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2
 
 

Regardless of whether researchers approach their field of study from a stimulus, response, or
transactional perspective, there is a general recognition that individual differences exist in how
individuals respond to stressful situations (Lazarus and Folkman, 1984; McEwen, 1998).

A striking example of this appeared on television during Hurricane Andrew in which the high
winds leveled two neighbors¶ homes with no loss of life. A news reporter interviewed the
middle-aged fathers from both families who were standing in front of slabs of concrete that were
once their respective Palm Beach houses.

One man was crying profusely, exclaiming that he had lost everything he had worked for all his
life, while the other calmly expressed his thanks that everyone in his family was safe, even the
dog.

Clearly, the stressor was identical for these two men, but their responses, at least the responses
that were captured by the camera, were quite different. Observations like these lead one to
consider individual difference variables that might affect the intensity or pattern of the acute
stress response, and theoretically alter risk for subsequent disease processes. 2





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Some individual difference variables that have been examined regarding their association with
stress responses are listed in Table 3.3. 
2










 


 
 
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For presentation purposes, the individual difference variables

that have been examined in the literature have been grouped
into three categories: demographic or historic developmental
factors that are presumably unchangeable, psychological
variables that could be modified through existing behavioral
interventions, and social variables that could be modified by
changing one¶s environmental context.

Although a comprehensive analysis of each individual

difference variable will not be attempted, representative
references are provided.

Larkin, K. T., Taylor, B. K., Hernandez, D. H., Goodie, J. L., Doyle, A., O'Quinn, S. R.
Published with assistance from the foundation established in memory of Amasa Stone Mather of
the Class of 1907, Yale College.





@? Abel, J. A., and Larkin, K. T. (1991). Assessment of cardiovascular reactivity across laboratory and natural settings. Journal of
Psychosomatic Research, 35, 365 - 373.
@? Achmon, J., Granek, M., Golomb, M., and Hart, J. (1989). Behavioral treatment of essential hypertension: A comparison between
cognitive therapy and biofeedback of heart rate. Psychosomatic Medicine, 51, 152 - 164.
@? Agras, W. S., Horne, M., and Taylor, C. B. (1982). Expectation and the blood-pressure-lowering effects of relaxation. Psychosomatic
Medicine, 44, 389 - 395.
@? Agras, W. S., Taylor, C. B., Kraemer, H. C., Southam, M. A., and Schneider, J. A. (1987). Relaxation training for essential
hypertension at the worksite: II. The poorly controlled hypertensive. Psychosomatic Medicine, 49, 264 - 273.
@? Aivazyan, T. A., Zaitsev, V. P., Khramelashvili, V. V., Golenov, E. V., and Kichkin, V. I. (1988). Psychophysiological interrelations
and reactivity characteristics in hypertensives. Health Psychology, 7, 137 - 144.
@? al'Absi, M., and Wittmers, L. E. (2003). Enhanced adrenocortical responses to stress in hypertension-prone men and women. Annals
of Behavioral Medicine, 25, 52 - 33.
@? Albright, C. L., Winkleby, M. A., Ragland, D. R., Fisher, J., and Syme, S. L. (1992). Job strain and prevalence of hypertension in a
biracial population of urban bus drivers. American Journal of Public Health, 82, 984 - 989.
@? Davidyan, A. (1989). Emotional factors in essential hypertension. Psychosomatic Medicine, 55, 505 - 517.
@? Alfredsson, L., Davidyan, A., Fransson, E., de Faire, U., Hallqvist, J., Knutsson, A., et al. (2002). Job strain and major risk factors for
coronary heart disease among employed males and females in a Swedish study on work, lipids, and fibrinogen. Scandinavian Journal
of Work, Environment and Health, 28, 238 - 248.

? ?
oth clinical experience and the results of research demonstrate that older adults vary considerably
in the impact that stress has upon well-being. Stress-process models have identified a number of
factors that may decrease the negative impacts of stressors, including appraisals, internal and
external resources, and coping responses. These may be thought of as factors that can protect a
person from the negative consequences of stress. From the perspective of a stress-process model,
the experience of stress may be seen as a µµbalancing act¶¶ between stressors and resources. High
levels of stressors, with few resources, will place individuals at high risk, while individuals with
substantial psychological or social resources may be less vulnerable.

Depending on the mechanism through which variables affect the relationship between stressors
and well-being, these responses and resources may have direct effects, or they may serve as
either î  or î  of the relationship between stressors and well-being. In a direct
effect, people with a high level of a resource (such as income) may be found to have higher well-
being regardless of whether highly stressful circumstances occur. A moderator variable, on the
other hand, may confer either risk or protection only on individuals facing a high level of stress.
For example, research on the stress-buffering hypothesis suggests that under circumstances of
high stress, individuals with strong social support may be at lower risk for depression than
individuals with weaker social support, but that social support may matter little under conditions
of low stress. In other words, the moderator model tests the significance of interactions among
independent variables in predicting outcome. A mediator functions as an intermediate factor
between stress and well-being; for example, research may find that a life event only affects
depression if is subsequently appraised as a threat to well-being. Identification of these
mechanisms of vulnerability and resistance to stress may be very useful in targeting interventions
that may be helpful when a life event occurs.

Early writers who addressed coping in older persons tended to view older adults as unable to
cope with stress, and they suggested that coping in late life was characterized by rigidity in
coping mechanisms, and even regression. Contrary to these early speculations, older adults are
often found to cope with stress as well as, if not more successfully than, younger individuals, due
in part to the benefits of life experience. Older persons often face stressors that are expected, and
they have either coped successfully with such stresses themselves or seen their peers cope with
common late-life stressors.

    
 Appraisal is a subjective judgment about the nature of a stressor. It reflects
individual variations in how people perceive and interpret their events or circumstances. One
widely studied type of appraisal is pîpp which is the perception of the degree of
threat, harm, or challenge represented by potentially stressful life events. Research on family
caregivers of patients with Alzheimer¶s disease has shown that, even after controlling for the
objective stressors of caregiving, subjective primary appraisals are important factors predicting
care-giver depression.

In addition to primary appraisals, appraisals of self-efficacy, or one¶s ability manage a stressor,

can be important factors in successful coping. Other appraisals that have been studied include
perceptions of the predictability or controllability of a stressor. A relatively recent innovation in
stress-process research is the study of positive appraisals. Contrary to earlier research that
focused only on the negative impacts of stress, it has been increasingly found that individuals
undergoing stress may report benefits and positive experiences. For example, people may find
meaning in adversity, or stress may provide a way to strengthen relationships or develop spiritual
growth. The ability to appraise stress as being a challenge or growth experience, and to identify
positive aspects of stress, may be a major asset in coping.

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The consideration of appraisal as a variable has led researchers to go beyond the assumption that
stressors can be quantified regarding their relative stressfulness, and to study individual
differences in appraisal of stress. For example, the death of a spouse after a long and painful
illness may be experienced quite differently than a sudden, unexpected death. A financial stress
may be appraised as less threatening by an individual with substantial financial resources. Thus,
assessment of the occurrence of life events may be less informative than the personal appraisal of
such events in evaluating the potential impact on depression or life satisfaction. Despite
important theoretical distinctions between occurrence and appraisals of life events, subjective
appraisals of the impact of life events in older adults have received much less attention than
studies viewing stressors as objective experiences.

In terms of age differences in the appraisal process, older adults are more likely to perceive their
situations as unchangeable, but they are also more likely to face situations that are objectively
difficult to change. As discussed below, an appraisal of the changeability of a stressor is an
important predictor of the type of coping response utilized.

c 
 

 Individuals¶ psychological resources constitute an important domain of
individual differences in the stress process. Psychological resources include the personality
characteristics that people draw upon to respond to stress. Research has demonstrated that
psychological resources have great effects on how individuals perceive stressors and how
stressors manifest themselves. Some positive personality traits such as optimism, self-esteem,
internal locus of control, and mastery²and more negative traits such as neuroticism²have been
shown to affect appraisal and choice of coping responses. For example, neurotic individuals are
likely to focus on negative aspects of stressors, while optimists are more likely to view stress as a
challenge and to cope positively.

As of 2002, there has been increasing interest in the role of spiritual beliefs and religious
participation as factors promoting successful coping, although few studies of this topic have been
completed. Results suggest that religious or spiritual beliefs and religious participation may
improve coping with a variety of stressors. Possible mechanisms for such effects include aiding
people in finding meaning in the face of adversity, and allowing access to a social support
network including clergy and others in the faith.

#-
 

 Besides internal sources of coping, such external factors as economic
resources or social resources may be valuable aids in dealing with stress. Higher socioeconomic
status and income are often found to be protective factors in studies of stress, because financial
resources can be used to provide concrete assistance such as transportation, medical care, and
optimal housing arrangements. Other important external resources include social networks and
social supports. Social networks are comprised of individuals with whom an older person can
interact, and they represent potential sources of assistance. Social support refers to the actual
receipt of some emotional, tangible, or informational help from others, and the subjective
perceptions of support. Numerous studies have confirmed that social resources play important
roles in improving life satisfaction and well-being Studies indicate that individuals with strong
social networks and social support are often in better physical and mental health.

Read more: Stress and Coping - Individual Differences In Coping With Stress - Age, Social,
Clinical, Resources, Stressors, Social, Life, Individuals, and Appraisal
http://medicine.jrank.org/pages/1666/Stress-Coping-Individual-differences-in-coping-with-
stress.html#ixzz1BO7ylUYr
? ?
^


 

 

0


º.
There is increasing evidence that stressors contribute to the severity of chronic

inflammatory diseases such as psoriasis. However, much less is known about possible individual
differences between patients in their stress reactivity, particularly the role of cognitive and
behavioural factors, such as the role of worrying or scratching behaviour, in reaction to itch.
/0

To investigate the direct and moderating role of individual stress reactivity factors,
particularly of cognitive and behavioural patterns of worrying and scratching, on the relationship
between daily stressors and changes in disease severity [Psoriasis Area and Severity Index
(PASI)] and itch in patients with psoriasis.
!
 
Patients were followed for 6 months through monthly clinical and self-reported
measures of daily stressors, itch, disease severity and individual reactivity factors. Data from 62
patients were suitable for analysis.

 Cognitive and behavioural patterns of worrying and scratching were both independently
related to an increase 4 weeks later in disease severity (PASI) and itch, at moments when
patients experienced a high level of daily stressors. At these moments, stressors also interacted
with vulnerability factors, showing that patients with more daily stress and high worrying and
scratching had particularly worsened disease severity and itch.
1   Patients with high levels of worrying and scratching are most vulnerable to the
impact of stressors on their psoriasis, particularly at highly stressful periods.

c  
 

Many patients with psoriasis believe that there is a relationship between stressors and their skin
disease.[1±7] For example, over 60% of patients with psoriasis retrospectively report having
experienced stressful life events in the month before exacerbation of the disease.[8±10] As one of
the first prospective studies we previously showed that daily stressors were related to an increase
4 weeks later in disease severity and itch in psoriasis.[11] However, relationships between daily
stressors and changes in disease severity were moderate, and individual patient characteristics of
stress reactivity may play a role in moderating this relationship.[1,12] For example, patients with
psoriasis who consider themselves highly reactive to stressful life events or to their disease have
higher scores on measures of disease outcome and have lower cortisol levels after an
experimentally induced stressful experience than patients who do not believe themselves to be
highly reactive to stress.[5,7,13] Patients might consequently differ in their reactivity to stressful
events and in the related physiological stress response, which may influence the disease-related
outcome.

The reactivity of patients to stressors can be distinguished according to at least two main
components of cognitive and behavioural aspects. Perseverative worrying, a cognitive response,
is a common response to stressful events and has been reported to prolong stress-related affective
and physiological activation of, for example, the endocrine and immune system.[14]
Consequently, worrying could influence physical well-being through several psychological and
physiological pathways. In patients with psoriasis worrying has indeed been shown to affect
disease severity and itch negatively, particularly in patients with high levels of worrying.[15±17]
Additionally, scratching in response to itch is a particularly important feature of skin diseases
accompanied by itch, as is reflected by the definition of itch as an unpleasant sensation that
evokes the desire to scratch.[12,18] Although early textbooks described psoriasis as a nonitching
skin disease, more recent data showed that approximately 60±80% of all patients with psoriasis
report experiencing itch,[6,19,20] with the highest percentage found among patients seen in
dermatological wards.[6] The immediate reinforcement of scratching is the reduction of itch,
although patients with enduring itch frequently persist in their scratching behaviour even until
the skin bleeds, resulting in a vicious itch-scratch-itch cycle. Due to this vicious cycle, scratching
frequently becomes a problem in its own right. Moreover, scratching induces several
physiological responses, such as the secretion of several immunological markers, for example
interferon-Ȗ, which has been described to mediate the disease severity of psoriasis.[6,12]
Consequently, cognitive and behavioural reactivity of specifically worrying or scratching could
directly affect the disease outcome of chronic skin diseases. Additionally, these reactivity factors
might also influence the relationship between daily stressors and disease outcome.

In order to investigate the possible role of individual reactivity factors for the disease outcome on
psoriasis, the aim of the current study was to examine the relationship of individual cognitive and
behavioural reactivity factors (specifically worrying and scratching) on the change in psoriasis
disease severity and itch 4 weeks later in a prospective design with monthly repeated
measurements over a 6-month period. As we have previously shown that daily stressors affected
the course of disease severity and itch at moments when patients experienced a high level of
daily stressors,[12] we expected that individual cognitive and behavioural reactivity factors
(worrying and scratching) would be positively associated with the change in disease severity and
itch at moments of high stress.


 
  

£

 
 £ 

Patients were recruited from the Departments of Dermatology at the University Medical Centre
St Radboud, Nijmegen and the Canisius Wilhelmina Hospital, Nijmegen, the Netherlands.
Inclusion criteria were a diagnosis of psoriasis, a minimum age of 18 years and a stable
medication regimen in the 3 months prior to the start of the study (no change in the type of
systemic medication or start of phototherapy). Exclusion criteria were comorbid conditions (such
as rheumatoid arthritis, psoriatic arthritis, malignancy, cardiac, respiratory and renal
insufficiency), pregnancy and psychiatric or mental disturbances that would severely interfere
with adherence to the study protocol. Patients who used antidepressant medication were also
excluded. Patients whose medication regimen (type of systemic medication or start of
phototherapy) changed during the study were also excluded. Participants were followed up over
6 months through monthly clinical and self-reported measures of disease severity [Psoriasis Area
and Severity Index (PASI)], itch, daily stressors and individual reactivity factors, except for
seven patients who stopped the study after 4 months due to changes in medication regimen (five
due to a change in systemic medication, one due to the start of antidepressant, one due to the start
of phototherapy).
Ô




 
were assessed using a general checklist for age, gender and educational
level. The latter was measured using seven categories that can be classified as primary,
secondary and tertiary levels of education, representing on average 7, 12 and 17 years of formal
education.



/
were assessed with measures of   
 and  . Disease severity
was assessed with the PASI.[21] Itch was assessed with the validated four-item scale from the
Impact of Chronic Skin Disease on Daily Life (ISDL) questionnaire, which assesses the severity
and frequency of itching during the past 4 weeks.[22] The scale includes the following items with
response categories on a four-point Likert scale: 'My skin disease has been accompanied by itch
during the past 4 weeks', 'I have had itch attacks during the past 4 weeks' and 'I suffered
continuously from itch during the past 4 weeks'. The mean level of itch in the past 4 weeks was
measured on a visual analogue scale (VAS; 0 = no itching; 10 = worst itching ever experienced).
The total itch score was calculated by adding together the scores on all four items, after
converting the score of the VAS to a four-point scale.


 were assessed with a short 49-item version of the Everyday Problem
Checklist.[23,24] This validated questionnaire includes items such as 'You had to wait a long time
for an appointment', 'You blundered in company' or 'Important belongings got lost'. When
patients answered that they experienced an event, they indicated the intensity of this event,
ranging from 0 (no impact at all) to 3 (very high impact). The total score for daily stressors
experienced was calculated by summation.

1 

º

 were assessed with validated self-reported
questionnaires. The cognitive factor of worrying was measured with an adapted version of the
Pain Coping Inventory, in which the term 'pain' was replaced by 'itch'.[16,25] This instrument
measures different ways of dealing with symptoms of itch on a four-point Likert scale ranging
from 1 (rarely or never) to 4 (very frequently). Worrying was measured using a nine-item scale
measuring negative disease cognitions. Items on this scale ask patients, for example, how often
they worry about their itch. A representative item is 'I think that the itch of my psoriasis will get
worse'. Scratching was assessed through the scratching scale of the ISDL.[22] This scale
determines the amount of scratching during the previous 4 weeks on a four-point Likert scale
using the following items: 'I scratched during the past 4 weeks', 'I scratched myself with my nails
in the past 4 weeks' (ranging from 'rarely' to 'almost always') and 'The longest time I
continuously scratched myself' ('less than half a minute' to 'more than 5 minutes'). The total
scratching score was calculated by adding up the scores on all three items.

a





In order to investigate the possible influence of individual reactivity factors, prospective

relationships between individual reactivity factors and changes in disease outcome 4 weeks later
were examined at the different monthly assessment points, by calculating Pearson correlation
coefficients between the individual reactivity factors of worrying and scratching and the change
in measures of disease outcome (PASI disease severity and itch). In addition, the month with the
highest level of daily stressors experienced was determined for each participant. Residual gain
scores were used to measure the change in PASI and itch. These scores take into account the
individual baseline levels and control for regression to the mean effects.[26] Residual gain scores
were calculated by regressing the outcome measure (e.g. PASI score) at the follow-up
assessment after 4 weeks on the score of this measure at the previous month. Moreover, in order
to examine the role of these individual reactivity factors on the relationship between daily
stressors and changes in disease outcome, centred interaction terms between the predictor
(experience of daily stressors) and reactivity factors (cognitive and behavioural factors of
worrying and scratching) were calculated.[27] Next, we determined the Pearson correlation
coefficients between these interaction terms and the change in disease severity and itch. Finally,
sequential regression analyses were conducted to get an indication about the relative contribution
of the predictors. All statistical analyses were carried out with the SPSS 14.0 for Windows
statistical package (SPSS, Chicago, IL, U.S.A.) with a complete data set of at least 95% of all
assessments.