment of General Stress Susceptibility; ADS–K ϭ Center for Epidemiological Studies Depression Scale, German version; PSS ϭ Perceived Stress Scale.
required for well-being. As recommended by dual-process theories 3. Once a personal goal has been established, individual re- (for review, see Strack & Deutsch, 2004), the formation of these sources, defined as helpful means to achieve the personal goal, are personal resources is organized according to the person’s explicit built up around this goal. To enhance the facilitation of goal motives as well as implicit needs. According to Damasio (1994), achievement, psychodramatic embodiment techniques are used.
somatic markers as evaluative signals stem from an experience- Embodiment work in the ZRM training is based on facial and based part of the brain that has an implicit mode of information postural feedback theories (Ekman, 2003; Neumann & Strack, processing. Thus, the ZRM training uses somatic markers as 2000). To do so, participants develop their individual goal-related diagnostic indicators of activated implicit needs. In this under- embodiment; this is a posture and/or a movement that, subjectively standing, somatic markers function as indicators of personal au- perceived by the participant, expresses the attitude, information- thorship, adding an embodied quality to the experience of will processing style, emotion, and behavior that facilitates the attain- ment of the personal goal. The physical, emotional, and cognitive To achieve this purpose, the ZRM training aims to enhance the experiences of the individual goal-related embodiment are then proprioception of somatic markers to become aware of important implicit needs and to develop cognitions and behaviors that syn- 4. In Phase 4, the goal-oriented use of these resources in pre- chronize implicit needs and explicit motives. ZRM training con- dictable as well as unpredictable situations is prepared and prac- sists of five phases (for further details, see Storch, 2004b; Storch ticed in role-plays. An emphasis in the fourth phase is placed on the identification and knowledge of precursors (so-called warning 1. The first phase is designed to activate personal resources. To signals, e.g., “I turn away and a strong feeling of being powerless activate these resources, participants are presented with a set of rushes through me”) of problematic or unwanted emotions, cog- pictures showing positive content (flowers, friendly encounters, nitions, or behaviors (e.g., “I begin to stutter and, then, black out”).
beautiful landscapes, animals, etc.) and encouraged to select the On the basis of these warning signals, strategies to stop the picture that evokes positive somatic responses, such as pleasant unwanted emotions, cognitions, or behaviors are sought and prac- bodily feeling (e.g., “Picture of a running dog” 3 somatic re- ticed, such as positive self-instructions and thought-stop tech- sponse: “Rush of blood to the head, feeling strong and capable of doing things, wanting to jump and run”). Then the participants are 5. In the last phase, the contents and results of ZRM training asked to explore why the respective pictures produced positive are revised and discussed. Also, observed changes are discussed in responses. This process is facilitated through group participation in small groups of 2 persons, with the aim of integrating these the form of questions and hypotheses.
changes into the self-concept of one’s own abilities and to allow 2. In the second step, action-oriented personal goals are devel- oped on the basis of activated controllability by the participantsand their motivational properties. To do so, personal goals are proposed and discussed in small groups of 3 (e.g., personal re-source [“Picture of a running dog”] 3 personal goal: “To be active Sampling methods and biochemical analyses. and to take risks”). After the formulation of a personal goal, collected saliva using a device called the Salivette (manufac- participants are asked to write down a definition and operational- tured by Sarstedt AG, Sevelen, Switzerland). Saliva samples ization of this goal with regard to its application and its anticipated were stored at room temperature until completion of the ses- sion. Samples were then stored at –20 °C until biochemical PSYCHONEUROENDOCRINE EFFECTS OF STRESS MANAGEMENT analysis. The Salivettes were then centrifuged at 3,000 rpm for5 min, which resulted in a clear supernatant of low viscosity.
Salivary free cortisol concentrations were measured using acommercially available kit (Cortisol LIA; IBL, Hamburg,Germany) for chemiluminescence assay with high analyticalsensitivity of 0.16 ng/ml.
vant parameters at baseline (Questionnaire for Competence andControl Orientations; Measure for Assessment of General StressSusceptibility; Center for Epidemiological Studies DepressionScale, German version; and PSS) in the TSST (PASA) and beforeand after the intervention (PSS), we used the following question-naires: • Questionnaire for Competence and Control Orientations (Fragebogen zur Kontrollu¨berzeugungen und Kompetenzerwar-tung, or FKK; Krampen, 1989)—This 32-item questionnaireassesses the following personality traits (Cronbach’s ␣): self- Cortisol responses in the Trier Social Stress Test (TSST) concept of one’s own competence (␣ ϭ .76), internality (␣ ϭ between groups (means and standard deviations). Treatment group ϭ white .70), powerful others control (␣ ϭ .73), and chance control circle; control group ϭ black circle. Note: Absolute levels are depicted.
• Measure for Assessment of General Stress Susceptibility (Messinstrument zur Erfassung der Stressanfa¨lligkeit, or MESA;Schulz, Jansen, & Schlotz, in press)—This instrument assesses stress susceptibility on six scales (Cronbach’s ␣): Sensitivity to Analyses of covariance and variance for repeated measures were Failure (␣ ϭ .81), Tolerance of Work Load (␣ ϭ .87), Tolerance computed to analyze endocrine responses between groups, con- of Social Conflicts (␣ ϭ .56), Sensitivity to Criticism (␣ ϭ .80), trolling for differences in endocrine baseline levels when indi- Tolerance of Uncertainty (␣ ϭ .88), and Ability to Relax (␣ ϭ cated. All reported results were corrected by the Greenhouse- .81). The MESA yields information on the duration and magnitude Geisser procedure where appropriate (violation of sphericity of cognitive, physical, social, and emotional reactions that a person assumption). Regression analysis was used to assess associations typically shows in response to a stressful event. Although the between psychological and cortisol parameters. For cortisol pa- single scales provide information about distinct aspects of stress rameters, areas under the response curve were calculated with susceptibility, the total test score serves as a measure of general respect to increase (AUCi) and ground (AUCg), using the trape- zoidal method as an indicator for the integrated cortisol response in • Center for Epidemiological Studies Depression Scale, Ger- the TSST (Pruessner, Kirschbaum, Meinlschmid, & Hellhammer, man version (Allgemeine Depressions Skala—Kurzform, or 2003). Data were tested for normal distribution and homogeneity ADS–K; Hautzinger & Bailer, 1993)—The ADS–K is a German of variance using the Kolmogorov-Smirnov test and Levene’s test version of the Center for Epidemiological Studies Depression before statistical procedures were applied. The optimal total sam- Scale (Radloff, 1977). It was developed specifically for use in ple size of 64 to detect an expected multivariate effect size of .25 investigations in nonclinical samples to screen for depressive (representing a medium to large effect size) with a power of .85 affect and negative thought patterns. Cronbach’s alpha for this and equal to .05 was calculated a priori with the statistical software G-Power (Buchner, Faul, & Erdfelder, 1997). For all analyses, the • PSS (Cohen, Kamarck, & Mermelstein, 1983)—A German significance level was .05. Unless indicated, all results are shown translation of the PSS was used to assess the degree to which situations in life experienced during the previous month are ap-praised as stressful. The PSS was designed to assess with 14 items how predictable, uncontrollable, and overloading participants findtheir lives. Cronbach’s alpha is .85.
As a result of dropout, not all allocated participants participated • PASA (Gaab et al., 2005)—This instrument was specifically in the ZRM training (treatment condition, n ϭ 26; control condi- constructed to assess cognitive appraisal processes in the TSST tion, n ϭ 28). Reasons for dropout were as follows: inability to according to transactional stress theory. The PASA is composed of attend intervention dates (n ϭ 7), lost interest in participating in four situation-specific subscales assessing (primary appraisal) study (n ϭ 2), or no reasons provided (n ϭ 1). Groups did not Challenge (␣ ϭ .64) and Perceived Threat (␣ ϭ .85) as well as differ in their proportion of dropouts, and dropouts did not differ (secondary appraisal) Self-Concept of One’s Own Competence in any baseline variable from participants (data not shown).
(␣ ϭ .79) and Control Expectancy (␣ ϭ .76). The primary scales Groups did not differ significantly in mean age in years (treatment can be summarized to form two secondary scales (Primary Ap- group M ϭ 24.8, SD ϭ 2.5; control group M ϭ 24.8, SD ϭ 2.8), praisal, ␣ ϭ .80, and Secondary Appraisal, ␣ ϭ .74). Scales range F(1, 52) ϭ 0.001, p ϭ .98; body mass index (treatment group M ϭ from 1 (very little) to 6 (very much). To be able to assess antici- 22.1, SD ϭ 1.9; control group M ϭ 21.7, SD ϭ 1.7), F(1, 52) ϭ patory cognitive appraisals, the PASA was administered between 0.7, p ϭ .41; or in any of the descriptive and pretreatment psy- the introduction to the TSST and the actual TSST (see Figure 1).
The TSST resulted in a significant cortisol response, time effect (a) regressing the mediator (PASA Primary Appraisal scale) on the F(2.10, 109.41) ϭ 83.51, p Ͻ .001 (Figure 1). Groups showed a independent variable (grouping), (b) regressing the dependent vari- trend to differ in their basal cortisol levels before the TSST, F(1, able (AUCg) on the independent variable (grouping), and (c) 52) ϭ 3.27, p ϭ .07 (Figure 1); therefore, baseline cortisol levels regressing the dependent variable (AUCg) on the independent were treated as covariates in the following repeated measures variable (grouping) and the mediator (PASA Primary Appraisal analysis. Controlling for baseline cortisol levels, which signifi- scale) variable. Results of these regression analyses indicated that cantly influenced cortisol responses over time, Baseline Cortisol all three conditions were needed for the mediation of the primary Level ϫ Time interaction effect F(1, 52) ϭ 10.59, p Ͻ .001, stress appraisal between the grouping and the cortisol responses held in responses over time differed significantly between groups, the predicted direction: (a) The independent variable (grouping) Group ϫ Time Interaction effect F(2.00, 102.33) ϭ 3.81, p ϭ .03, affected the mediator (PASA Primary Appraisal scale), adjusted effect size f 2 ϭ 0.28 (Figure 1), with participants in the treatment R2 ϭ .12, F(1, 51) ϭ 8.16, p ϭ .006, ␤ ϭ 0.37, t(50) ϭ 2.86, p ϭ group showing a lower cortisol response curve. When baseline .006; (b) the independent variable (grouping) affected the depen- cortisol level differences were not controlled for, groups showed a dent variable (AUCg), adjusted R2 ϭ .16, F(1, 51) ϭ 11.12, p ϭ trend to differ in their cortisol stress response over time, Group ϫ .002, ␤ ϭ 0.42, t(50) ϭ 3.34, p ϭ .002; and (c) the mediator Time interaction effect F(2.10, 109.41) ϭ 2.25, p ϭ .10; effect size (PASA Primary Appraisal scale) affected the dependent variable f 2 ϭ 0.22 (Figure 1). Groups differed significantly in the overall (AUCg), and the effect of the independent variable (grouping) is cortisol response, group effect F(1, 52) ϭ 10.83, p ϭ .002, and the lower in the third equation than in the second, adjusted R2 ϭ .22, integrated cortisol responses, as indicated by the AUCg, F(1, F(1, 51) ϭ 8.59, p ϭ .001 (grouping ␤ ϭ 0.31, t(50) ϭ 2.86, p ϭ 52) ϭ 4.41, p ϭ .04, effect size d ϭ 0.83 (Figure 2, left), and .02; PASA Primary Appraisal ␤ ϭ 0.30, t(50) ϭ 2.27, p ϭ .02).
AUCi, F(1, 52) ϭ 11.11, p ϭ .002, effect size d ϭ 0.55 (Figure 2, With regard to the level of perceived stress, groups showed a trend toward differences over time, Group ϫ Time interaction Groups differed significantly in their anticipatory cognitive ap- effect F(1, 49) ϭ 3.5, p ϭ .07, effect size f 2 ϭ .06, with a praisal of the TSST, as assessed by the PASA (see Table 2). To moderate reduction of PSS levels in the treatment group (treatment assess whether group differences in cognitive appraisal of the group: pretreatment M ϭ 22.7, SD ϭ 4.4; posttreatment M ϭ 20.0, TSST (see below) had an influence on the cortisol stress response, SD ϭ 4.5; and control group: pretreatment M ϭ 21.5, SD ϭ 6.6; the PASA scales were included in the calculations as covariates.
posttreatment M ϭ 21.9, SD ϭ 5.1).
Analysis of covariance results indicated that primary stress ap-praisal showed a trend to influence the cortisol stress response, time effect F(2.07, 105.44) ϭ 2.25, p ϭ .10, effect size f 2 ϭ .15.
The inclusion of this psychological factor eliminated the observed This study set out to evaluate the effectiveness of a resource- trend toward significance of group differences in the cortisol focused intervention to reduce psychobiological stress responses in response over time, Group ϫ Time interaction effect F(2.07, healthy participants. Randomization yielded two groups with com- parable baseline stress susceptibility, levels of perceived stress, The possible mediation of the intervention effects on the cortisol depressive symptoms, and personality profile, with the exception response through primary stress appraisal was also tested by the of a single personality scale (the FKK’s Chance Control). Both statistical approach described by Baron and Kenny (1986, p.
groups also had inconspicuous scores on these scales, making it 1177). Therefore, we ran the following three regression equations: unlikely that the participants were particularly stressed or stressprone.
Three months after receiving ZRM training, participants in the treatment group showed a decreased cortisol stress response in thestandardized stress test. As indicated by analysis of covariance andthe regression analyses, the endocrine response differences wereinfluenced by differences in participants’ stress appraisal of thesituation, which was lower in the treatment group than in thecontrol group. The participants trained in ZRM also showed atrend toward a modest reduction in the level of perceived stress.
However, it should be mentioned that study participants had al-ready low levels of perceived stress at baseline, so that chances tofurther diminish perceived stress were restricted.
In summary, the results show that resource-activating self- management training has beneficial effects on the psychobiologi-cal stress response. The results are comparable in direction andmagnitude to those seen in previous studies with similar designsand methods using CBSM techniques but focusing on problem-oriented procedures (Gaab et al., 2003; Hammerfald et al., 2006).
Area under the cortisol response curve in the Trier Social Stress The fact that the treatment had an effect on primary but not Test (means and standard deviations). Treatment group ϭ white bars; secondary appraisal needs to be addressed. From an anatomical control group ϭ black bars; AUCg ϭ area under the response curve withrespect to ground; AUCi ϭ area under the response curve with respect to perspective, psychosocial stress is assumed to be processed through limbic forebrain circuits, with stress-inhibiting inputs from PSYCHONEUROENDOCRINE EFFECTS OF STRESS MANAGEMENT Table 2Group Differences in Anticipatory Cognitive Appraisal in the Trier Social Stress Test PASA ϭ Primary Appraisal Secondary Appraisal Scale.
prefrontal cortex areas and stress-enhancing inputs from the amyg- extrapolated directly to elderly individuals (Kudielka, Buske- dala (Herman et al., 2003). This anatomical differentiation may Kirschbaum, Hellhammer, & Kirschbaum, 2004) or to patient reflect the distinction between implicit, affective evaluation populations with preexisting HPA axis dysregulations (see, e.g., through limbic system areas, such as the amygdala, and the ex- Gaab et al., 2002; Heim et al., 2000). Further studies are clearly plicit, mnemonic functions of the frontal cortex and the hippocam- needed to replicate the reported effects in other populations before pus. In line with these anatomical assumptions, a recent study definite conclusions are drawn. Also, it needs to be noted that the reported the interesting finding that primary appraisal, reflecting described inclusion and exclusion criteria were solely assessed the affective evaluation of a given situation, is an important pre- through self-report. As our study protocol did not include a med- dictor of consecutive cortisol responses, whereas secondary ap- ical examination, we cannot rule out the possibility that study praisal processes were of lesser importance in this regard (Gaab et participants did not meet the described criterion for participation.
al., 2005). The observed differences between primary and second- Second, we did not assess cortisol levels under resting condi- ary appraisal could also be a result of differences in the importance tions. Therefore, we cannot rule out that the response differences of these two aspects of cognitive appraisal. As Slovic, Peters, were caused by preexisting HPA axis differences. Likewise, be- Finucane, and MacGregor (2005) stated, the implicit affective cause cortisol responses in the TSST habituate in the majority of evaluation may serve as a cue for judgment—in our case, for people (Kirschbaum et al., 1995), it was not possible to assess judging a situation as not stressful. Meichenbaum and Fitzpatrick cortisol stress responses before and after the intervention. How- (1993) discussed that primary appraisal is specifically needed in ever, groups did not differ in their baseline cortisol levels before the face of oncoming stressors, whereas secondary appraisal pro- the stress test, but they clearly differed in their total integrated cesses are useful for coping with past stressors. Consequently, to cortisol responses. Furthermore, both groups showed similar proactively buffer people against the stresses of daily life, it may scores on the pretreatment personality and stress scales. For this be crucial to address primary appraisal processes. Here, implicit reason, we are confident that the results are not due to preexisting self-enhancement might be the way to go.
endocrine or psychological differences between treatment and It should be noted that, with regard to possible psychological mediators between the intervention and the observed endocrine Third, we did not include a direct comparison with other treat- responses, we did only assess the results of a seemingly effortful ments, such as CBSM. This makes it difficult to determine what cognitive evaluation process of the oncoming situation. However, treatment component or combination of components, respectively, we did not attempt to assess processes that might have been more was responsible for modification of the cortisol response.
directly related to the type of intervention in use. Here, other Fourth, our findings focus on the TSST, a standardized labora- procedures and approaches need to be addressed in future research.
tory stressor, that has been shown to be a potent and reliable For example, Ellenbogen, Schwartzman, Stewart, and Walker activator of the HPA axis response (Kirschbaum et al., 1993).
(2006) recently reported that effortful and automatic processing However, changes in cortisol levels in response to naturalistic regulate different aspects of the stress response. It would be very daily stressors and negative affect are clearly of a smaller magni- interesting to examine the effect of psychotherapeutic interven- tude (Smyth et al., 1998). Also, there are no studies as yet available tions on these different aspects of stress processing and to study with direct comparisons between the psychobiological stress re- possible differences between different psychotherapeutic ap- sponses to the TSST and to naturalistic daily stressors.
proaches to influence these processes.
The results of this study have implications for future research.
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