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Is cortisol an effective measure of stress for pre and post task performance?

Is cortisol an effective measure of stress for pre and post task performance?

I have a teleoperation system and I want to see how much stress a person is under before during and after operating it. I thought cortisol would be a correlate of stress. Can I measure levels rapidly, say over minutes, and detect an appreciable difference?

Is there a better way? How?


I don't think measuring serum cortisol levels would be a great method of testing for stress. It is expensive, painful, and the results are difficult to interpret. Salivary levels might be better, but this would also be expensive.

To actually determine the effect of stress on cortisol levels, you would need to control for variables including (but not limited to): age, gender, sex steroid levels, pregnancy, lactation, smoking, coffee and alcohol use, diet, level of exercise, genetic factors and habituation to repeated psychosocial stress exposures.[1]

An easier and less costly method would be before and after blood pressure and heart rate measurements.

[1] Why do we respond so differently? Reviewing determinants of human salivary cortisol responses to challenge? Psychoneuroendocrinology Volume 34, Issue 1, January 2009, Pages 2-18


Parenting, Cortisol, and Risky Behaviors in Emerging Adulthood: Diverging Patterns for Males and Females

Parenting behaviors in early development are associated with risk-taking behaviors in emerging adulthood. Risky behaviors are also shown to be associated with cortisol response to stressors. This study examined the moderating effect of neuroendocrine response to stressors on the link between parenting behaviors in early development and risky behaviors in emerging adulthood.

Methods

Participants were 78 healthy college students (38 males). Following a habituation session, participants completed a modified version of the Trier Social Stress Task prior to completing measures of risky behavior. Salivary cortisol was measured before the stressor, 20, and 40 min post-stressor.

Results

Parenting behaviors and cortisol response to stressor were seen to be linked risky behavior. For males, the link between harsh father behaviors and risky behavior was significantly moderated by cortisol response to stressor such that higher cortisol response was related to decreased risky behaviors. For females, risk-taking was associated with harsh and warm parenting behaviors, but the link between parenting and risky behaviors was not related to or moderated by cortisol response.

Conclusions

These results provide evidence that parents might have separate effect on predicting risky behaviors and provides support for literature that chronic stressors can influence sensitivity to acute stressors and subsequent risk-taking behaviors.


Discussion

Here, we aimed to investigate the protective power of a short humorous intervention against psychological and physiological stress and its subsequent impact on cognitive performance, more specifically on attention. With respect to the first research question, our results confirm the hypothesized beneficial role of humor. Watching funny video clips attenuates psychological stress as well as cortisol levels in the absence of evidence of physiological stress. These findings are in line with previously reported ones, although the current study differs in three important aspects from earlier research. First, we specifically targeted the question whether humor could shield against future stress. This required the humorous intervention to naturally precede the stressful event. In previous studies stress induction usually took place before the humorous intervention 6 or concurrently 5 but 4 . Second, we put emphasis on a very short intervention that is easily applicable in everyday life. Third, most studies investigating humor and stress assess stress solely psychologically, i.e., subjects were asked for anxiety ratings or ratings on daily stressors or hassles 3,6 . Only some of these studies additionally obtained data on physiological stress, with an emphasis on markers affecting the nervous system, such as heart rate, skin conductance response or blood pressure (or a combination of those) 5,8 . They consistently reported a decrease in these variables in the humor condition, however, only Newman & Stone 5 induced a specific physiological stress response whereas Rizollo and colleagues 8 looked at general physiological stress levels. By observing an attenuation of cortisol levels in the humor condition, we found a similar decrease in physiological stress markers, yet despite successfully evoking psychological stress, we were not able to provide evidence for a physiological stress response. This may be less surprising than it seems. Firstly, perceived stress and physiological stress levels can be only little to moderately associated given the complexity of the neurobiological processes involved 29 . Secondly, our measurement time points of salivary cortisol were chosen in accordance with other studies investigating physiological stress responses e.g. 25 and to examine whether cortisol levels from the humor group return faster to baseline levels than those of the control group. Therefore, we might have missed the optimal time point to measure peak cortisol levels, which possibly explains why we did not observe an increase in physiological stress levels following the stress induction phase. Similar to the decrease in physiological stress markers, Martin & Dobbins 3 found sense of humor to moderate immunosuppressive effects of stress. In the present study, physiological stress was operationalized by inspecting the change in salivary cortisol levels. Cortisol has been proven to reliably indicate stress levels 1,30 , and has been called the “method of choice” when assessing cortisol effects in stress research 29 . A combination of markers tapping into the nervous, the immune as well as the endocrinological stress responses would allow future research, for instance via latent change modelling, to even further specify the impact of humor on the specific physiological stress markers.

Interestingly, we found no group differences in trait anxiety and sense of humor, indicating that the observed effects on psychological stress and cortisol levels are rather likely driven by the humorous vs. control intervention. Contrary to previous studies, we did not observe group differences in state anxiety, which could be due to different experimental designs, particularly due to the order of stressful and humorous events 6 or to the absence of a stress induction phase 7 . In line with that thought, participants of the present study completed the questionnaires at the end of the study, i.e., there was a considerable lapse of time compared to previous studies. However, how precisely timing affects the relationship of humor and stress should be subject to further research.

Our results show that humor protects against psychological stress and effectively attenuates salivary cortisol levels, however, it is still unclear why participants may benefit from a humorous intervention. Although our study was not explicitly designed to investigate the underlying mechanisms systematically, a closer examination of our results regarding pain tolerance might give a hint. We observed higher levels of pain tolerance in the humor compared to the control group thus replicating earlier results 9,31 . Yet, comparable findings have been reported when subjects saw sad or dramatic clips, or listened to their favorite music. Therefore, these authors concluded, that it is not the humorous intervention per se, that has the beneficial effect, but rather the distraction it provides 10 . Additionally, since in our design the humorous intervention precedes the stressful event, carry-over effects may also play an important role. Furthermore, we do not know whether and how participants actively utilized humor to strategically cope with the stressor. Within the frame of the present study, we can neither conclusively confirm or negate the distraction hypothesis, the possibility of carry-over effects nor the active utilization of humor to build up resilience. Yet, it is conceivable, that the protective effect of humor on stress is based on similar mechanisms. Nonetheless, even though psychological stress and cortisol levels are reduced by humor, the underlying neural and cognitive mechanisms may still be different. Consistent with previous research reporting only moderate associations between the two kind of stress levels 29 , the change in psychological and physiological did not correlate in the present study. Future research is needed to not only further investigate the underlying mechanisms of the beneficial effect of humor on stress but also to discern whether humor impacts psychological and physiological stress in a similar manner.

Regarding the second research aim of the paper and contrary to our expectations, we found no reliable effect of humor on attention, neither in response times nor in accuracy rates. Likewise, further analyses investigating possible effects of changes in psychological and salivary cortisol levels due to the beneficial effects of humor yielded null effects as well. As positive emotions have been found to broaden the scope of attention in global–local visual attention tasks, we hypothesized to observe a similar effect in the humor group compared to the control one 16 . What we have found instead, is a successful attenuation of psychological stress and cortisol levels in the humor group without simultaneously impacting cognitive performance. A number of reasons may account for these results. First, the visual search task we employed was specifically designed to test the participants’ ability to integrate global features 19,20,21,22 as we solely induced positive emotion. The stimuli themselves as well as the number of stimuli is thus different to the global–local visual attention tasks previously used 16 . We can only speculate whether these differences led to varying degrees of complexity, which in turn not only tapped visual attention but also further cognitive domains. The relatively large number of erroneous and null responses may substantiate this assumption. We strongly encourage future research to use tasks, which both differentiate between perceptual and cognitive processes and further address different levels of complexity when investigating the effect of humor on cognition and perception. Second, with the humorous clip being rated funnier than the control clip, the present study was able to successfully induce humor in one group of participants. However, an exploratory analysis of individual funniness ratings within this humor group showed that the funnier these individuals rated the movie, the less accurate they performed in the visual search task. Interestingly, this finding is contrary to our predictions and leaves ample room for speculation. For instance, individuals that rated the movie clip as funnier, may have engaged more strongly with the film, thus showing a higher motivational intensity 32 , a concept closely related to valence and arousal 33 . As has been argued for humor and pain, it may be the level of arousal that drives the distraction effect 9 . Consequently, a comparable mechanism may account for the observed relationship between funniness ratings and accuracy rates within the humor group of the present study. Similarly, the higher the motivational intensity, the narrower the scope of attention 32 , which in turn would promote rather local than global processing strategies for those most involved. In fact, this is the pattern, we observed within the humor group. However, it needs to be pointed out, that at the group level no such differences were found, neither for accuracy rates nor on response times. Whether the result of our exploratory analysis accounts for a genuine or rather spurious effect remains an open question and demands further investigation. Likewise, the roles of motivational intensity and arousal, respectively, deserve additional attention. Finally, due to technical failure, all analyses regarding psychological stress were carried out with only 39 participants. Clearly, a larger sample may have yielded different results.

In conclusion, the present study clearly demonstrates the beneficial effects of a short humorous intervention on the psychological and physiological perception of subsequent stressful event. To our knowledge, it is the first study to have done so, extending findings from stress responses relating to the nervous as well as the immune system to those of the endocrine system. Yet, the exact nature of how humor affects psychological and physiological stress in detail are still subject to further research. While being beneficial for attenuating stress and cortisol levels, humor was found to have had no impact on cognitive performance, specifically on visual attention. On the surface, this may contradict assumptions of the broaden-and-build theory, yet results of an exploratory analysis point towards influential roles of motivational intensity and arousal, respectively. Taken together, a short humorous intervention can be a powerful instrument, improving our mental and physical health—not just on the way to the job interview but in many other situations of everyday life.


The Use of Testosterone/Cortisol Ratio in Response to Acute Stress as an Indicator of Propensity to Anger in Informal Caregivers

Caring for an offspring diagnosed with a psychological chronic disorder is used in research as a model of chronic stress. Indeed, it is usually associated with disturbances in the salivary cortisol (Csal) levels of the caregiver. An imbalance between salivary testosterone (Tsal) and Csal levels is a marker of proneness to social aggression. Given this, we aimed to establish whether the salivary testosterone/cortisol (Tsal/Csal) ratio response to acute stress could be employed as a marker of proneness to anger in informal caregivers of offspring with autism spectrum (ASD). Tsal/Csal ratio and anger responses to a set of different cognitive tasks as well as anger trait and expression were compared in these informal caregivers and controls. Caregivers, particularly those of offspring with ASD, had higher Tsal/Csal ratios than controls in response to acute stress, concretely after the stress in the case of fathers ( p = .05) and before stress when analyzing mothers ( p = .05). Moreover, ASD fathers and mothers obtained higher magnitude of the T/C ratio response to stress ( p = .03 and p =.04, respectively), anger state ( p = .02 and p = .02, respectively) and expression scores ( p = .05 and p = .05, respectively) than controls. Finally, high Tsal/Csal ratio levels and response to stress were significantly associated with high anger feelings increases ( p < .01 and p < .001, respectively), trait ( p < .001 and p > .05, respectively) and expression ( p < .05 and p > .05, respectively) in caregivers.


The Influence of Cortisol, Flow, and Anxiety on Performance in E-Sports: A Field Study

Background and Objectives. Most performance theories were tested under controlled laboratory settings and offer therefore only limited transferability to real-life situations. E-sport competitions offer a relatively controllable while at the same time competitive setting, and our aim was to examine different influencing factors on competitive performance. Design and Methods. Salivary cortisol was measured immediately before, after, and 30 minutes after a game of 23 computer players during e-sport tournaments. The players answered the Flow Short Scale, which consists of the two subdimensions “flow experience” and “anxiety” subsequent to their game. The performance was assessed by the result of each player’s game (win or loss). Results. Mean cortisol levels increased significantly during the game but response patterns were inconsistent. Winners and losers differed significantly in anxiety with winners showing higher anxiety levels. After dividing the sample into three groups of different cortisol response patterns, significant differences in performance and anxiety were found, with low to moderate levels of cortisol being associated with the highest performance and anxiety. Conclusions. A low to moderate physiological arousal and a simultaneously high level of anxiety represent a favorable state for achieving optimal performance during e-sports. Anxiety seems to exert a stronger influence on performance than physiological arousal.

1. Introduction

The history of theories and models which try to explain the relationship between performance and different influencing factors dates back to the time when Yerkes and Dodson first published their model of an inverted U-shaped relationship between arousal and performance [1]. According to this model, optimal performance should be given when arousal was at a moderate level [1]. When arousal is too low or too high, performance will be inferior [1]. For example, Arent and Landers [2] could clearly demonstrate that the relationship between physiological arousal and performance in a simple response time task followed the proposed inverted U-shaped function.

A further theory ascribing an optimal level of performance to a moderate level of arousal is the flow theory [3–5]. When in a flow state, an individual is able to access its maximal potential and perform at full capacity, while perceiving an optimal level of challenge and arousal without sensed stress [5, 6]. To enter the flow state, two critical prerequisites must be given: (1) an opportunity for action that is perceived as a challenge which engages the person’s full skill level (i.e., neither an overload nor an underload) and (2) clear proximal goals and immediate feedback about the progress of goal achievement [6]. Therefore, an important prerequisite for flow is that the task demands are not beyond the person’s perceived skills or capabilities [7]. Studies that examined the relationship between markers of physiological arousal and certain aspects of the flow experience predominantly found that a moderate level of physiological arousal corresponds with the highest level of flow experience, resulting in an inverted U-shaped relationship between physiological arousal and flow. For example, Peifer et al. [8] found an inverted U-shaped relationship between physiological arousal (i.e., cortisol and heart rate variability) and flow experience in terms of flow absorption (i.e., being completely immersed in the activity) during a computer task, with moderate levels of physiological arousal correlating with the highest flow levels. Another study could prove that during chess play the highest flow state or flow experience (i.e., flow absorption) correlates with a moderate level of physiological arousal (i.e., cortisol), showing an inverted U-shaped relationship [9]. Furthermore, Tian and colleagues [10] could show that moderate physiological arousal (i.e., heart rate, heart rate variability, and skin conductance) correlates with the highest flow experience, also demonstrating an inverted U-shaped relationship between physiological arousal and flow during playing computer games. In contrast, Keller et al. [11] found that during computer tasks the highest level of physiological arousal (i.e., heart rate variability, and cortisol) corresponds with the highest level of flow experience (i.e., skill-demand-compatibility). However, the problem with these studies is that they are conducted under controlled laboratory conditions and mainly used tasks that were artificially manipulated so that the flow was taken as given when subjects perceived a high level of skill-demand-compatibility. Consequently, group comparisons were almost exclusively done by comparing subjects of different skill-demand-compatibility levels.

A more sophisticated model, which also proposes an optimal relationship between physiological arousal and performance, is the catastrophe model of anxiety and performance [12], which adds anxiety as a further influencing factor of performance. According to this model, the optimal level of performance depends on the interaction of physiological arousal and cognitive anxiety [7]. An increase in cognitive anxiety leads to an enhanced performance when at the same time physiological arousal is low to moderate, but it impairs performance when physiological arousal is high [7]. Furthermore, performance can suddenly drop from a high level to a low level when cognitive anxiety is high and physiological arousal increases, resulting in a performance catastrophe [7]. Thus, optimal performance can be achieved at a high level of cognitive anxiety and a simultaneously low to moderate level of physiological arousal during flow.

Only a few studies have investigated the relationship between physiological arousal, anxiety, flow, and performance at the same time. For example, Hardy and Parfitt [13] found that performances of basketball players were highest during states of high anxiety and low to moderate physiological arousal. Bowlers achieved their best performance in a high anxiety state while being low to moderately physiologically aroused [14]. Furthermore, rock climbers performed better when they were physiologically aroused and when they were anxious compared to when they were not [15]. Duncan et al. [16] found that performance in an anticipation timing test was not negatively affected by high physiological arousal when cognitive anxiety was low, but it deteriorated under high cognitive anxiety and simultaneously high physiological arousal. Of note, in most of these studies, physiological arousal was induced by physical exertion and anxiety was artificially manipulated.

The results of hitherto conducted laboratory studies are not transferable to real-life situations without further ado. To the best of our knowledge, no study has yet explicitly tested these three models and theories under uncontrolled real-life conditions. Hence, we wanted to measure physiological arousal, flow experience, and anxiety as well as the performance itself during a real-life competitive situation without artificially manipulating the underlying conditions (i.e., skill-demand-compatibility, physiological arousal, and anxiety). Therefore, we chose a computer game event, where computer players competed against each other for placement and prices, as an appropriate real-life condition. We hypothesized that (1) playing a computer game during a real-life competition elicits a marked increase in physiological arousal compared to the baseline conditions before the game (cf. [17–19]), (2) winners and losers differ in physiological arousal, flow experience, and anxiety, (3) the relationship between physiological arousal and performance follows an inverted U-form, with moderate levels of physiological arousal corresponding to the best performance (cf. [1, 2]), and (4) the relationship between physiological arousal, anxiety, and performance parallels the catastrophe model of anxiety and performance, with low to moderate levels of physiological arousal and simultaneously high levels of anxiety corresponding to the best performance (cf. [7, 13, 14]).

2. Materials and Methods

2.1. Participants

The participants were informed about the applied procedures in oral and written forms. All participants gave their written informed consent before participating voluntarily in the study. Participants were free to withdraw from the study at any time without further consequences. The study was conducted in accordance with the Declaration of Helsinki [20] and was approved by the internal review board of the conducting institution. Exclusion criteria for participation in this study were mental health problems and treatment with glucocorticoids due to their impact on measures of interest. At the time of data collection, all participants were in good health and free of any physical and mental complaints. The sample consisted of 19 male and 4 female participants. The characteristics of the participants are displayed in Table 1.

2.2. Experimental Approach and Procedure

Playing video games has been found to significantly increase physiological arousal [19]. This effect should be further enhanced by the competitive setting, as competitions have been shown to induce an increase in physiological arousal and anxiety [17] as well as flow [21]. The tournaments took place in the evening between 9 p.m. and 2 a.m. Players could choose between different tournaments in different games (League of Legends and Counter-Strike: Global Offensive). League of Legends is a strategy game in the MOBA (Multiplayer Online Battle Arena) genre and Counter-Strike: Global Offensive is a tactical shooter game, both applying tactical and precision pressure in a real-time setting on the players. The average duration of a player’s game was 35 ± 22 minutes. We measured the physiological arousal of the players by collecting cortisol saliva samples since cortisol has been shown to be a valid marker of physiological arousal due to a stress-induced increased activity of the hypothalamus-pituitary-adrenal axis [22, 23]. Baseline cortisol levels were measured immediately before the start of a player’s game, immediately after the completion of the game, and 30 minutes afterward. Flow experience and anxiety were assessed using the Flow Short Scale, a questionnaire consisting of two subdimensions that measure flow experience and anxiety individually [24, 25]. The players answered the Flow Short Scale immediately upon ending their game.

2.3. Measurements and Instruments
2.3.1. Cortisol

Saliva samples were taken using Salivette® (Sarstedt AG & Co., Nümbrecht, Germany), a synthetic fiber roll, on which the participants had to chew for one minute. After chewing, the saliva samples were put in the plastic container of the Salivette® and stored at −20°C until analysis. Cortisol was analyzed using the Cobas© e 411 analyzer (Roche Diagnostics Germany GmbH, Mannheim, Germany) and applying the electrochemiluminescence technology. Every sample was analyzed in duplicate, and the mean value was then used for the data analysis. Since cortisol levels show a delayed increase in saliva [23, 26], we collected a first postgame saliva sample immediately after the game and a second postgame saliva sample 30 minutes after the completion of the game to capture the stress-induced cortisol peak. We then took the higher one of the two postgame values as cortisol peak for further analysis. However, besides a general cortisol increase from baseline to postgame, our data also showed a cortisol decrease from baseline to postgame in certain subjects. In this case, we took the lower one of the two postgame values as cortisol nadir for further analysis. The participants were instructed not to eat, smoke, drink alcohol or coffee, and refrain from physical activities from one hour prior to their game until the second postgame saliva sample to exclude any influences on cortisol release [27].

2.3.2. Flow Experience and Anxiety

We measured flow experience and anxiety with the Flow Short Scale [24, 25]. Assessing both flow and anxiety is important as flow-inducing challenges are often accompanied by feelings of anxiety or worry [25]. The Flow Short Scale consists of the two subdimensions “flow experience” and “anxiety.” Flow experience is assessed with ten items that cover all the abovementioned components of the flow experience (Cronbach’s α = 0.90), whereas anxiety is assessed with three items (Cronbach’s α = 0.80–0.90 [25]). All items are measured on a seven-point Likert scale ranging from 1 to 7. Although flow experience can be further divided into the two factors “absorption” and “fluency,” we operated only with the overall score for flow experience. This is legitimated by the high consistency of the ten flow items.

2.3.3. Performance

The performance of the computer players was assessed by the result of each player’s game (i.e., win or defeat). The performance of the different cortisol response groups is then expressed as the ratio of won and lost games among all players in that group.

2.4. Data Analysis and Statistics

In order to investigate the difference between baseline and postgame cortisol levels, we calculated a Wilcoxon signed-rank test, since cortisol values were not normally distributed. To compare winners and losers concerning their physiological arousal, flow experience, and anxiety, unpaired t-tests were used. We divided the whole sample into three groups, depending on their cortisol response pattern from baseline to postgame (i.e., cortisol decrease (n = 6 −3.1 to −0.3 nmol/l), low to moderate cortisol increase (n = 10 +0.4 to +5.3 nmol/l), and high cortisol increase (n = 7 +10.6 to +13.2 nmol/l)). The two groups showing a cortisol increase were divided at the mean. The groups were then compared concerning their flow experience and anxiety levels using one-way ANOVA. We adjusted the significance level for the post hoc tests using Bonferroni corrections to account for multiple tests with the same sample. The level of significance was set at

for the two-sided tests. Effect sizes were calculated as Cohen’s d for the t-tests and the Wilcoxon signed-rank test and as partial eta-squared (

) for ANOVA. All analyses and statistics were performed with the IBM SPSS Statistics 24 software (IBM Corp., Armonk, USA).

3. Results

The average cortisol level of all participants increased significantly from baseline to postgame conditions, demonstrating a strong effect and constituting a marked physiological arousal (3.5 ± 2.2 versus 7.7 ± 6.3 nmol/l z = −2.95,

Winners and losers only differed significantly concerning their anxiety level (t = 3.80, , d = 1.58), with winners showing higher anxiety levels (5.5 ± 1.6 versus 3.2 ± 1.3). Concerning cortisol and flow levels, the differences were not significant (see Table 2).


How Teachers’ Stress Affects Students: A Research Roundup

By Sarah D. Sparks — June 07, 2017 4 min read

New research is helping to clarify how teachers become chronically stressed, and how it can affect their students’ well-being and achievement.

“Relationships really matter for learning there’s a lot of evidence around that,” said Robert Whitaker, a professor of public health and pediatrics at Temple University.

In one 2016 study, University of British Columbia researchers tracked the levels of stress hormones of more than 400 elementary students in different classes. They found teachers who reported higher levels of burnout had students with higher levels of the stress hormone cortisol each morning, suggesting classroom tensions could be “contagious.”

For example, in one forthcoming study previewed at the American Educational Research Association (AERA) meeting in San Antonio in April, researchers from the University of Groningen in the Netherlands interviewed a small pool of 143 beginning teachers over the course of a year. Those who showed higher levels of stress at the beginning of the year displayed fewer effective teaching strategies over the rest of the school year, including clear instruction, effective classroom management, and creation of a safe and stimulating classroom climate for their students, than did the teachers with lower initial stress levels.

Meanwhile, the University of Virginia is conducting one of the first long-term experimental studies of how classroom-management techniques affect teachers’ stress and effectiveness in instruction. Researchers from the university’s YouthNex research center and the Center for Advanced Study of Teaching and Learning randomly assigned nearly 200 early-career teachers in 100 schools in three districts to normal district training or training in the Good Behavior Game, a research-backed social-emotional-learning program in which teachers reward students’ positive group behaviors. Teachers who used the game also had one-on-one video coaching every two to three weeks for a year, to help them identify their own stress levels and ways they can improve their interactions with students.

In the first study from the project, which is forthcoming, Jason Downer, the director of the Center for Advanced Study, found that nonparticipating teachers who started the school year feeling very stressed and “emotionally drained” had significantly worse classroom management and a spike in student disruptions by the spring. Stressed teachers who participated in the Good Behavior Game stayed stressed during the year, but it didn’t affect their classes as much, Downer found. “With the intervention, you weren’t seeing dramatic improvements over the year, but you had the status quo. With stressed teachers [who did not participate], you see a dive” in classroom behavior. There was no effect for teachers who didn’t start the year stressed.

“We need to consider the context for interventions, when teachers are stressed coming in and are teaching a chaotic classroom,” Downer said in a discussion at another research conference earlier this year.

How Teachers See Stress

So what makes a classroom normal for one teacher and stressful to another? University of Texas at Austin researchers, led by psychology professor Chris McCarthy, found that the answer depends on whether teachers feel they have the cognitive and other resources to meet their students’ needs.

The researchers used federal Schools and Staffing Survey data to create profiles of the “demands” on teachers, based on: their and their students’ background characteristics whether their classes had high proportions of English-learners, students with disabilities, or students in poverty and whether their racial group made up a minority of those in the school. They then compared those demands to teachers’ reported resources and whether the teachers felt they had autonomy in their classrooms. Teachers whose demands were greater than their perceived resources were only half as likely to say they would choose to become teachers again as were teachers who saw their demands and resources as balanced. Teachers who reported more resources than demands (a smaller group), were more than twice as likely as teachers with “balanced demands and resources” to say they would become teachers again and would return to their district next year.

“This is purely about perceived demand and resources two teachers in the same school and teaching the same kids could feel they have more or less resources,” said Richard Lambert, who co-wrote the study. But, he added, individual schools often had very different concentrations of the most high-need students in different classrooms. “That’s something that administrators absolutely have control over. If I’m a 4th grade teacher, and there are three others down the hall, we all know five minutes [into the school year] that Ms. Jones got dealt a much harder hand this year. The perception of whether you feel treated fairly by your principal is enormous” in its relation to teacher stress, he said in a discussion of the study at AERA.


Stress-induced cortisol is associated with generation of non-negative interpretations during cognitive reappraisal

Enhanced processing of emotional stimuli after stress exposure is reported to be associated with stress-induced cortisol. Because enhanced emotional information processing could make cognitive emotion regulation more difficult, it was hypothesized that stress-induced cortisol would be associated with non-negative interpretation generation associated with the cognitive reappraisal processes.

Methods

A total of 36 participants (Mean age = 21.3 years, SD = 1.8) watched video clips of depression-related stressful situations before and after the administration of a stress induction task. They were then asked to generate as many non-negative interpretations as possible to reduce the depressive mood. Saliva samples were obtained before and after the stress induction task to measure change in the cortisol level.

Results

Participants were allocated post-hoc to either a responder (n = 19) or non-responder group (n = 17) based on the cortisol response to the stress induction task. The number of non-negative interpretations generated following the stress induction task was reduced only in the cortisol responders. The number of post-stress non-negative interpretations was fewer in the responder group when compared by sex, baseline cortisol level, and the number of pre-stress non-negative interpretations, statistically controlled.

Conclusions

Although baseline cortisol and sex may have impacted the results, the results suggest that stress-induced cortisol is associated with difficulty in non-negative interpretation generation during the cognitive reappraisal process.


References

We agree completely with Ursin that part of the neurophysiological response of paramedics to severe emergencies could be defined as arousal (although we did not use this label). In addition, we agree that “activity” or, more precisely, multiple energetic mechanisms are responsible for acute adaptation to the changing environment and these reactions might be expected to be found during work in these and every worker. However, we believe that this “extra” arousal that Ursin is referring to (on top of the expected circadian level of activity because workers generally are “quite awake” during working time) would be shown as adrenaline or noradrenaline excretions and not necessarily as extra cortisol excretion. This differential hormonal reactivity pattern between the catecholamines and hormones of the hypothalamo-pituitary-adrenocortical axis has been shown in several worker studies.

Secondly, the conclusions of our study do not mention any “perils”or other consequences of being wide awake. Our concerns with repeated rises in acute cortisol excretion in these workers is based on the increased risk for adverse long term health consequences of these paramedics when their goal is to keep on working in the same jobs for another 20 years. Cortisol is seen as the biomarker of stress reactions and one of the biomarkers of allostatic load. Studies testing the allostatic load theory of McEwen, Seeman, and colleagues confirm that chronic health consequences occur through repeated ups and downs of physiological responses that impact on the wear and tear of a number of organs and tissues and can predispose the organism to disease. 1, 2

Thirdly, the reason why Ursin believes that we interpreted our findings in terms of “lack of habituation” is unclear because no such statements were made in the article.

Finally, Ursin’s last argument is that nothing could be said about coping from these data. Healthy coping in terms of Ursin’s (and Eriksen’s) own cognitive activation theory of stress suggests that positive expectancy outcomes take place in the paramedic’s mind at the moment that the emergency call comes in (at baseline) because these workers are experienced and skilled in the task at hand. What might be expected, however, is that this “healthy coping” does coincide with more mental effort to prepare ongoing events and, therefore, will result in increased activity levels (which will mainly be shown through reactivity of catecholamines) but will not result in any rise of cortisol levels. It was not possible for the paramedics under study to predict the severity of these patients at baseline when the emergency bell rung, and data on the non-severe emergencies did show that the emergency call per se did not initiate a stress (cortisol) reaction after 20 minutes (the second measurement). Specifically, given the fact that coping is mostly better among experienced workers, such as the ones studied, compared to novice or less experienced workers, we did expres our concerns regarding cortisol reactivity in less experienced staff.


Stress and Quality of Life of Patients with Cancer: The Mediating Role of Mindfulness

Background. Cancer is one of the major health problems worldwide, which in addition to physical disorders, causes stress and anxiety in patients and affects the quality of life of cancer patients. Mindfulness can affect stress and improve the quality of life. This research explained the correlation between stress, quality of life, and mindfulness. Materials and Methods. Two hundred five cancer patients participated in this cross-sectional study. Patients completed the EORTC Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), the Mindfulness Attention and Awareness Scale (MAAS), and Perceived Stress Scale (PSS). Results. Perceived stress and mindfulness predict nearly 39% of the changes of QOL in cancer patients. In addition, perceived stress was negatively associated with mindfulness and quality of life

. Mindfulness was positively correlated with quality of life . Mindfulness played a mediating role in the relationship between perceived stress and quality of life (standardized β = −0.13 SE = 0.07, 95% confidence interval = −0.28 to −0.01 value = 0.04). Conclusion. In the present study, the variables of mindfulness and perceived stress affected the quality of life of cancer patients. Mindfulness can affect the quality of life of cancer patients directly and indirectly. These results emphasize the importance of mindfulness in the lives of cancer patients.

1. Introduction

Cancer is a major health problem worldwide, and the US has the second highest rate of victims [1]. The World Health Organization declared 10 million cancer patients in 2000, which is expected to go up to 15 million by 2020, with 60% of them in underdeveloped countries [2].

Cancer and its treatments often cause physical and mental disorders in patients, and the biggest problem of the cancer patients is the stress and anxiety caused by the disease. According to statistics, one in three people with cancer suffer from significant psychological disorders, which reduce the quality of treatment and their recovery [3–5]. One of the problems of the cancer patients is the stress of coping with the disease. Diagnosing, treating, and living with cancer can all be very stressful. Stress can affect the development, progression, and metastasis of cancerous tumors. If the stress experienced by the patient is not managed properly, it will have a great impact on his/her health [3, 4, 6]. The results of clinical studies support the correlation between stressful events and the survival and improvement of cancer. Despite insufficient knowledge about specific mechanisms involved in stress-induced tumorigenic processes, clinical studies have shown that stress can lead to cancer progression [7].

Stress is often defined as an internal or external challenge, disorder, or stimulus others perceive stress as a physiological challenge or response [3]. Stress is the correlation between a person and a health-threatening environment [4]. Chronic stress causes changes in the hormone levels and has negative physiological effects on the body [7]. Stress has adverse effects on the health, and it is one of the most important factors in the progression and development of the cancer. Growing evidence suggests that stress can affect the neuroendocrine system and exacerbate tumor activity [8]. Short-term stress lasts from a few minutes to several hours (for example, job interviews, prereading before lectures, and sports activities), and chronic stress is defined as long-term stresses (such as patient care, communication problems, and long-term financial problems) [3].

Stress affects many aspects of the cancer patients’ life, including their quality of life. Quality of life includes all aspects of life experiences, illnesses, and treatment. The cancer patients’ quality of life changes over time, and the poor quality of life of the chronic patients is one of the consequences of stress [3, 4, 6]. Kwon et al. showed that the quality of life of patients was significantly lower three years after diagnosis compared with the time of diagnosis [9]. DeNysschen et al. also showed that improving the quality of life was one of the most important measures to increase survival of those recovered from breast cancer [10].

Today, patients are interested in using other methods such as meditation and psychological methods along with pharmaceutical methods [11]. Mindfulness is one of the methods affecting stress [12]. Mindfulness is the quality of being present and fully engaged with whatever we are doing now without judgment. Mindfulness varies from one moment to another and from one person to another [13]. A mindful person pays attention to the present and does not consider the past and the future [14]. Therefore, a mindful person does not lose his/her direct connection with reality and intrapsychic and environmental events [13].

Mindfulness can reduce stress and anxiety improve sleep disorders reduce depression and stress, self-harm, and aggressive behaviors, increase patience and relaxation in the treatment process create enthusiasm and motivation to fight against disease improve quality of life reduce pain and suffering caused by illness and strengthen the immune system [11, 12, 15–23]. In fact, meditation increases the feeling of well-being [24]. In addition, mindfulness-based interventions reduce psychological symptoms and have positive effects on health outcomes such as experiencing positive emotions, gaining effective coping skills, purposeful thinking in life, and reducing emotional exhaustion [25, 26]. Tate et al. systematically studied qualitative evidence of cancer patients’ attitudes toward mindfulness and found that the evolution of mindfulness practice created a new and alternative perspective on how patients were able to change their perceptions of themselves and the world around them [27].

Mindfulness plays a special role in explaining the important components of mental health of cancer patients. Pour and Kord have shown that mindfulness was correlated with the quality of life of the cancer patients. Mindful people evaluate life-threatening situations with less stress and are more adaptable to stressful situations [28]. Zhong et al. showed that the higher the mindfulness, the lower the psychological symptoms of the cancer patients [29]. Studies have shown that mindfulness can also improve positive emotions, sense of energy, and happiness in depressed people, which can play a role in increasing the quality of life of these people. Although some studies have shown that mindfulness improves the quality of life of cancer patients [6, 30, 31], Lengacher et al. indicated that mindfulness improved stress and anxiety of the cancer patients rather than their quality of life and further research would be needed [32].

Many researchers have considered mindfulness and its positive effects in various fields, including cancer treatment. However, according to the review of literature, limited studies have examined the correlation between stress, quality of life, and mindfulness and the mediating role of mindfulness in the relationship between stress and quality of life. Therefore, this study aimed to investigate the correlation between stress, quality of life, and mindfulness of the cancer patients in southeastern Iran.

2. Methods

2.1. Study Design and Setting

This was a cross-sectional and descriptive analytical study. The research setting was the oncology ward of Bahonar Hospital and Javadalaimeh Clinic in Kerman. These are the main centers for providing services to patients with cancer in the city of Kerman and southeastern Iran.

2.2. Sample Size and Sampling

The study population consisted of male and female patients with cancer referred to the research setting. Patients adhering to the inclusion criteria were considered eligible to participate in the study.

Inclusion criteria: (a) patients aged over 18 years (to have a correct understanding of the questions) (b) patients diagnosed with cancer and (c) awake and aware patients.

Exclusion criteria: (a) patients psychologically and physiologically unstable during sampling and (b) patients not able to complete more than 10% of each of the questionnaires.

The following formula and the study of Zhong et al. were used to estimate the sample size [29]:

The type I and type II errors were considered 0.05% and 20%, respectively. According to the results of Zhong et al., the correlation coefficient between mindfulness and general health of the patients with cancer was considered 0.20. According to the aforementioned indicators, 205 samples were included in this study. Concerning the probability of dropouts, 255 questionnaires were provided to the eligible samples, of which 240 questionnaires were completed. Therefore, the response rate was 94.11%. Furthermore, out of 240 completed questionnaires, 35 questionnaires were removed because of missing values. Finally, 205 questionnaires were statistically analyzed. Convenience sampling method was used.

2.3. Measures
2.3.1. Demographic Characteristics Form

This form included age, gender, marital status, educational level, occupation, monthly income, cancer type, cancer stage, duration of diagnosis, type of treatment, and other diseases.

2.3.2. Mindfulness Attention and Awareness Scale

The Mindfulness Attention and Awareness Scale (MAAS) was developed by Ryan and Brown in 2003 to measure mindfulness. This scale consists of 15 questions with a 6-point Likert scale (1 = almost always, 6 = almost never). The minimum score of this scale is 15, and the maximum score is 90. The higher the score, the higher the level of mindfulness [33].

The MAAS shows a good internal consistency. Its Cronbach’s alpha was reported to be 0.82 for the student sample and 0.87 for the adult sample. The MAAS has a convergent validity with Mindfulness/Mindfulness Scale (MMS) and Rosenberg Self-Esteem Scale (RSS). In addition, the MAAS has a divergent validity with Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) [33]. In the study of Ghorbani et al., the Cronbach’s alpha of its Persian version was 0.81 in 723 student samples. In terms of validity, the Persian version of this scale had a significant correlation with the Internal State Awareness (ISA) [34].

2.3.3. Perceived Stress Scale (PSS)

Cohen et al. developed the Perceived Stress Scale (PSS) in 1983 to measure the perception of stress, thoughts, and feelings about stressful events, controlling, overcoming, and coping with stress over the past month [35]. The scale is self-administered and has 14 items. Each item is scored by a five-point Likert scale (0 = never, 1 = almost never, 2 = sometimes, 3 = often, 4 = always). Items 4, 5, 6, 7, 9, 10, and 13 are scored reversely. The total score of the scale is obtained from the sum of the scores of all the items. The lowest score on this scale is 0, and the highest is 56. The higher the score, the more perceived the stress [35]. A study has mentioned that this scale has two subscales of positively worded and negatively worded [36].

According to Cohen et al., the Cronbach’s alpha coefficient for reliability of this scale was 0.84. The PSS has a convergent validity with the Life-Event Scale. For its criterion validity, the correlation coefficient of the scale was between 0.52 and 0.76 using the Symptomatological Measures [35]. In the study of Behrozy et al., the Cronbach alpha and split-half coefficient were 0.73 and 0.74, respectively. The construct validity coefficient of this scale was 0.63 according to a researcher-made criterion, and the significance level was

2.3.4. Quality of Life Questionnaire-Core 30 (QLQ-C30)

Quality of Life Questionnaire-Core 30 (QLQ-C30) was developed by the European Organization for Research and Treatment of Cancer (EORTC) in 1987 to measure the quality of life of the patients with cancer [38]. The QLQ-C30 has four versions (QLQ-C30 version 1.0, QLQ-C30 (+3) interim version, QLQ-C30 version 2.0, and QLQ-C30 version 3.0). The QLQ-C30 version 3.0 is currently the standard version [39].

Version 3.0 of the questionnaire was designed to measure cancer patients’ physical, psychological, and social functions. The questionnaire is composed of 5 multi-item scales (physical, role, social, emotional, and cognitive functioning) and 9 single items (fatigue, pain, nausea/vomiting, airway obstruction, insomnia, loss of appetite, constipation, diarrhea, and financial problems). Items 1 to 28 were scored based on a 4-point Likert scale (1 = never, 4 = too much), and items 29 and 30 were based on a 7-point Likert scale (1 = very poor, 7 = excellent). The scores range from 0 to 100. In the dimensions of function and overall quality of life, the higher the score, the better the function or quality of life. In the dimension of symptoms, the higher the score, the greater the symptoms [39].

Aaronson et al. studied QLQ-C30 version 3.0 on patients with narcotic cancer. The reliability of all dimensions was good (Alpha Cronbach > 0.7). In addition, the questionnaire had a proper validity [38]. Safaee et al. measured the validity and reliability of the Persian version of QLQ-C30 v. 3.0 in patients with breast cancer. The questionnaire had a good convergent validity in all dimensions (r > 0.4). Divergent validity has been reported in all items except for physical functioning (item 4). The questionnaire had a good reliability in most dimensions (Cronbach alpha >0.7), except for fatigue (0.65), pain (0.69), and nausea/vomiting (0.66), which reliability was less than 0.7. However, they have been in an acceptable range [40].

2.4. Data Collection Procedure

After receiving the code of ethics and obtaining permissions from “REDACTED,” researchers referred to the research setting. They explained the goals and methodology of the study to the eligible patients. For those patients who were unaware of their disease, a researcher asked the questions orally and filled the questionnaire. In case one sample had not been able to cooperate the sampling, his/her companion would have helped him/her. Sampling lasted from January to February 2020.

2.5. Statistical Analysis

SPSS 20 and AMOS 24 were used for data analysis. Descriptive statistic (frequency, percentage, mean, and standard deviation) was used to describe the characteristics of the participants. Independent t-test, Mann–Whitney U, Kruskal–Wallis H, and analysis of variance (ANOVA) were used to examine the mean differences in mindfulness according to the qualitative variables. The Pearson correlation coefficient was used to investigate the correlation between mindfulness, perceived stress, and quality of life. Furthermore, the structural equation modeling method was used to test the proposed relationship between mindfulness, perceived stress, and quality of life. The Mahalanobis d 2 index was examined to check the multivariate outliers. Accordingly, six outliers were excluded from the analysis. The univariate normality of the main variables was checked using the skewness and kurtosis indices. The multivariate normality was checked using Mardia’s normalized multivariate kurtosis value, which was 1.39. Therefore, the multivariate normality was confirmed [41–43]. Model adequacy was evaluated by the chi-square test. The main model fit indices were the Goodness of Fit Index (GFI), Incremental Fit Index (IFI), Parsimonious Comparative Fit Index (PCFI), Comparative Fit Index (CFI), Parsimonious Normed Fit Index (PNFI), and root-mean-squared error of approximation (RMSEA). Acceptable model fit is indicated by χ 2 /df < 5.0 (<3.0 good), CFI, IFI, GFI > 0.9, PNFI, PCFI > 0.5, and RMSEA < 0.08 [41]. Two thousand bootstrap resamples were used to determine the role of mindfulness as a moderator variable between perceived stress and quality of life. The significance level was set at 0.05.

2.6. Ethical Considerations

The code of ethics (IR.KMU.REC.1398.390) was received from the Ethics Committee of Kerman University of Medical Sciences. In this project, the purpose of the research was fully explained to the participants who could withdraw from the study at any time. They were explained that participating in or withdrawing from the study would not affect their treatment process in any way, and all their information would remain confidential.

3. Results

The mean age of the study participants was 50.49 ± 15.27 years. The majority of the samples were male, married, educated, and employed. The monthly income level of most samples was <2 million tomans a month (13000 tomans = one dollar). Eighteen percent of the patients had been diagnosed with cancer for more than two years. The majority of the participants had breast or respiratory or blood cancers. The majority of the participants had no other history of chronic disease (Table 1).

The mean score of mindfulness was 68.41 ± 13.12, which was greater than the midpoint of the questionnaire (52.5). The mean score of perceived stress was 27.61 ± 7.23, which was greater than the midpoint of the questionnaire (28). The mean scores of overall quality of life, functioning, and symptom were 56.34, 61.24, and 38.71, respectively (Table 2).

VariableMean (SD)Pearson correlation coefficient
1234567
1. Mindfulness68.41 (13.12)1
2. Perceived stress27.61 (7.23)−0.27

No significant correlation was found between mindfulness and age (r = 0.005, P = 0.95). Mindfulness was significantly greater in patients who had been diagnosed with cancer for less than two years than those above two years . The Bonferroni post hoc test showed that mindfulness was not different between patients who had been diagnosed with cancer for one or two years

, but it was significantly lower in patients who had been diagnosed with cancer for above two years than those with one year or two years . Mindfulness score was not different among other qualitative variables (Table 1).

Mindfulness was negatively correlated with perceived stress, subscale of PSS-NW, and symptom subscale of QOL. Mindfulness was positively correlated with the functioning subscale of QOL. No significant correlation was found between mindfulness and overall quality of life (Table 2).

Table 3 shows that the proposed model has relatively good fit indices. The model was modified by drawing the correlation between the measurement errors e5 and e7 (Table 3).

The results showed that the R 2 for quality of life was 0.384, indicating that all independent and mediating variables, perceived stress and mindfulness, can predict nearly 39% of the variances in QOL of the cancer patients.

The results of the path analysis showed a significantly direct correlation between the variables. Perceived stress was negatively associated with mindfulness and quality of life . In addition, mindfulness was positively associated with quality of life (Table 4) (Figure 1). Mindfulness played a mediating role in the relationship between perceived stress and quality of life (Table 4).

4. Discussion

The current study found a positive correlation between mindfulness and functioning (a dimension of QOL) and a negative correlation between mindfulness, symptoms (a dimension of QOL), and perceived stress.

The results of some studies have also shown that mindfulness can increase the quality of life of cancer patients [6, 30, 31]. Past studies have shown that mindfulness training is closely correlated with the development of attentional functions [44], cognitive flexibility [45], and problem solving [46], and such factors can affect and improve patients’ condition. In addition, Poulin et al. found that mindfulness improved the two aspects of nonjudgment and acting with awareness of the cancer patients, which prevented patients’ fear and helped them get better results in life. Poulin et al. showed that mindfulness reduced pain of cancer patients and made them better adapt to the disease and increased their quality of life [31]. All of these results suggest that mindfulness can help cancer patients overcome their fear and better adapt to, affect, and improve different aspects of life, including the quality of life. However, Lengacher et al. showed that mindfulness did not improve quality of life of these patients [32]. These results could be due to the study of various variables in this study, and the simultaneous study of patients and caregivers can also affect the results.

The present study showed that the higher the mindfulness of the cancer patients, the lower their perceived stress. Hsieh et al. indicated that mindfulness of the cancer patients was negatively correlated with their stress [47]. This result has been confirmed in several studies [29, 32, 48, 49]. These results highlight the importance of mindfulness in reducing mood disorders and stress of the cancer patients. Cancer patients who are more mindful can be more aware of their experiences and more self-accepting [50], which can help them satisfy with their values and beliefs [51] and reduce their anxiety, confusion, and stress. Bao et al. showed that mindfulness activated an important behavioral mechanism called regulation of emotion (ROE), which might reduce perceived stress. Mindfulness is also a mediator between use of emotion (UOE) and perceived stress [48], meaning that people with a high level of mindfulness use their emotions more to improve functioning, which help reduce perceived stress. Lengacher et al. found that mindfulness affected certain stress hormones (e.g., cortisol) and cytokine levels (e.g., IL-6), stress, and immune system function [32]. These results suggest that people with high levels of mindfulness have more control over stress because of the mediators affecting the body emotions and physiological system.

As we proposed, the results showed that mindfulness could buffer the impact of perceived stress on QOL. In other words, the quality of life of the cancer patients with perceived stress will increase as they become more mindful. Results of the current study may reveal the process of how mindfulness can improve QOL of the patients with cancer.

Hsieh et al. also showed that mindfulness in people who were aware of the factors affecting stress could moderate the perceived stress [47]. Despite the effectiveness of mindfulness in various psychological disorders, it is unclear how mindfulness regulates the emotion and stress. Shapiro et al. believe that mindfulness may act with changes in attention, intention, and attitude [52]. Others argue that the positive effects of mindfulness can be explained by mechanisms such as observing, describing, acting with awareness, not judging internal experiences, and not responding to internal experiences [53]. These results suggest that people who are more mindful can focus on current problems and remove negative thoughts that reduce perceived physical stress and mental stress and lead to improved quality of life.

Hölzel et al. suggested that mindfulness could regulate attention, body awareness, emotion, and self-perspectives through gentle changes in brain function and thus could influence on individuals’ health [54]. The main goal of mindfulness programs is to correct dysfunctional individual strategies and regulate emotions, so it may help people regulate their emotional capacities that lead to symptomatic and clinical recovery and improve people’s quality of life. Furthermore, Poulin et al. showed that mindfulness reduced pain intensity, pain catastrophizing, pain interference, and depression of cancer patients and increased their quality of life [31]. The results of the present study emphasize that mindfulness can improve the quality of life of cancer patients by reducing perceived stress. Therefore, strengthening mindfulness should be considered as one of the effective mechanisms in controlling the stress of cancer patients. It is also necessary to pay attention and understand the factors affecting mindfulness to improve the quality of life of the cancer patients.

The present study showed no correlation between mindfulness and age, which is consistent with previous studies [6, 30, 47]. In addition, patients who had been diagnosed with cancer for less than two years were more mindful compared with other cancer patients. One reason can be patients’ disappointment and fatigue because of the disease recurrence, so they did not consider medical issues. Al-Ghabeesh et al. found that the quality of life of cancer patients reduced over time [6]. The reason can be long-term involvement of the patients with metastatic disease or their exposure to a growing number of diseases that affect their psychological functioning and keep patients away from mindfulness issues. The results of the studies suggest that patients who are more mindful may be better able to regulate their emotional responses [55], which can help the patients cope with the disease and improve their living conditions and quality of life.

The results of this study show that a high level of mindfulness is important in reducing the cancer patients’ stress and some aspects of quality of life. Given the direct mediating role of mindfulness, this study recommends the use of mindfulness training in reducing some of the consequences of cancer, such as stress. Physicians can use mindfulness-based interventions in supportive therapies in addition to the main treatments of the disease, with the aim of empowering patients and improving their acute condition, especially reducing their psychological symptoms. Therefore, a mindfulness-based program aiming at improving some aspects of quality of life and reducing stress can strengthen cancer patients for long-term problems and have a significant impact on their lives. In addition, nurses and physicians, the main caregivers of patients, should pay attention to the mindfulness program that can be effective in implementing mindfulness interventions by patients and their empowerment.

There are limitations in our study that can be addressed in future research. Since the present study is cross-sectional and does not examine the cause-and-effect relationship, the future research should be conducted in the form of longer-term longitudinal designs or an intervention study. Results should be generalized with caution because the study population was the cancer patients in two governmental centers and their specific condition and long course of treatment can affect the mindfulness, perceived stress, and quality of life of these patients.

5. Conclusion

The results of this study showed that the variables of mindfulness and perceived stress affected the quality of life of cancer patients. Mindfulness can directly affect the quality of life of cancer patients, indirectly reduce their stress, and potentially affect their quality of life. According to the results, it is suggested that special attention be paid to mindfulness constructs to increase the quality of life, the power to deal effectively with mental stress and tensions, and empower the cancer patients. It is also suggested that the present study be conducted on other sample groups, including normal and healthy individuals and other age groups, and that future research should focus on the dimensions and components of mindfulness. The correlation between other psychological factors and the components of mindfulness should also be examined.

Data Availability

Data are available from the corresponding author upon request.

Conflicts of Interest

The authors declare that there are no conflicts of interest.

Acknowledgments

The authors would thank all patients for their cooperation. The approved research project code was 98000533.

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Copyright

Copyright © 2020 Mahlagha Dehghan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Abstract

Storytelling is a distinctive human characteristic that may have played a fundamental role in humans’ ability to bond and navigate challenging social settings throughout our evolution. However, the potential impact of storytelling on regulating physiological and psychological functions has received little attention. We investigated whether listening to narratives from a storyteller can provide beneficial effects for children admitted to intensive care units. Biomarkers (oxytocin and cortisol), pain scores, and psycholinguistic associations were collected immediately before and after storytelling and an active control intervention (solving riddles that also involved social interaction but lacked the immersive narrative aspect). Compared with the control group, children in the storytelling group showed a marked increase in oxytocin combined with a decrease in cortisol in saliva after the 30-min intervention. They also reported less pain and used more positive lexical markers when describing their time in hospital. Our findings provide a psychophysiological basis for the short-term benefits of storytelling and suggest that a simple and inexpensive intervention may help alleviate the physical and psychological pain of hospitalized children on the day of the intervention.

We are all storytellers. From the bards and troubadours of the Middle Ages to the most recent Hollywood blockbuster, humans are exceptionally attracted to telling and listening to stories. Storytelling is culturally ubiquitous (1, 2). In fact, our taste for narrative has likely played a critical adaptive role in human society (3 ⇓ –5). The act of telling stories has been shown to be a central element for establishing human connections and influencing subjective emotions in both the storyteller and the audience (1, 6, 7).

From a psychological standpoint, stories allow us to make meaning of our world (8). Furthermore, storytelling helps us navigate our social world by turning the continuum of lived events into a coherent and organized narrative, despite life’s emotional peaks and valleys (9, 10), and helps to simulate possible social realities (11, 12).

Recent research into the universal human interest in narratives and storytelling provides insight into possible mechanisms. One main hypothesis is derived from a process known as “narrative transportation,” a dynamic and complex interaction between language, text, and imagination which creates a state of cognitive and emotional immersion that deeply engages listeners in the world of the narrative (13 ⇓ –15). Stories invite readers or listeners to immerse themselves in the portrayed action and thus lose themselves for the duration of the narrative. During this process, the world of origin becomes partially inaccessible to the listener, marking a separation in terms of the “here” and the “there,” the “now” and the “before,” the narrative world of the story and the world of origin. Current psychological and neuroscientific evidence supports the basic premises of this transportation process (16, 17) and its plausible origins based on evolutionarily relevant preadaptations involving mirror neuron systems, conversational language structures, metaphor processing, and imagination. Furthermore, cognitive theories suggest that stories facilitate and enable mental simulations, thereby facilitating mental models that people use to simulate social realities. Mar and Oatley (11) argue that narratives offer models or simulations of the social world via abstraction, simplification, and compression, which then allow for vicarious learning of social realities through the experience of fictional characters. These narrative transportations and mental simulations can help reframe personal experiences, broaden perspectives, deepen emotional processing abilities, increase empathy, and regulate self-models and emotional experiences (17 ⇓ –19).

These various lines of inquiry provide some rationale for using storytelling as a form of behavioral intervention. Indeed, it is not uncommon to find storytelling programs at hospitals all over the world. However, the effect of storytelling is mainly anecdotal, and its impact on children’s well-being and physiology is still insufficiently understood (20). Here, we present evidence that storytelling can positively influence both psychological and physiological variables in hospitalized children, even within highly challenging settings such as intensive care units (ICUs).

Being admitted to hospitals inflicts significant trauma on children (21). Hospitalizations abruptly remove children from their daily routines, both at home and at school. In addition to experiencing the difficulties and discomforts associated with their illnesses, this sudden disruption can cause disturbances that impact children’s lives in dramatic ways. These disturbances may be so severe that children develop unhealthy or painful habits that negatively affect them after discharge from the hospital (22, 23). Removed from their core social networks of friends and families and placed in highly unfamiliar surroundings, children are deprived of the social elements that bring them comfort and security during trying and painful times. Such factors create a stressful situation that may interrupt their development and often cause affective and cognitive impairments, even after the hospitalization event (24 ⇓ –26).

Given the centrality of storytelling for building and maintaining human connection (as indicated by anthropological literature), and the noted psychological effects of storytelling for creating meaning in lived experiences and narratives, we propose and test whether storytelling can mitigate the suffering caused by these conditions.

Thus, we hypothesize that storytelling induces children to feel transported to another possible world, one that is distant and different from the threatening, aversive and tedious environment of the ICU. As a result, the adverse physiological and psychological reactions experienced during their ICU stay should be temporarily reduced.

To comprehensively capture both the psychological and physiological effects of storytelling, we focus on physiological biomarkers, standardized psychometric tests, and psycholinguistic indicators. To identify biomarkers, we consider storytelling’s central role as an effective intervention for increasing empathy, reinforcing human connection, and decreasing stress. Two promising biomarkers that provide insight into these mechanisms are oxytocin and cortisol.

Converging evidence strongly implicates oxytocin in the empathic processes (27) of establishing and maintaining positive interpersonal behavior, modulating trust in social interactions, and reducing stress (28). Studies have shown that oxytocin affects the establishment of social bonds. Researchers have demonstrated a direct link between oxytocin and empathy, emotional processing (and, by extension, a reduction in mood disorders), the lessening of fear responses, and the capacity to infer other people’s emotional states (29, 30). Cortisol is a hormone secreted by the adrenal glands that plays a central role in the human stress response (31). In response to a stressor, either real or imagined, the body activates a complex and dynamic lifesaving system to restore homeostasis. During this process, the action of the hypothalamic–pituitary–adrenal axis is a central determinant (32), and cortisol is one of the main effectors. The ease of measurement and the high specificity/sensitivity of the cortisol response makes it one of the most useful physiological markers. Therefore, we predict that storytelling leads to a reduction in cortisol and an increase in oxytocin poststorytelling compared to before and compared to an active control intervention. In combination with the physiological changes, we also expect that subjective ratings of pain will decrease in the storytelling condition compared to an active control condition. Furthermore, the meaning-making content of a story is expected to change the linguistic associations that children form about the hospital environment.

In summary, the human connection and meaning-making induced by storytelling will lead to changes in biomarkers, pain scores, and psycholinguistic associations with the hospital environment.

To test our hypotheses, we recruited 81 children hospitalized in ICUs, randomized into two intervention groups: 1) Storytelling (n = 41) and 2) Riddle (n = 40). These children presented quite similar clinical conditions, respiratory problems (e.g., asthma, bronchitis, and pneumonia) being the most common. Sedated children and those who had neurological problems that would prevent them from taking part in the interventions were not included in the study. We randomly assigned each child to one condition (story or riddle). In the story condition, children were given the option to choose among eight stories typically found in children’s literature. All of the selected stories were light-hearted or amusing (SI Appendix provides an emotion-word analysis of the stories as well as ratings of those stories). At any moment, a child could change the story or ask for a particular story to be retold. We excluded stories that were deemed to be too emotionally loaded by a group of 10 seasoned storytellers who did not participate in this research. We recruited six storytellers with more than 10 y of experience in hospitals to read the story selected by the child for 25 to 30 min. For the Riddle group, the same storyteller played a riddle game for 25 or 30 min during which the child had to solve an amusing question posed by the storyteller (“What is it?” “Something you don’t eat that’s good for eating?” “What opens all the doors without ever going in or out of them?”).

This active control condition was designed to carefully control social interactions and attention, which were very similar to the storytelling condition but lacked the narrative immersion provided by the stories. Children in both groups had a saliva sample collected at the beginning of the study (1 min before the intervention) and another immediately after the intervention. They completed a standardized pain scale to assess how much pain they felt before and after the intervention. All children were also asked to complete a free-association word quiz after the intervention. They were shown seven cards with illustrations of a nurse, hospital, doctor, sick person, book, pain, and medicine (see SI Appendix for the stimulus material). Their associations were audio-recorded and later transcribed.


INTRODUCTION

Work stress and human performance

The relationship between stress and the work environment has been a topic of study for the last century [ 1]. Employed adults between 25 and 54 years of age spend almost 9 hr on an average weekday engaging in work or work-related activities, making this topic highly relevant across professions [ 2]. Occupational stress “arises from demands experienced in the working environment that affect how one functions at work or outside work” [ 3]. Acute stress, defined by the American Psychological Association (APA) as “demands and pressures of the recent past and anticipated demands and pressures of the near future,” is characterized as a brief, event-based phenomenon [ 4]. Because of its fleeting nature, acute stress represents an aspect of occupational stress that could be managed with preventative approaches in order to optimize performance of employees across work settings.

Present day interpretations of the classic Yerkes-Dodson law state that higher amounts of stress can, to a point, lead to a higher level of performance [ 5]. If the optimal point is exceeded, in moments of acute stress for example, task performance and decision-making abilities could become impaired followed by a decline in performance quality [ 6]. This decrement in performance is due in part to the inhibition of executive functions, particularly working memory, which can block an individual experiencing acute stress from recruiting past and present resources to aid in performing at an ideal level [ 7]. The stress response is known to vary according to the nature of the stressor, perception of the severity of the stressor, and factors inherent to each individual with acute stress representing a shorter duration of the stress response [ 8]. Because of the dynamic nature of stress, assessing an individual’s response during well-defined episodes of acute stress could be a key method to finding the balance between the detrimental effects of stress and optimal performance. In episodes of acute stress, the cognitive appraisal of the stressor dictates the response to the stressor. For example, a challenge response results when the individual perceives the ability to cope with the demands of the situation whereas a threat response results when situational demands are appraised to surpass the available resources inhibiting the individual to cope with the demands [ 9]. Threat responses to acute stress could lead to subsequent impairments in performance outcomes.

Acute stress in healthcare workers

Performance decrement within healthcare providers has significant implications not only for patients, but for the providers themselves. Work demands in the healthcare sector are increasing and becoming more complex with advances in technology, the rising prevalence of chronic diseases, the aging baby boomer population, and the expansion of individuals currently covered under the Affordable Care Act [ 10–12]. These baseline changes in the day-to-day stress of a healthcare provider could potentially increase the magnitude of acute stress in response to an additional stress-inducing task. Previous literature has investigated concepts of occupational stress within healthcare providers [ 13, 14] and observable changes indicative of strain have been noted to occur over time [ 15]. With the relationship between acute stress and performance established, adding the high risks common to a healthcare work setting could substantially compound performance decrement. Because eliminating acute stress is not an appropriate option, training protocols that incorporate acute stress management strategies represent a promising area of research that could be applied to the healthcare sector [ 16]. In response to the ever-changing demands of their job role, healthcare professionals could potentially learn to mitigate their reactions, and therefore negative consequences, to acutely stressful situations [ 17].

Reducing negative reactions to stress is desirable because an inappropriate response to acute stress has implications beyond individual cognition it threatens the performance of an entire team. Previous literature has established that the emotions and behaviors of one person can transfer to another person and unconsciously trigger parallel emotions and behaviors in a phenomenon that is referred to as stress contagion [ 18, 19]. Therefore, an individual provider reacting negatively to acute stress could affect other members of the healthcare team, creating a cycle of performance decrement. Because delivery of high quality healthcare is dependent on effective teamwork, promoting positive reactions to acute stress could benefit individual providers, their colleagues, and most importantly, patients.

Measuring acute stress

Stress is a state that cannot be directly observed yet affects performance [ 5]. Evaluation of an individual’s physiological response while experiencing high mental demands with subsequent inference on performance quality is an established concept [ 20]. Advancements in sensor technology have broadened the number of physiological measures that can be reliably recorded in an unobtrusive and passive manner. Additionally, these measures can be recorded in real-time and in settings outside of a highly controlled research laboratory [ 21]. Studying acute stress in the real-world ensures an accurate representation of the stressors experienced in daily work life and provides assurance that the stressors encountered will be meaningful to participants [ 22]. Monitoring physiological responses in real-time secures the capture of response patterns indicative of acute stress and could reveal proactive starting points for intervening to optimize performance under stress [ 16]. Real-time monitoring also potentially allows researchers to immediately capture biological responses and impart a degree of exactness in the relationship between stimuli and response [ 20, 22].

This systematic review aims to identify previous empirical research focused on acute stress in working professionals. The results will be interpreted with an emphasis placed on the implications for the healthcare sector. As healthcare providers are expected to make accurate clinical judgments that lead to improved patient care, it is critical to explore their performance in real-time under acute stress. Our specific research questions included: What are the commonly employed measures, both subjective and objective, to record acute changes in physiology related to acute stress? How does acute stress impair performance in defined occupations?


The Use of Testosterone/Cortisol Ratio in Response to Acute Stress as an Indicator of Propensity to Anger in Informal Caregivers

Caring for an offspring diagnosed with a psychological chronic disorder is used in research as a model of chronic stress. Indeed, it is usually associated with disturbances in the salivary cortisol (Csal) levels of the caregiver. An imbalance between salivary testosterone (Tsal) and Csal levels is a marker of proneness to social aggression. Given this, we aimed to establish whether the salivary testosterone/cortisol (Tsal/Csal) ratio response to acute stress could be employed as a marker of proneness to anger in informal caregivers of offspring with autism spectrum (ASD). Tsal/Csal ratio and anger responses to a set of different cognitive tasks as well as anger trait and expression were compared in these informal caregivers and controls. Caregivers, particularly those of offspring with ASD, had higher Tsal/Csal ratios than controls in response to acute stress, concretely after the stress in the case of fathers ( p = .05) and before stress when analyzing mothers ( p = .05). Moreover, ASD fathers and mothers obtained higher magnitude of the T/C ratio response to stress ( p = .03 and p =.04, respectively), anger state ( p = .02 and p = .02, respectively) and expression scores ( p = .05 and p = .05, respectively) than controls. Finally, high Tsal/Csal ratio levels and response to stress were significantly associated with high anger feelings increases ( p < .01 and p < .001, respectively), trait ( p < .001 and p > .05, respectively) and expression ( p < .05 and p > .05, respectively) in caregivers.


Discussion

Here, we aimed to investigate the protective power of a short humorous intervention against psychological and physiological stress and its subsequent impact on cognitive performance, more specifically on attention. With respect to the first research question, our results confirm the hypothesized beneficial role of humor. Watching funny video clips attenuates psychological stress as well as cortisol levels in the absence of evidence of physiological stress. These findings are in line with previously reported ones, although the current study differs in three important aspects from earlier research. First, we specifically targeted the question whether humor could shield against future stress. This required the humorous intervention to naturally precede the stressful event. In previous studies stress induction usually took place before the humorous intervention 6 or concurrently 5 but 4 . Second, we put emphasis on a very short intervention that is easily applicable in everyday life. Third, most studies investigating humor and stress assess stress solely psychologically, i.e., subjects were asked for anxiety ratings or ratings on daily stressors or hassles 3,6 . Only some of these studies additionally obtained data on physiological stress, with an emphasis on markers affecting the nervous system, such as heart rate, skin conductance response or blood pressure (or a combination of those) 5,8 . They consistently reported a decrease in these variables in the humor condition, however, only Newman & Stone 5 induced a specific physiological stress response whereas Rizollo and colleagues 8 looked at general physiological stress levels. By observing an attenuation of cortisol levels in the humor condition, we found a similar decrease in physiological stress markers, yet despite successfully evoking psychological stress, we were not able to provide evidence for a physiological stress response. This may be less surprising than it seems. Firstly, perceived stress and physiological stress levels can be only little to moderately associated given the complexity of the neurobiological processes involved 29 . Secondly, our measurement time points of salivary cortisol were chosen in accordance with other studies investigating physiological stress responses e.g. 25 and to examine whether cortisol levels from the humor group return faster to baseline levels than those of the control group. Therefore, we might have missed the optimal time point to measure peak cortisol levels, which possibly explains why we did not observe an increase in physiological stress levels following the stress induction phase. Similar to the decrease in physiological stress markers, Martin & Dobbins 3 found sense of humor to moderate immunosuppressive effects of stress. In the present study, physiological stress was operationalized by inspecting the change in salivary cortisol levels. Cortisol has been proven to reliably indicate stress levels 1,30 , and has been called the “method of choice” when assessing cortisol effects in stress research 29 . A combination of markers tapping into the nervous, the immune as well as the endocrinological stress responses would allow future research, for instance via latent change modelling, to even further specify the impact of humor on the specific physiological stress markers.

Interestingly, we found no group differences in trait anxiety and sense of humor, indicating that the observed effects on psychological stress and cortisol levels are rather likely driven by the humorous vs. control intervention. Contrary to previous studies, we did not observe group differences in state anxiety, which could be due to different experimental designs, particularly due to the order of stressful and humorous events 6 or to the absence of a stress induction phase 7 . In line with that thought, participants of the present study completed the questionnaires at the end of the study, i.e., there was a considerable lapse of time compared to previous studies. However, how precisely timing affects the relationship of humor and stress should be subject to further research.

Our results show that humor protects against psychological stress and effectively attenuates salivary cortisol levels, however, it is still unclear why participants may benefit from a humorous intervention. Although our study was not explicitly designed to investigate the underlying mechanisms systematically, a closer examination of our results regarding pain tolerance might give a hint. We observed higher levels of pain tolerance in the humor compared to the control group thus replicating earlier results 9,31 . Yet, comparable findings have been reported when subjects saw sad or dramatic clips, or listened to their favorite music. Therefore, these authors concluded, that it is not the humorous intervention per se, that has the beneficial effect, but rather the distraction it provides 10 . Additionally, since in our design the humorous intervention precedes the stressful event, carry-over effects may also play an important role. Furthermore, we do not know whether and how participants actively utilized humor to strategically cope with the stressor. Within the frame of the present study, we can neither conclusively confirm or negate the distraction hypothesis, the possibility of carry-over effects nor the active utilization of humor to build up resilience. Yet, it is conceivable, that the protective effect of humor on stress is based on similar mechanisms. Nonetheless, even though psychological stress and cortisol levels are reduced by humor, the underlying neural and cognitive mechanisms may still be different. Consistent with previous research reporting only moderate associations between the two kind of stress levels 29 , the change in psychological and physiological did not correlate in the present study. Future research is needed to not only further investigate the underlying mechanisms of the beneficial effect of humor on stress but also to discern whether humor impacts psychological and physiological stress in a similar manner.

Regarding the second research aim of the paper and contrary to our expectations, we found no reliable effect of humor on attention, neither in response times nor in accuracy rates. Likewise, further analyses investigating possible effects of changes in psychological and salivary cortisol levels due to the beneficial effects of humor yielded null effects as well. As positive emotions have been found to broaden the scope of attention in global–local visual attention tasks, we hypothesized to observe a similar effect in the humor group compared to the control one 16 . What we have found instead, is a successful attenuation of psychological stress and cortisol levels in the humor group without simultaneously impacting cognitive performance. A number of reasons may account for these results. First, the visual search task we employed was specifically designed to test the participants’ ability to integrate global features 19,20,21,22 as we solely induced positive emotion. The stimuli themselves as well as the number of stimuli is thus different to the global–local visual attention tasks previously used 16 . We can only speculate whether these differences led to varying degrees of complexity, which in turn not only tapped visual attention but also further cognitive domains. The relatively large number of erroneous and null responses may substantiate this assumption. We strongly encourage future research to use tasks, which both differentiate between perceptual and cognitive processes and further address different levels of complexity when investigating the effect of humor on cognition and perception. Second, with the humorous clip being rated funnier than the control clip, the present study was able to successfully induce humor in one group of participants. However, an exploratory analysis of individual funniness ratings within this humor group showed that the funnier these individuals rated the movie, the less accurate they performed in the visual search task. Interestingly, this finding is contrary to our predictions and leaves ample room for speculation. For instance, individuals that rated the movie clip as funnier, may have engaged more strongly with the film, thus showing a higher motivational intensity 32 , a concept closely related to valence and arousal 33 . As has been argued for humor and pain, it may be the level of arousal that drives the distraction effect 9 . Consequently, a comparable mechanism may account for the observed relationship between funniness ratings and accuracy rates within the humor group of the present study. Similarly, the higher the motivational intensity, the narrower the scope of attention 32 , which in turn would promote rather local than global processing strategies for those most involved. In fact, this is the pattern, we observed within the humor group. However, it needs to be pointed out, that at the group level no such differences were found, neither for accuracy rates nor on response times. Whether the result of our exploratory analysis accounts for a genuine or rather spurious effect remains an open question and demands further investigation. Likewise, the roles of motivational intensity and arousal, respectively, deserve additional attention. Finally, due to technical failure, all analyses regarding psychological stress were carried out with only 39 participants. Clearly, a larger sample may have yielded different results.

In conclusion, the present study clearly demonstrates the beneficial effects of a short humorous intervention on the psychological and physiological perception of subsequent stressful event. To our knowledge, it is the first study to have done so, extending findings from stress responses relating to the nervous as well as the immune system to those of the endocrine system. Yet, the exact nature of how humor affects psychological and physiological stress in detail are still subject to further research. While being beneficial for attenuating stress and cortisol levels, humor was found to have had no impact on cognitive performance, specifically on visual attention. On the surface, this may contradict assumptions of the broaden-and-build theory, yet results of an exploratory analysis point towards influential roles of motivational intensity and arousal, respectively. Taken together, a short humorous intervention can be a powerful instrument, improving our mental and physical health—not just on the way to the job interview but in many other situations of everyday life.


INTRODUCTION

Work stress and human performance

The relationship between stress and the work environment has been a topic of study for the last century [ 1]. Employed adults between 25 and 54 years of age spend almost 9 hr on an average weekday engaging in work or work-related activities, making this topic highly relevant across professions [ 2]. Occupational stress “arises from demands experienced in the working environment that affect how one functions at work or outside work” [ 3]. Acute stress, defined by the American Psychological Association (APA) as “demands and pressures of the recent past and anticipated demands and pressures of the near future,” is characterized as a brief, event-based phenomenon [ 4]. Because of its fleeting nature, acute stress represents an aspect of occupational stress that could be managed with preventative approaches in order to optimize performance of employees across work settings.

Present day interpretations of the classic Yerkes-Dodson law state that higher amounts of stress can, to a point, lead to a higher level of performance [ 5]. If the optimal point is exceeded, in moments of acute stress for example, task performance and decision-making abilities could become impaired followed by a decline in performance quality [ 6]. This decrement in performance is due in part to the inhibition of executive functions, particularly working memory, which can block an individual experiencing acute stress from recruiting past and present resources to aid in performing at an ideal level [ 7]. The stress response is known to vary according to the nature of the stressor, perception of the severity of the stressor, and factors inherent to each individual with acute stress representing a shorter duration of the stress response [ 8]. Because of the dynamic nature of stress, assessing an individual’s response during well-defined episodes of acute stress could be a key method to finding the balance between the detrimental effects of stress and optimal performance. In episodes of acute stress, the cognitive appraisal of the stressor dictates the response to the stressor. For example, a challenge response results when the individual perceives the ability to cope with the demands of the situation whereas a threat response results when situational demands are appraised to surpass the available resources inhibiting the individual to cope with the demands [ 9]. Threat responses to acute stress could lead to subsequent impairments in performance outcomes.

Acute stress in healthcare workers

Performance decrement within healthcare providers has significant implications not only for patients, but for the providers themselves. Work demands in the healthcare sector are increasing and becoming more complex with advances in technology, the rising prevalence of chronic diseases, the aging baby boomer population, and the expansion of individuals currently covered under the Affordable Care Act [ 10–12]. These baseline changes in the day-to-day stress of a healthcare provider could potentially increase the magnitude of acute stress in response to an additional stress-inducing task. Previous literature has investigated concepts of occupational stress within healthcare providers [ 13, 14] and observable changes indicative of strain have been noted to occur over time [ 15]. With the relationship between acute stress and performance established, adding the high risks common to a healthcare work setting could substantially compound performance decrement. Because eliminating acute stress is not an appropriate option, training protocols that incorporate acute stress management strategies represent a promising area of research that could be applied to the healthcare sector [ 16]. In response to the ever-changing demands of their job role, healthcare professionals could potentially learn to mitigate their reactions, and therefore negative consequences, to acutely stressful situations [ 17].

Reducing negative reactions to stress is desirable because an inappropriate response to acute stress has implications beyond individual cognition it threatens the performance of an entire team. Previous literature has established that the emotions and behaviors of one person can transfer to another person and unconsciously trigger parallel emotions and behaviors in a phenomenon that is referred to as stress contagion [ 18, 19]. Therefore, an individual provider reacting negatively to acute stress could affect other members of the healthcare team, creating a cycle of performance decrement. Because delivery of high quality healthcare is dependent on effective teamwork, promoting positive reactions to acute stress could benefit individual providers, their colleagues, and most importantly, patients.

Measuring acute stress

Stress is a state that cannot be directly observed yet affects performance [ 5]. Evaluation of an individual’s physiological response while experiencing high mental demands with subsequent inference on performance quality is an established concept [ 20]. Advancements in sensor technology have broadened the number of physiological measures that can be reliably recorded in an unobtrusive and passive manner. Additionally, these measures can be recorded in real-time and in settings outside of a highly controlled research laboratory [ 21]. Studying acute stress in the real-world ensures an accurate representation of the stressors experienced in daily work life and provides assurance that the stressors encountered will be meaningful to participants [ 22]. Monitoring physiological responses in real-time secures the capture of response patterns indicative of acute stress and could reveal proactive starting points for intervening to optimize performance under stress [ 16]. Real-time monitoring also potentially allows researchers to immediately capture biological responses and impart a degree of exactness in the relationship between stimuli and response [ 20, 22].

This systematic review aims to identify previous empirical research focused on acute stress in working professionals. The results will be interpreted with an emphasis placed on the implications for the healthcare sector. As healthcare providers are expected to make accurate clinical judgments that lead to improved patient care, it is critical to explore their performance in real-time under acute stress. Our specific research questions included: What are the commonly employed measures, both subjective and objective, to record acute changes in physiology related to acute stress? How does acute stress impair performance in defined occupations?


Stress-induced cortisol is associated with generation of non-negative interpretations during cognitive reappraisal

Enhanced processing of emotional stimuli after stress exposure is reported to be associated with stress-induced cortisol. Because enhanced emotional information processing could make cognitive emotion regulation more difficult, it was hypothesized that stress-induced cortisol would be associated with non-negative interpretation generation associated with the cognitive reappraisal processes.

Methods

A total of 36 participants (Mean age = 21.3 years, SD = 1.8) watched video clips of depression-related stressful situations before and after the administration of a stress induction task. They were then asked to generate as many non-negative interpretations as possible to reduce the depressive mood. Saliva samples were obtained before and after the stress induction task to measure change in the cortisol level.

Results

Participants were allocated post-hoc to either a responder (n = 19) or non-responder group (n = 17) based on the cortisol response to the stress induction task. The number of non-negative interpretations generated following the stress induction task was reduced only in the cortisol responders. The number of post-stress non-negative interpretations was fewer in the responder group when compared by sex, baseline cortisol level, and the number of pre-stress non-negative interpretations, statistically controlled.

Conclusions

Although baseline cortisol and sex may have impacted the results, the results suggest that stress-induced cortisol is associated with difficulty in non-negative interpretation generation during the cognitive reappraisal process.


Stress and Quality of Life of Patients with Cancer: The Mediating Role of Mindfulness

Background. Cancer is one of the major health problems worldwide, which in addition to physical disorders, causes stress and anxiety in patients and affects the quality of life of cancer patients. Mindfulness can affect stress and improve the quality of life. This research explained the correlation between stress, quality of life, and mindfulness. Materials and Methods. Two hundred five cancer patients participated in this cross-sectional study. Patients completed the EORTC Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), the Mindfulness Attention and Awareness Scale (MAAS), and Perceived Stress Scale (PSS). Results. Perceived stress and mindfulness predict nearly 39% of the changes of QOL in cancer patients. In addition, perceived stress was negatively associated with mindfulness and quality of life

. Mindfulness was positively correlated with quality of life . Mindfulness played a mediating role in the relationship between perceived stress and quality of life (standardized β = −0.13 SE = 0.07, 95% confidence interval = −0.28 to −0.01 value = 0.04). Conclusion. In the present study, the variables of mindfulness and perceived stress affected the quality of life of cancer patients. Mindfulness can affect the quality of life of cancer patients directly and indirectly. These results emphasize the importance of mindfulness in the lives of cancer patients.

1. Introduction

Cancer is a major health problem worldwide, and the US has the second highest rate of victims [1]. The World Health Organization declared 10 million cancer patients in 2000, which is expected to go up to 15 million by 2020, with 60% of them in underdeveloped countries [2].

Cancer and its treatments often cause physical and mental disorders in patients, and the biggest problem of the cancer patients is the stress and anxiety caused by the disease. According to statistics, one in three people with cancer suffer from significant psychological disorders, which reduce the quality of treatment and their recovery [3–5]. One of the problems of the cancer patients is the stress of coping with the disease. Diagnosing, treating, and living with cancer can all be very stressful. Stress can affect the development, progression, and metastasis of cancerous tumors. If the stress experienced by the patient is not managed properly, it will have a great impact on his/her health [3, 4, 6]. The results of clinical studies support the correlation between stressful events and the survival and improvement of cancer. Despite insufficient knowledge about specific mechanisms involved in stress-induced tumorigenic processes, clinical studies have shown that stress can lead to cancer progression [7].

Stress is often defined as an internal or external challenge, disorder, or stimulus others perceive stress as a physiological challenge or response [3]. Stress is the correlation between a person and a health-threatening environment [4]. Chronic stress causes changes in the hormone levels and has negative physiological effects on the body [7]. Stress has adverse effects on the health, and it is one of the most important factors in the progression and development of the cancer. Growing evidence suggests that stress can affect the neuroendocrine system and exacerbate tumor activity [8]. Short-term stress lasts from a few minutes to several hours (for example, job interviews, prereading before lectures, and sports activities), and chronic stress is defined as long-term stresses (such as patient care, communication problems, and long-term financial problems) [3].

Stress affects many aspects of the cancer patients’ life, including their quality of life. Quality of life includes all aspects of life experiences, illnesses, and treatment. The cancer patients’ quality of life changes over time, and the poor quality of life of the chronic patients is one of the consequences of stress [3, 4, 6]. Kwon et al. showed that the quality of life of patients was significantly lower three years after diagnosis compared with the time of diagnosis [9]. DeNysschen et al. also showed that improving the quality of life was one of the most important measures to increase survival of those recovered from breast cancer [10].

Today, patients are interested in using other methods such as meditation and psychological methods along with pharmaceutical methods [11]. Mindfulness is one of the methods affecting stress [12]. Mindfulness is the quality of being present and fully engaged with whatever we are doing now without judgment. Mindfulness varies from one moment to another and from one person to another [13]. A mindful person pays attention to the present and does not consider the past and the future [14]. Therefore, a mindful person does not lose his/her direct connection with reality and intrapsychic and environmental events [13].

Mindfulness can reduce stress and anxiety improve sleep disorders reduce depression and stress, self-harm, and aggressive behaviors, increase patience and relaxation in the treatment process create enthusiasm and motivation to fight against disease improve quality of life reduce pain and suffering caused by illness and strengthen the immune system [11, 12, 15–23]. In fact, meditation increases the feeling of well-being [24]. In addition, mindfulness-based interventions reduce psychological symptoms and have positive effects on health outcomes such as experiencing positive emotions, gaining effective coping skills, purposeful thinking in life, and reducing emotional exhaustion [25, 26]. Tate et al. systematically studied qualitative evidence of cancer patients’ attitudes toward mindfulness and found that the evolution of mindfulness practice created a new and alternative perspective on how patients were able to change their perceptions of themselves and the world around them [27].

Mindfulness plays a special role in explaining the important components of mental health of cancer patients. Pour and Kord have shown that mindfulness was correlated with the quality of life of the cancer patients. Mindful people evaluate life-threatening situations with less stress and are more adaptable to stressful situations [28]. Zhong et al. showed that the higher the mindfulness, the lower the psychological symptoms of the cancer patients [29]. Studies have shown that mindfulness can also improve positive emotions, sense of energy, and happiness in depressed people, which can play a role in increasing the quality of life of these people. Although some studies have shown that mindfulness improves the quality of life of cancer patients [6, 30, 31], Lengacher et al. indicated that mindfulness improved stress and anxiety of the cancer patients rather than their quality of life and further research would be needed [32].

Many researchers have considered mindfulness and its positive effects in various fields, including cancer treatment. However, according to the review of literature, limited studies have examined the correlation between stress, quality of life, and mindfulness and the mediating role of mindfulness in the relationship between stress and quality of life. Therefore, this study aimed to investigate the correlation between stress, quality of life, and mindfulness of the cancer patients in southeastern Iran.

2. Methods

2.1. Study Design and Setting

This was a cross-sectional and descriptive analytical study. The research setting was the oncology ward of Bahonar Hospital and Javadalaimeh Clinic in Kerman. These are the main centers for providing services to patients with cancer in the city of Kerman and southeastern Iran.

2.2. Sample Size and Sampling

The study population consisted of male and female patients with cancer referred to the research setting. Patients adhering to the inclusion criteria were considered eligible to participate in the study.

Inclusion criteria: (a) patients aged over 18 years (to have a correct understanding of the questions) (b) patients diagnosed with cancer and (c) awake and aware patients.

Exclusion criteria: (a) patients psychologically and physiologically unstable during sampling and (b) patients not able to complete more than 10% of each of the questionnaires.

The following formula and the study of Zhong et al. were used to estimate the sample size [29]:

The type I and type II errors were considered 0.05% and 20%, respectively. According to the results of Zhong et al., the correlation coefficient between mindfulness and general health of the patients with cancer was considered 0.20. According to the aforementioned indicators, 205 samples were included in this study. Concerning the probability of dropouts, 255 questionnaires were provided to the eligible samples, of which 240 questionnaires were completed. Therefore, the response rate was 94.11%. Furthermore, out of 240 completed questionnaires, 35 questionnaires were removed because of missing values. Finally, 205 questionnaires were statistically analyzed. Convenience sampling method was used.

2.3. Measures
2.3.1. Demographic Characteristics Form

This form included age, gender, marital status, educational level, occupation, monthly income, cancer type, cancer stage, duration of diagnosis, type of treatment, and other diseases.

2.3.2. Mindfulness Attention and Awareness Scale

The Mindfulness Attention and Awareness Scale (MAAS) was developed by Ryan and Brown in 2003 to measure mindfulness. This scale consists of 15 questions with a 6-point Likert scale (1 = almost always, 6 = almost never). The minimum score of this scale is 15, and the maximum score is 90. The higher the score, the higher the level of mindfulness [33].

The MAAS shows a good internal consistency. Its Cronbach’s alpha was reported to be 0.82 for the student sample and 0.87 for the adult sample. The MAAS has a convergent validity with Mindfulness/Mindfulness Scale (MMS) and Rosenberg Self-Esteem Scale (RSS). In addition, the MAAS has a divergent validity with Beck Depression Inventory (BDI) and the State-Trait Anxiety Inventory (STAI) [33]. In the study of Ghorbani et al., the Cronbach’s alpha of its Persian version was 0.81 in 723 student samples. In terms of validity, the Persian version of this scale had a significant correlation with the Internal State Awareness (ISA) [34].

2.3.3. Perceived Stress Scale (PSS)

Cohen et al. developed the Perceived Stress Scale (PSS) in 1983 to measure the perception of stress, thoughts, and feelings about stressful events, controlling, overcoming, and coping with stress over the past month [35]. The scale is self-administered and has 14 items. Each item is scored by a five-point Likert scale (0 = never, 1 = almost never, 2 = sometimes, 3 = often, 4 = always). Items 4, 5, 6, 7, 9, 10, and 13 are scored reversely. The total score of the scale is obtained from the sum of the scores of all the items. The lowest score on this scale is 0, and the highest is 56. The higher the score, the more perceived the stress [35]. A study has mentioned that this scale has two subscales of positively worded and negatively worded [36].

According to Cohen et al., the Cronbach’s alpha coefficient for reliability of this scale was 0.84. The PSS has a convergent validity with the Life-Event Scale. For its criterion validity, the correlation coefficient of the scale was between 0.52 and 0.76 using the Symptomatological Measures [35]. In the study of Behrozy et al., the Cronbach alpha and split-half coefficient were 0.73 and 0.74, respectively. The construct validity coefficient of this scale was 0.63 according to a researcher-made criterion, and the significance level was

2.3.4. Quality of Life Questionnaire-Core 30 (QLQ-C30)

Quality of Life Questionnaire-Core 30 (QLQ-C30) was developed by the European Organization for Research and Treatment of Cancer (EORTC) in 1987 to measure the quality of life of the patients with cancer [38]. The QLQ-C30 has four versions (QLQ-C30 version 1.0, QLQ-C30 (+3) interim version, QLQ-C30 version 2.0, and QLQ-C30 version 3.0). The QLQ-C30 version 3.0 is currently the standard version [39].

Version 3.0 of the questionnaire was designed to measure cancer patients’ physical, psychological, and social functions. The questionnaire is composed of 5 multi-item scales (physical, role, social, emotional, and cognitive functioning) and 9 single items (fatigue, pain, nausea/vomiting, airway obstruction, insomnia, loss of appetite, constipation, diarrhea, and financial problems). Items 1 to 28 were scored based on a 4-point Likert scale (1 = never, 4 = too much), and items 29 and 30 were based on a 7-point Likert scale (1 = very poor, 7 = excellent). The scores range from 0 to 100. In the dimensions of function and overall quality of life, the higher the score, the better the function or quality of life. In the dimension of symptoms, the higher the score, the greater the symptoms [39].

Aaronson et al. studied QLQ-C30 version 3.0 on patients with narcotic cancer. The reliability of all dimensions was good (Alpha Cronbach > 0.7). In addition, the questionnaire had a proper validity [38]. Safaee et al. measured the validity and reliability of the Persian version of QLQ-C30 v. 3.0 in patients with breast cancer. The questionnaire had a good convergent validity in all dimensions (r > 0.4). Divergent validity has been reported in all items except for physical functioning (item 4). The questionnaire had a good reliability in most dimensions (Cronbach alpha >0.7), except for fatigue (0.65), pain (0.69), and nausea/vomiting (0.66), which reliability was less than 0.7. However, they have been in an acceptable range [40].

2.4. Data Collection Procedure

After receiving the code of ethics and obtaining permissions from “REDACTED,” researchers referred to the research setting. They explained the goals and methodology of the study to the eligible patients. For those patients who were unaware of their disease, a researcher asked the questions orally and filled the questionnaire. In case one sample had not been able to cooperate the sampling, his/her companion would have helped him/her. Sampling lasted from January to February 2020.

2.5. Statistical Analysis

SPSS 20 and AMOS 24 were used for data analysis. Descriptive statistic (frequency, percentage, mean, and standard deviation) was used to describe the characteristics of the participants. Independent t-test, Mann–Whitney U, Kruskal–Wallis H, and analysis of variance (ANOVA) were used to examine the mean differences in mindfulness according to the qualitative variables. The Pearson correlation coefficient was used to investigate the correlation between mindfulness, perceived stress, and quality of life. Furthermore, the structural equation modeling method was used to test the proposed relationship between mindfulness, perceived stress, and quality of life. The Mahalanobis d 2 index was examined to check the multivariate outliers. Accordingly, six outliers were excluded from the analysis. The univariate normality of the main variables was checked using the skewness and kurtosis indices. The multivariate normality was checked using Mardia’s normalized multivariate kurtosis value, which was 1.39. Therefore, the multivariate normality was confirmed [41–43]. Model adequacy was evaluated by the chi-square test. The main model fit indices were the Goodness of Fit Index (GFI), Incremental Fit Index (IFI), Parsimonious Comparative Fit Index (PCFI), Comparative Fit Index (CFI), Parsimonious Normed Fit Index (PNFI), and root-mean-squared error of approximation (RMSEA). Acceptable model fit is indicated by χ 2 /df < 5.0 (<3.0 good), CFI, IFI, GFI > 0.9, PNFI, PCFI > 0.5, and RMSEA < 0.08 [41]. Two thousand bootstrap resamples were used to determine the role of mindfulness as a moderator variable between perceived stress and quality of life. The significance level was set at 0.05.

2.6. Ethical Considerations

The code of ethics (IR.KMU.REC.1398.390) was received from the Ethics Committee of Kerman University of Medical Sciences. In this project, the purpose of the research was fully explained to the participants who could withdraw from the study at any time. They were explained that participating in or withdrawing from the study would not affect their treatment process in any way, and all their information would remain confidential.

3. Results

The mean age of the study participants was 50.49 ± 15.27 years. The majority of the samples were male, married, educated, and employed. The monthly income level of most samples was <2 million tomans a month (13000 tomans = one dollar). Eighteen percent of the patients had been diagnosed with cancer for more than two years. The majority of the participants had breast or respiratory or blood cancers. The majority of the participants had no other history of chronic disease (Table 1).

The mean score of mindfulness was 68.41 ± 13.12, which was greater than the midpoint of the questionnaire (52.5). The mean score of perceived stress was 27.61 ± 7.23, which was greater than the midpoint of the questionnaire (28). The mean scores of overall quality of life, functioning, and symptom were 56.34, 61.24, and 38.71, respectively (Table 2).

VariableMean (SD)Pearson correlation coefficient
1234567
1. Mindfulness68.41 (13.12)1
2. Perceived stress27.61 (7.23)−0.27

No significant correlation was found between mindfulness and age (r = 0.005, P = 0.95). Mindfulness was significantly greater in patients who had been diagnosed with cancer for less than two years than those above two years . The Bonferroni post hoc test showed that mindfulness was not different between patients who had been diagnosed with cancer for one or two years

, but it was significantly lower in patients who had been diagnosed with cancer for above two years than those with one year or two years . Mindfulness score was not different among other qualitative variables (Table 1).

Mindfulness was negatively correlated with perceived stress, subscale of PSS-NW, and symptom subscale of QOL. Mindfulness was positively correlated with the functioning subscale of QOL. No significant correlation was found between mindfulness and overall quality of life (Table 2).

Table 3 shows that the proposed model has relatively good fit indices. The model was modified by drawing the correlation between the measurement errors e5 and e7 (Table 3).

The results showed that the R 2 for quality of life was 0.384, indicating that all independent and mediating variables, perceived stress and mindfulness, can predict nearly 39% of the variances in QOL of the cancer patients.

The results of the path analysis showed a significantly direct correlation between the variables. Perceived stress was negatively associated with mindfulness and quality of life . In addition, mindfulness was positively associated with quality of life (Table 4) (Figure 1). Mindfulness played a mediating role in the relationship between perceived stress and quality of life (Table 4).

4. Discussion

The current study found a positive correlation between mindfulness and functioning (a dimension of QOL) and a negative correlation between mindfulness, symptoms (a dimension of QOL), and perceived stress.

The results of some studies have also shown that mindfulness can increase the quality of life of cancer patients [6, 30, 31]. Past studies have shown that mindfulness training is closely correlated with the development of attentional functions [44], cognitive flexibility [45], and problem solving [46], and such factors can affect and improve patients’ condition. In addition, Poulin et al. found that mindfulness improved the two aspects of nonjudgment and acting with awareness of the cancer patients, which prevented patients’ fear and helped them get better results in life. Poulin et al. showed that mindfulness reduced pain of cancer patients and made them better adapt to the disease and increased their quality of life [31]. All of these results suggest that mindfulness can help cancer patients overcome their fear and better adapt to, affect, and improve different aspects of life, including the quality of life. However, Lengacher et al. showed that mindfulness did not improve quality of life of these patients [32]. These results could be due to the study of various variables in this study, and the simultaneous study of patients and caregivers can also affect the results.

The present study showed that the higher the mindfulness of the cancer patients, the lower their perceived stress. Hsieh et al. indicated that mindfulness of the cancer patients was negatively correlated with their stress [47]. This result has been confirmed in several studies [29, 32, 48, 49]. These results highlight the importance of mindfulness in reducing mood disorders and stress of the cancer patients. Cancer patients who are more mindful can be more aware of their experiences and more self-accepting [50], which can help them satisfy with their values and beliefs [51] and reduce their anxiety, confusion, and stress. Bao et al. showed that mindfulness activated an important behavioral mechanism called regulation of emotion (ROE), which might reduce perceived stress. Mindfulness is also a mediator between use of emotion (UOE) and perceived stress [48], meaning that people with a high level of mindfulness use their emotions more to improve functioning, which help reduce perceived stress. Lengacher et al. found that mindfulness affected certain stress hormones (e.g., cortisol) and cytokine levels (e.g., IL-6), stress, and immune system function [32]. These results suggest that people with high levels of mindfulness have more control over stress because of the mediators affecting the body emotions and physiological system.

As we proposed, the results showed that mindfulness could buffer the impact of perceived stress on QOL. In other words, the quality of life of the cancer patients with perceived stress will increase as they become more mindful. Results of the current study may reveal the process of how mindfulness can improve QOL of the patients with cancer.

Hsieh et al. also showed that mindfulness in people who were aware of the factors affecting stress could moderate the perceived stress [47]. Despite the effectiveness of mindfulness in various psychological disorders, it is unclear how mindfulness regulates the emotion and stress. Shapiro et al. believe that mindfulness may act with changes in attention, intention, and attitude [52]. Others argue that the positive effects of mindfulness can be explained by mechanisms such as observing, describing, acting with awareness, not judging internal experiences, and not responding to internal experiences [53]. These results suggest that people who are more mindful can focus on current problems and remove negative thoughts that reduce perceived physical stress and mental stress and lead to improved quality of life.

Hölzel et al. suggested that mindfulness could regulate attention, body awareness, emotion, and self-perspectives through gentle changes in brain function and thus could influence on individuals’ health [54]. The main goal of mindfulness programs is to correct dysfunctional individual strategies and regulate emotions, so it may help people regulate their emotional capacities that lead to symptomatic and clinical recovery and improve people’s quality of life. Furthermore, Poulin et al. showed that mindfulness reduced pain intensity, pain catastrophizing, pain interference, and depression of cancer patients and increased their quality of life [31]. The results of the present study emphasize that mindfulness can improve the quality of life of cancer patients by reducing perceived stress. Therefore, strengthening mindfulness should be considered as one of the effective mechanisms in controlling the stress of cancer patients. It is also necessary to pay attention and understand the factors affecting mindfulness to improve the quality of life of the cancer patients.

The present study showed no correlation between mindfulness and age, which is consistent with previous studies [6, 30, 47]. In addition, patients who had been diagnosed with cancer for less than two years were more mindful compared with other cancer patients. One reason can be patients’ disappointment and fatigue because of the disease recurrence, so they did not consider medical issues. Al-Ghabeesh et al. found that the quality of life of cancer patients reduced over time [6]. The reason can be long-term involvement of the patients with metastatic disease or their exposure to a growing number of diseases that affect their psychological functioning and keep patients away from mindfulness issues. The results of the studies suggest that patients who are more mindful may be better able to regulate their emotional responses [55], which can help the patients cope with the disease and improve their living conditions and quality of life.

The results of this study show that a high level of mindfulness is important in reducing the cancer patients’ stress and some aspects of quality of life. Given the direct mediating role of mindfulness, this study recommends the use of mindfulness training in reducing some of the consequences of cancer, such as stress. Physicians can use mindfulness-based interventions in supportive therapies in addition to the main treatments of the disease, with the aim of empowering patients and improving their acute condition, especially reducing their psychological symptoms. Therefore, a mindfulness-based program aiming at improving some aspects of quality of life and reducing stress can strengthen cancer patients for long-term problems and have a significant impact on their lives. In addition, nurses and physicians, the main caregivers of patients, should pay attention to the mindfulness program that can be effective in implementing mindfulness interventions by patients and their empowerment.

There are limitations in our study that can be addressed in future research. Since the present study is cross-sectional and does not examine the cause-and-effect relationship, the future research should be conducted in the form of longer-term longitudinal designs or an intervention study. Results should be generalized with caution because the study population was the cancer patients in two governmental centers and their specific condition and long course of treatment can affect the mindfulness, perceived stress, and quality of life of these patients.

5. Conclusion

The results of this study showed that the variables of mindfulness and perceived stress affected the quality of life of cancer patients. Mindfulness can directly affect the quality of life of cancer patients, indirectly reduce their stress, and potentially affect their quality of life. According to the results, it is suggested that special attention be paid to mindfulness constructs to increase the quality of life, the power to deal effectively with mental stress and tensions, and empower the cancer patients. It is also suggested that the present study be conducted on other sample groups, including normal and healthy individuals and other age groups, and that future research should focus on the dimensions and components of mindfulness. The correlation between other psychological factors and the components of mindfulness should also be examined.

Data Availability

Data are available from the corresponding author upon request.

Conflicts of Interest

The authors declare that there are no conflicts of interest.

Acknowledgments

The authors would thank all patients for their cooperation. The approved research project code was 98000533.

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Copyright

Copyright © 2020 Mahlagha Dehghan et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


References

We agree completely with Ursin that part of the neurophysiological response of paramedics to severe emergencies could be defined as arousal (although we did not use this label). In addition, we agree that “activity” or, more precisely, multiple energetic mechanisms are responsible for acute adaptation to the changing environment and these reactions might be expected to be found during work in these and every worker. However, we believe that this “extra” arousal that Ursin is referring to (on top of the expected circadian level of activity because workers generally are “quite awake” during working time) would be shown as adrenaline or noradrenaline excretions and not necessarily as extra cortisol excretion. This differential hormonal reactivity pattern between the catecholamines and hormones of the hypothalamo-pituitary-adrenocortical axis has been shown in several worker studies.

Secondly, the conclusions of our study do not mention any “perils”or other consequences of being wide awake. Our concerns with repeated rises in acute cortisol excretion in these workers is based on the increased risk for adverse long term health consequences of these paramedics when their goal is to keep on working in the same jobs for another 20 years. Cortisol is seen as the biomarker of stress reactions and one of the biomarkers of allostatic load. Studies testing the allostatic load theory of McEwen, Seeman, and colleagues confirm that chronic health consequences occur through repeated ups and downs of physiological responses that impact on the wear and tear of a number of organs and tissues and can predispose the organism to disease. 1, 2

Thirdly, the reason why Ursin believes that we interpreted our findings in terms of “lack of habituation” is unclear because no such statements were made in the article.

Finally, Ursin’s last argument is that nothing could be said about coping from these data. Healthy coping in terms of Ursin’s (and Eriksen’s) own cognitive activation theory of stress suggests that positive expectancy outcomes take place in the paramedic’s mind at the moment that the emergency call comes in (at baseline) because these workers are experienced and skilled in the task at hand. What might be expected, however, is that this “healthy coping” does coincide with more mental effort to prepare ongoing events and, therefore, will result in increased activity levels (which will mainly be shown through reactivity of catecholamines) but will not result in any rise of cortisol levels. It was not possible for the paramedics under study to predict the severity of these patients at baseline when the emergency bell rung, and data on the non-severe emergencies did show that the emergency call per se did not initiate a stress (cortisol) reaction after 20 minutes (the second measurement). Specifically, given the fact that coping is mostly better among experienced workers, such as the ones studied, compared to novice or less experienced workers, we did expres our concerns regarding cortisol reactivity in less experienced staff.


How Teachers’ Stress Affects Students: A Research Roundup

By Sarah D. Sparks — June 07, 2017 4 min read

New research is helping to clarify how teachers become chronically stressed, and how it can affect their students’ well-being and achievement.

“Relationships really matter for learning there’s a lot of evidence around that,” said Robert Whitaker, a professor of public health and pediatrics at Temple University.

In one 2016 study, University of British Columbia researchers tracked the levels of stress hormones of more than 400 elementary students in different classes. They found teachers who reported higher levels of burnout had students with higher levels of the stress hormone cortisol each morning, suggesting classroom tensions could be “contagious.”

For example, in one forthcoming study previewed at the American Educational Research Association (AERA) meeting in San Antonio in April, researchers from the University of Groningen in the Netherlands interviewed a small pool of 143 beginning teachers over the course of a year. Those who showed higher levels of stress at the beginning of the year displayed fewer effective teaching strategies over the rest of the school year, including clear instruction, effective classroom management, and creation of a safe and stimulating classroom climate for their students, than did the teachers with lower initial stress levels.

Meanwhile, the University of Virginia is conducting one of the first long-term experimental studies of how classroom-management techniques affect teachers’ stress and effectiveness in instruction. Researchers from the university’s YouthNex research center and the Center for Advanced Study of Teaching and Learning randomly assigned nearly 200 early-career teachers in 100 schools in three districts to normal district training or training in the Good Behavior Game, a research-backed social-emotional-learning program in which teachers reward students’ positive group behaviors. Teachers who used the game also had one-on-one video coaching every two to three weeks for a year, to help them identify their own stress levels and ways they can improve their interactions with students.

In the first study from the project, which is forthcoming, Jason Downer, the director of the Center for Advanced Study, found that nonparticipating teachers who started the school year feeling very stressed and “emotionally drained” had significantly worse classroom management and a spike in student disruptions by the spring. Stressed teachers who participated in the Good Behavior Game stayed stressed during the year, but it didn’t affect their classes as much, Downer found. “With the intervention, you weren’t seeing dramatic improvements over the year, but you had the status quo. With stressed teachers [who did not participate], you see a dive” in classroom behavior. There was no effect for teachers who didn’t start the year stressed.

“We need to consider the context for interventions, when teachers are stressed coming in and are teaching a chaotic classroom,” Downer said in a discussion at another research conference earlier this year.

How Teachers See Stress

So what makes a classroom normal for one teacher and stressful to another? University of Texas at Austin researchers, led by psychology professor Chris McCarthy, found that the answer depends on whether teachers feel they have the cognitive and other resources to meet their students’ needs.

The researchers used federal Schools and Staffing Survey data to create profiles of the “demands” on teachers, based on: their and their students’ background characteristics whether their classes had high proportions of English-learners, students with disabilities, or students in poverty and whether their racial group made up a minority of those in the school. They then compared those demands to teachers’ reported resources and whether the teachers felt they had autonomy in their classrooms. Teachers whose demands were greater than their perceived resources were only half as likely to say they would choose to become teachers again as were teachers who saw their demands and resources as balanced. Teachers who reported more resources than demands (a smaller group), were more than twice as likely as teachers with “balanced demands and resources” to say they would become teachers again and would return to their district next year.

“This is purely about perceived demand and resources two teachers in the same school and teaching the same kids could feel they have more or less resources,” said Richard Lambert, who co-wrote the study. But, he added, individual schools often had very different concentrations of the most high-need students in different classrooms. “That’s something that administrators absolutely have control over. If I’m a 4th grade teacher, and there are three others down the hall, we all know five minutes [into the school year] that Ms. Jones got dealt a much harder hand this year. The perception of whether you feel treated fairly by your principal is enormous” in its relation to teacher stress, he said in a discussion of the study at AERA.


Abstract

Storytelling is a distinctive human characteristic that may have played a fundamental role in humans’ ability to bond and navigate challenging social settings throughout our evolution. However, the potential impact of storytelling on regulating physiological and psychological functions has received little attention. We investigated whether listening to narratives from a storyteller can provide beneficial effects for children admitted to intensive care units. Biomarkers (oxytocin and cortisol), pain scores, and psycholinguistic associations were collected immediately before and after storytelling and an active control intervention (solving riddles that also involved social interaction but lacked the immersive narrative aspect). Compared with the control group, children in the storytelling group showed a marked increase in oxytocin combined with a decrease in cortisol in saliva after the 30-min intervention. They also reported less pain and used more positive lexical markers when describing their time in hospital. Our findings provide a psychophysiological basis for the short-term benefits of storytelling and suggest that a simple and inexpensive intervention may help alleviate the physical and psychological pain of hospitalized children on the day of the intervention.

We are all storytellers. From the bards and troubadours of the Middle Ages to the most recent Hollywood blockbuster, humans are exceptionally attracted to telling and listening to stories. Storytelling is culturally ubiquitous (1, 2). In fact, our taste for narrative has likely played a critical adaptive role in human society (3 ⇓ –5). The act of telling stories has been shown to be a central element for establishing human connections and influencing subjective emotions in both the storyteller and the audience (1, 6, 7).

From a psychological standpoint, stories allow us to make meaning of our world (8). Furthermore, storytelling helps us navigate our social world by turning the continuum of lived events into a coherent and organized narrative, despite life’s emotional peaks and valleys (9, 10), and helps to simulate possible social realities (11, 12).

Recent research into the universal human interest in narratives and storytelling provides insight into possible mechanisms. One main hypothesis is derived from a process known as “narrative transportation,” a dynamic and complex interaction between language, text, and imagination which creates a state of cognitive and emotional immersion that deeply engages listeners in the world of the narrative (13 ⇓ –15). Stories invite readers or listeners to immerse themselves in the portrayed action and thus lose themselves for the duration of the narrative. During this process, the world of origin becomes partially inaccessible to the listener, marking a separation in terms of the “here” and the “there,” the “now” and the “before,” the narrative world of the story and the world of origin. Current psychological and neuroscientific evidence supports the basic premises of this transportation process (16, 17) and its plausible origins based on evolutionarily relevant preadaptations involving mirror neuron systems, conversational language structures, metaphor processing, and imagination. Furthermore, cognitive theories suggest that stories facilitate and enable mental simulations, thereby facilitating mental models that people use to simulate social realities. Mar and Oatley (11) argue that narratives offer models or simulations of the social world via abstraction, simplification, and compression, which then allow for vicarious learning of social realities through the experience of fictional characters. These narrative transportations and mental simulations can help reframe personal experiences, broaden perspectives, deepen emotional processing abilities, increase empathy, and regulate self-models and emotional experiences (17 ⇓ –19).

These various lines of inquiry provide some rationale for using storytelling as a form of behavioral intervention. Indeed, it is not uncommon to find storytelling programs at hospitals all over the world. However, the effect of storytelling is mainly anecdotal, and its impact on children’s well-being and physiology is still insufficiently understood (20). Here, we present evidence that storytelling can positively influence both psychological and physiological variables in hospitalized children, even within highly challenging settings such as intensive care units (ICUs).

Being admitted to hospitals inflicts significant trauma on children (21). Hospitalizations abruptly remove children from their daily routines, both at home and at school. In addition to experiencing the difficulties and discomforts associated with their illnesses, this sudden disruption can cause disturbances that impact children’s lives in dramatic ways. These disturbances may be so severe that children develop unhealthy or painful habits that negatively affect them after discharge from the hospital (22, 23). Removed from their core social networks of friends and families and placed in highly unfamiliar surroundings, children are deprived of the social elements that bring them comfort and security during trying and painful times. Such factors create a stressful situation that may interrupt their development and often cause affective and cognitive impairments, even after the hospitalization event (24 ⇓ –26).

Given the centrality of storytelling for building and maintaining human connection (as indicated by anthropological literature), and the noted psychological effects of storytelling for creating meaning in lived experiences and narratives, we propose and test whether storytelling can mitigate the suffering caused by these conditions.

Thus, we hypothesize that storytelling induces children to feel transported to another possible world, one that is distant and different from the threatening, aversive and tedious environment of the ICU. As a result, the adverse physiological and psychological reactions experienced during their ICU stay should be temporarily reduced.

To comprehensively capture both the psychological and physiological effects of storytelling, we focus on physiological biomarkers, standardized psychometric tests, and psycholinguistic indicators. To identify biomarkers, we consider storytelling’s central role as an effective intervention for increasing empathy, reinforcing human connection, and decreasing stress. Two promising biomarkers that provide insight into these mechanisms are oxytocin and cortisol.

Converging evidence strongly implicates oxytocin in the empathic processes (27) of establishing and maintaining positive interpersonal behavior, modulating trust in social interactions, and reducing stress (28). Studies have shown that oxytocin affects the establishment of social bonds. Researchers have demonstrated a direct link between oxytocin and empathy, emotional processing (and, by extension, a reduction in mood disorders), the lessening of fear responses, and the capacity to infer other people’s emotional states (29, 30). Cortisol is a hormone secreted by the adrenal glands that plays a central role in the human stress response (31). In response to a stressor, either real or imagined, the body activates a complex and dynamic lifesaving system to restore homeostasis. During this process, the action of the hypothalamic–pituitary–adrenal axis is a central determinant (32), and cortisol is one of the main effectors. The ease of measurement and the high specificity/sensitivity of the cortisol response makes it one of the most useful physiological markers. Therefore, we predict that storytelling leads to a reduction in cortisol and an increase in oxytocin poststorytelling compared to before and compared to an active control intervention. In combination with the physiological changes, we also expect that subjective ratings of pain will decrease in the storytelling condition compared to an active control condition. Furthermore, the meaning-making content of a story is expected to change the linguistic associations that children form about the hospital environment.

In summary, the human connection and meaning-making induced by storytelling will lead to changes in biomarkers, pain scores, and psycholinguistic associations with the hospital environment.

To test our hypotheses, we recruited 81 children hospitalized in ICUs, randomized into two intervention groups: 1) Storytelling (n = 41) and 2) Riddle (n = 40). These children presented quite similar clinical conditions, respiratory problems (e.g., asthma, bronchitis, and pneumonia) being the most common. Sedated children and those who had neurological problems that would prevent them from taking part in the interventions were not included in the study. We randomly assigned each child to one condition (story or riddle). In the story condition, children were given the option to choose among eight stories typically found in children’s literature. All of the selected stories were light-hearted or amusing (SI Appendix provides an emotion-word analysis of the stories as well as ratings of those stories). At any moment, a child could change the story or ask for a particular story to be retold. We excluded stories that were deemed to be too emotionally loaded by a group of 10 seasoned storytellers who did not participate in this research. We recruited six storytellers with more than 10 y of experience in hospitals to read the story selected by the child for 25 to 30 min. For the Riddle group, the same storyteller played a riddle game for 25 or 30 min during which the child had to solve an amusing question posed by the storyteller (“What is it?” “Something you don’t eat that’s good for eating?” “What opens all the doors without ever going in or out of them?”).

This active control condition was designed to carefully control social interactions and attention, which were very similar to the storytelling condition but lacked the narrative immersion provided by the stories. Children in both groups had a saliva sample collected at the beginning of the study (1 min before the intervention) and another immediately after the intervention. They completed a standardized pain scale to assess how much pain they felt before and after the intervention. All children were also asked to complete a free-association word quiz after the intervention. They were shown seven cards with illustrations of a nurse, hospital, doctor, sick person, book, pain, and medicine (see SI Appendix for the stimulus material). Their associations were audio-recorded and later transcribed.


Parenting, Cortisol, and Risky Behaviors in Emerging Adulthood: Diverging Patterns for Males and Females

Parenting behaviors in early development are associated with risk-taking behaviors in emerging adulthood. Risky behaviors are also shown to be associated with cortisol response to stressors. This study examined the moderating effect of neuroendocrine response to stressors on the link between parenting behaviors in early development and risky behaviors in emerging adulthood.

Methods

Participants were 78 healthy college students (38 males). Following a habituation session, participants completed a modified version of the Trier Social Stress Task prior to completing measures of risky behavior. Salivary cortisol was measured before the stressor, 20, and 40 min post-stressor.

Results

Parenting behaviors and cortisol response to stressor were seen to be linked risky behavior. For males, the link between harsh father behaviors and risky behavior was significantly moderated by cortisol response to stressor such that higher cortisol response was related to decreased risky behaviors. For females, risk-taking was associated with harsh and warm parenting behaviors, but the link between parenting and risky behaviors was not related to or moderated by cortisol response.

Conclusions

These results provide evidence that parents might have separate effect on predicting risky behaviors and provides support for literature that chronic stressors can influence sensitivity to acute stressors and subsequent risk-taking behaviors.


The Influence of Cortisol, Flow, and Anxiety on Performance in E-Sports: A Field Study

Background and Objectives. Most performance theories were tested under controlled laboratory settings and offer therefore only limited transferability to real-life situations. E-sport competitions offer a relatively controllable while at the same time competitive setting, and our aim was to examine different influencing factors on competitive performance. Design and Methods. Salivary cortisol was measured immediately before, after, and 30 minutes after a game of 23 computer players during e-sport tournaments. The players answered the Flow Short Scale, which consists of the two subdimensions “flow experience” and “anxiety” subsequent to their game. The performance was assessed by the result of each player’s game (win or loss). Results. Mean cortisol levels increased significantly during the game but response patterns were inconsistent. Winners and losers differed significantly in anxiety with winners showing higher anxiety levels. After dividing the sample into three groups of different cortisol response patterns, significant differences in performance and anxiety were found, with low to moderate levels of cortisol being associated with the highest performance and anxiety. Conclusions. A low to moderate physiological arousal and a simultaneously high level of anxiety represent a favorable state for achieving optimal performance during e-sports. Anxiety seems to exert a stronger influence on performance than physiological arousal.

1. Introduction

The history of theories and models which try to explain the relationship between performance and different influencing factors dates back to the time when Yerkes and Dodson first published their model of an inverted U-shaped relationship between arousal and performance [1]. According to this model, optimal performance should be given when arousal was at a moderate level [1]. When arousal is too low or too high, performance will be inferior [1]. For example, Arent and Landers [2] could clearly demonstrate that the relationship between physiological arousal and performance in a simple response time task followed the proposed inverted U-shaped function.

A further theory ascribing an optimal level of performance to a moderate level of arousal is the flow theory [3–5]. When in a flow state, an individual is able to access its maximal potential and perform at full capacity, while perceiving an optimal level of challenge and arousal without sensed stress [5, 6]. To enter the flow state, two critical prerequisites must be given: (1) an opportunity for action that is perceived as a challenge which engages the person’s full skill level (i.e., neither an overload nor an underload) and (2) clear proximal goals and immediate feedback about the progress of goal achievement [6]. Therefore, an important prerequisite for flow is that the task demands are not beyond the person’s perceived skills or capabilities [7]. Studies that examined the relationship between markers of physiological arousal and certain aspects of the flow experience predominantly found that a moderate level of physiological arousal corresponds with the highest level of flow experience, resulting in an inverted U-shaped relationship between physiological arousal and flow. For example, Peifer et al. [8] found an inverted U-shaped relationship between physiological arousal (i.e., cortisol and heart rate variability) and flow experience in terms of flow absorption (i.e., being completely immersed in the activity) during a computer task, with moderate levels of physiological arousal correlating with the highest flow levels. Another study could prove that during chess play the highest flow state or flow experience (i.e., flow absorption) correlates with a moderate level of physiological arousal (i.e., cortisol), showing an inverted U-shaped relationship [9]. Furthermore, Tian and colleagues [10] could show that moderate physiological arousal (i.e., heart rate, heart rate variability, and skin conductance) correlates with the highest flow experience, also demonstrating an inverted U-shaped relationship between physiological arousal and flow during playing computer games. In contrast, Keller et al. [11] found that during computer tasks the highest level of physiological arousal (i.e., heart rate variability, and cortisol) corresponds with the highest level of flow experience (i.e., skill-demand-compatibility). However, the problem with these studies is that they are conducted under controlled laboratory conditions and mainly used tasks that were artificially manipulated so that the flow was taken as given when subjects perceived a high level of skill-demand-compatibility. Consequently, group comparisons were almost exclusively done by comparing subjects of different skill-demand-compatibility levels.

A more sophisticated model, which also proposes an optimal relationship between physiological arousal and performance, is the catastrophe model of anxiety and performance [12], which adds anxiety as a further influencing factor of performance. According to this model, the optimal level of performance depends on the interaction of physiological arousal and cognitive anxiety [7]. An increase in cognitive anxiety leads to an enhanced performance when at the same time physiological arousal is low to moderate, but it impairs performance when physiological arousal is high [7]. Furthermore, performance can suddenly drop from a high level to a low level when cognitive anxiety is high and physiological arousal increases, resulting in a performance catastrophe [7]. Thus, optimal performance can be achieved at a high level of cognitive anxiety and a simultaneously low to moderate level of physiological arousal during flow.

Only a few studies have investigated the relationship between physiological arousal, anxiety, flow, and performance at the same time. For example, Hardy and Parfitt [13] found that performances of basketball players were highest during states of high anxiety and low to moderate physiological arousal. Bowlers achieved their best performance in a high anxiety state while being low to moderately physiologically aroused [14]. Furthermore, rock climbers performed better when they were physiologically aroused and when they were anxious compared to when they were not [15]. Duncan et al. [16] found that performance in an anticipation timing test was not negatively affected by high physiological arousal when cognitive anxiety was low, but it deteriorated under high cognitive anxiety and simultaneously high physiological arousal. Of note, in most of these studies, physiological arousal was induced by physical exertion and anxiety was artificially manipulated.

The results of hitherto conducted laboratory studies are not transferable to real-life situations without further ado. To the best of our knowledge, no study has yet explicitly tested these three models and theories under uncontrolled real-life conditions. Hence, we wanted to measure physiological arousal, flow experience, and anxiety as well as the performance itself during a real-life competitive situation without artificially manipulating the underlying conditions (i.e., skill-demand-compatibility, physiological arousal, and anxiety). Therefore, we chose a computer game event, where computer players competed against each other for placement and prices, as an appropriate real-life condition. We hypothesized that (1) playing a computer game during a real-life competition elicits a marked increase in physiological arousal compared to the baseline conditions before the game (cf. [17–19]), (2) winners and losers differ in physiological arousal, flow experience, and anxiety, (3) the relationship between physiological arousal and performance follows an inverted U-form, with moderate levels of physiological arousal corresponding to the best performance (cf. [1, 2]), and (4) the relationship between physiological arousal, anxiety, and performance parallels the catastrophe model of anxiety and performance, with low to moderate levels of physiological arousal and simultaneously high levels of anxiety corresponding to the best performance (cf. [7, 13, 14]).

2. Materials and Methods

2.1. Participants

The participants were informed about the applied procedures in oral and written forms. All participants gave their written informed consent before participating voluntarily in the study. Participants were free to withdraw from the study at any time without further consequences. The study was conducted in accordance with the Declaration of Helsinki [20] and was approved by the internal review board of the conducting institution. Exclusion criteria for participation in this study were mental health problems and treatment with glucocorticoids due to their impact on measures of interest. At the time of data collection, all participants were in good health and free of any physical and mental complaints. The sample consisted of 19 male and 4 female participants. The characteristics of the participants are displayed in Table 1.

2.2. Experimental Approach and Procedure

Playing video games has been found to significantly increase physiological arousal [19]. This effect should be further enhanced by the competitive setting, as competitions have been shown to induce an increase in physiological arousal and anxiety [17] as well as flow [21]. The tournaments took place in the evening between 9 p.m. and 2 a.m. Players could choose between different tournaments in different games (League of Legends and Counter-Strike: Global Offensive). League of Legends is a strategy game in the MOBA (Multiplayer Online Battle Arena) genre and Counter-Strike: Global Offensive is a tactical shooter game, both applying tactical and precision pressure in a real-time setting on the players. The average duration of a player’s game was 35 ± 22 minutes. We measured the physiological arousal of the players by collecting cortisol saliva samples since cortisol has been shown to be a valid marker of physiological arousal due to a stress-induced increased activity of the hypothalamus-pituitary-adrenal axis [22, 23]. Baseline cortisol levels were measured immediately before the start of a player’s game, immediately after the completion of the game, and 30 minutes afterward. Flow experience and anxiety were assessed using the Flow Short Scale, a questionnaire consisting of two subdimensions that measure flow experience and anxiety individually [24, 25]. The players answered the Flow Short Scale immediately upon ending their game.

2.3. Measurements and Instruments
2.3.1. Cortisol

Saliva samples were taken using Salivette® (Sarstedt AG & Co., Nümbrecht, Germany), a synthetic fiber roll, on which the participants had to chew for one minute. After chewing, the saliva samples were put in the plastic container of the Salivette® and stored at −20°C until analysis. Cortisol was analyzed using the Cobas© e 411 analyzer (Roche Diagnostics Germany GmbH, Mannheim, Germany) and applying the electrochemiluminescence technology. Every sample was analyzed in duplicate, and the mean value was then used for the data analysis. Since cortisol levels show a delayed increase in saliva [23, 26], we collected a first postgame saliva sample immediately after the game and a second postgame saliva sample 30 minutes after the completion of the game to capture the stress-induced cortisol peak. We then took the higher one of the two postgame values as cortisol peak for further analysis. However, besides a general cortisol increase from baseline to postgame, our data also showed a cortisol decrease from baseline to postgame in certain subjects. In this case, we took the lower one of the two postgame values as cortisol nadir for further analysis. The participants were instructed not to eat, smoke, drink alcohol or coffee, and refrain from physical activities from one hour prior to their game until the second postgame saliva sample to exclude any influences on cortisol release [27].

2.3.2. Flow Experience and Anxiety

We measured flow experience and anxiety with the Flow Short Scale [24, 25]. Assessing both flow and anxiety is important as flow-inducing challenges are often accompanied by feelings of anxiety or worry [25]. The Flow Short Scale consists of the two subdimensions “flow experience” and “anxiety.” Flow experience is assessed with ten items that cover all the abovementioned components of the flow experience (Cronbach’s α = 0.90), whereas anxiety is assessed with three items (Cronbach’s α = 0.80–0.90 [25]). All items are measured on a seven-point Likert scale ranging from 1 to 7. Although flow experience can be further divided into the two factors “absorption” and “fluency,” we operated only with the overall score for flow experience. This is legitimated by the high consistency of the ten flow items.

2.3.3. Performance

The performance of the computer players was assessed by the result of each player’s game (i.e., win or defeat). The performance of the different cortisol response groups is then expressed as the ratio of won and lost games among all players in that group.

2.4. Data Analysis and Statistics

In order to investigate the difference between baseline and postgame cortisol levels, we calculated a Wilcoxon signed-rank test, since cortisol values were not normally distributed. To compare winners and losers concerning their physiological arousal, flow experience, and anxiety, unpaired t-tests were used. We divided the whole sample into three groups, depending on their cortisol response pattern from baseline to postgame (i.e., cortisol decrease (n = 6 −3.1 to −0.3 nmol/l), low to moderate cortisol increase (n = 10 +0.4 to +5.3 nmol/l), and high cortisol increase (n = 7 +10.6 to +13.2 nmol/l)). The two groups showing a cortisol increase were divided at the mean. The groups were then compared concerning their flow experience and anxiety levels using one-way ANOVA. We adjusted the significance level for the post hoc tests using Bonferroni corrections to account for multiple tests with the same sample. The level of significance was set at

for the two-sided tests. Effect sizes were calculated as Cohen’s d for the t-tests and the Wilcoxon signed-rank test and as partial eta-squared (

) for ANOVA. All analyses and statistics were performed with the IBM SPSS Statistics 24 software (IBM Corp., Armonk, USA).

3. Results

The average cortisol level of all participants increased significantly from baseline to postgame conditions, demonstrating a strong effect and constituting a marked physiological arousal (3.5 ± 2.2 versus 7.7 ± 6.3 nmol/l z = −2.95,

Winners and losers only differed significantly concerning their anxiety level (t = 3.80, , d = 1.58), with winners showing higher anxiety levels (5.5 ± 1.6 versus 3.2 ± 1.3). Concerning cortisol and flow levels, the differences were not significant (see Table 2).