Professor of Psychiatry Faculty of Medicine

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Vulnerability to Stress and Psychopathology
by
Adriano Vaz Serra
Professor of Psychiatry Faculty of
Medicine Head of the Psychiatric Department
University Hospital
University of Coimbra - Portugal
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What can we say about stress?
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Stress

• In everyday life it is impossible for the human
  being to avoid stress inducing situations.
• Stress is not always harmful. What is harmful for
  the human being is
• A rather monotonous life, without stimuli that
  fulfill it or
• Having a life with a high number of disturbing
  and repetitive demands which cannot be adequately
  dealt with.

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Stress

• In intermediate situations stress is useful
  because it is a source of impulse which lead the
  individual to make decisions and solve problems,
  helping him improve his performance, skills and
  creativity.
• In this sense, stress brings some flavour to life
  and may become an incentive of professional and
  personal fulfillment.

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Stress

• Excessive stress becomes harmful because it may
• evoke strong negative emotions
• lead to the development or worsening of a
  physical and/or psychic illness
• have a negative influence on family, working and
  social life
• cause a higher number of labour and road
  accidents,
• harm the decision-making processes and
• have repercussions on aspects of an economical
  nature.

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Stress

• The stress inducing events may be of 3 types
• Fatalities coming from outside e. g., the sudden
  death of a relative.
• Causes coming from within, determined by the
  behaviour and attitudes of the individual which
  generate serious situations.
• Sometimes, a mixed causality, in which an
  individual, due to the way he(she) is, is unable
  to avoid disturbing situations facing him(her).

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Stress
Types of stress
Harmful
Beneficial
Centered on the event
Promotes personal development
Centered on the individual
Mixed
Is limited to a given situation which is
successfully overcome
Long term disturbance to the individuals
stability
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Coping strategies

• A person in stress can develop any one of 3 kinds
  of strategies
• problem-centered,
• emotion-centered, and
• centered on obtaining social support.
• There are individuals who are predisposed to use
  a given type of strategy instead of others. Any
  one of them can be used concomitantly.
• These strategies can be adequate or inadequate.

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Vulnerability to stress

• And now we must ask
• What does vulnerability mean?
• Are some persons more vulnerable to stress than
  others?

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Are some individuals more vulnerable to stress
than others?
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What does vulnerability mean?

• For Beck and Emery (1985) a vulnerable person is
  one who
• has the perception of being subjected to dangers
  of external or internal nature
• over which he has no control or, at least,
• has no control which he considers sufficient to
  give him a sense of security.

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Vulnerability to stress

• Leighton (1998) mentions that, in the 1950s,
  there was a belief in the aetiological
  destabilising power of environmental factors.
• This is currently being questioned, because it is
  recognised that there are individuals who suffer
  the impact of adverse circumstances without
  suffering great damage from them.

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Vulnerability to stress

• The effects of stress on the individual are
  greatly mediated by a certain number of
  variables, of biological, psychological and
  social nature, some of which lessen its effects
  and others, on the contrary, emphasize them
  (Leighton, 1998).

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Vulnerability to stress

• Brown (1993) mentions that it became necessary in
  the mid-70s to distinguish between life events
  and the vulnerability factors that change an
  individuals response to occurrences.
• Vulnerability represents the increased risk of
  reacting in a negative way before a given life
  event.

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Vulnerability to stress

• This formulation implies the presence of an
  interaction between the life event and the
  vulnerability factor.
• According to Brown (1993) the concept of
  vulnerability must be understood within the
  specific relation which is established between
  the individual and the circumstance.

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Vulnerability to stress

• In clinical practice, it is often proved that the
  vulnerability to stress varies a great deal from
  individual to individual.
• There are persons who decompensate before the
  slightest annoyance, whilst others appear to
  resist a large number of unpleasant situations,
  even those who threaten the individuals life and
  security.

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Vulnerability to stress

• Kessler and Magee (1994), mention that the
  relation established between the stress-inducing
  events and the consequent psychological
  disturbances explains less than 10 of the
  variance.
• Coyne and Whiffen (1995), note that most people
  do not become depressed, even when faced with
  clearly serious stress-inducing circumstances.

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Vulnerability to stress

• Due to these facts, there is a growing interest
  in the identification of the factors that protect
  people or make them vulnerable to stress.
• Allow us to mention a study we made on
  vulnerability to stress.

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A study on vulnerability to stress

• In order to construct a scale, following a
  revision of the literature, Vaz Serra (2000)
  selected 64 questions related to vulnerability to
  stress, about
• negative personality characteristics,
• positive personality characteristics,
• practice of regular physical exercise,
• access to a confident,
• social and family support, and
• adverse life conditions .

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A study on vulnerability to stress

• Each question may be answered in any of 5 ways.
  The value attributed to it varies between 0 and
  4, the highest score corresponding to the most
  negative aspects of the individuals description.
• In order to avoid answering tendencies, some
  questions were constructed to represent positive
  aspects, and others to represent negative aspects.

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A study on vulnerability to stress

• We asked each respondent to fill in, in addition
  to the scale, some psychometric instruments which
  are directly or indirectly related to
  psychopathology
• Brief Symptom Inventory (BSI, L. DeRogatis, 1982)
  
• Eysenck Personality Inventory (EPI, H.J. Eysenck
  e Sybil B.G. Eysenck, 1964).
• Problem Resolution Inventory (PRI, Vaz Serra,
  1987) which evaluates coping strategies.

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A study on vulnerability to stress

• When correlating the items of the scale of
  vulnerability to stress with the above-mentioned
  psychometric inventories we assumed that we would
  learn the profile of the individual who is more
  prone to developing psychopathological
  manifestations in stress conditions.

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A study on vulnerability to stress

• The work was conceived as follows

Cause
Individual
Effect
Psychopathology
?
Stressful event
Tolerance (no psychopathology)
?
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A study on vulnerability to stress

• Each respondent was evaluated in 7 possible
  classes of stress inducing situations
• Traumatic events
• Major life events
• Chronic stress events
• Hassles
• Macro stressors
• Nonevents
• Early life traumatic events

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A study on vulnerability to stress
The sample general population
Female
Male
Total
p
368
184
184
Age
Mean
42.43
42.70
42.15
N.S.
80
40
40
20s
30s
80
40
40
40s
80
40
40
50s
80
40
40
60s
48
24
24
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A study on vulnerability to stress

• Each respondent recorded whether himself, a
  parent or any other relative suffered or had once
  suffered from some nervous infirmity, a
  designation which usually is associated to
  emotional disturbances.
• The self-record of nervous infirmities helped
  us construct, at the end, a cut-off point,
  between vulnerable and non-vulnerable
  individuals, corresponding to the value of 43.

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A study on vulnerability to stress

• The sample was constituted by individuals of the
  general population distributed by all educational
  levels.
• As regards their civil status, most were married.
• The scale was finalised with 23 questions.
• Due to this fact, it was called 23 QVS (23
  Questions to measure Vulnerability to Stress).

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A study on vulnerability to stress

• As for the selection of items 41 of the 64
  initial questions were excluded for the following
  reasons
• 20 questions showed statistically significant
  differences between genders.
• 8 items failed to correlate with BSI, EPI or PRI.
  
• 7 questions showed a ceiling effect (most of the
  individuals described themselves as too
  perfect) .
• Cronbachs ?-value led to the exclusion of 6
  items which affected internal consistency .

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A study on vulnerability to stress

• Odd/Even correlation .732 and
• Spearman-Brown Coeff. .845
• Cronbachs ? .824 for all items. This value
  decreased if any one of the selected items was
  excluded, which underlines their importance as a
  contributive element to a good homogeneity.

Good internal consistency

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A study on vulnerability to stress

• The correlation of each question with the global
  note was positive and highly significant, both
  when the analysed item was included in the global
  note and when it was not.
• This fact confirms that it corresponds to an
  unidimensional scale, which defines a concept.

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A study on vulnerability to stress
The highest correlations with the global note
suggest that, the more an individual is
vulnerable to stress, the more he tends to show
the following profile

• Lack of self-assertion
• Low tolerance to frustration
• Difficulty in facing and solving problems
• Excessive concern with events of everyday life
• High emotionability.

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A study on vulnerability to stress

• Each item of the scale showed to be sensitive to
  variations of extreme groups, which underlines
  its discriminative power.
• The item correlation matrix showed that no
  correlation presented a particularly high value,
  which means that there are no redundant items.
• The test/retest correlation was undertaken within
  a minimum of 30 and a maximum of 239 days, with a
  median of 49 days. Value of r .816 (N 105).

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A study on vulnerability to stress

• Underlying dimensions
• We did a principal components factor analysis,
  followed by an orthogonal varimax-type rotation.
• We obtained through this 7 factors which explain
  57.5 of the total variance.

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A study on vulnerability to stress

• The highest-loading items in the various factors
  led us to admit that they express the
  significance which follows
• F1 Perfectionism and intolerance to
  frustration.
• F2 Inhibition and functional dependence.
• F3 Lack of social support.
• F4 Adverse life conditions.
• F5 Dramatisation of existence.
• F6 Subjugation, and
• F7 Deprivation of affection and rejection.

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A study on vulnerability to stress
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A study on vulnerability to stress
Correlations between 23 QVS and E.P.I., P.R.I.,
B.S.I.
E.P.I.
B.S.I.
P.R.I.
Neurot.
Extrav.
SGI
TPS
PSI
23 QVS
.674
-.182
.640
.570
.487
-.639
N 368
p lt .001 for all
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A study on vulnerability to stress
Summing up

• The higher the value of 23 QVS, the higher the
  likelihood that it corresponds to an individual
  who is
• emotional
• with poor coping strategies
• prone to developing psychopathology

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A study on vulnerability to stress

• Using the value of 43 as the cut-off point, we
  analysed the 7 stress-inducing classes in the 368
  subjects of the sample, separated in two groups
  according to the said value.
• The group of individuals with a 23 QVS value 43
  showed a higher number of stressors in all
  classes of events.

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A study on vulnerability to stress

• Hassles, chronic stress events and macro
  stressors were particularly evident.
• Serious traumas and early life traumatic events
  were the least frequent. Nevertheless, they
  showed a higher prevalency in the group with a 23
  QVS value 43.

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A study on vulnerability to stress

• Vaz Serra et al. (1991) had already found that
  individuals with poorer coping strategies tend to
  feel a higher number of problems in various areas
  of their lives, as compared with those who show
  better strategies.

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A study on vulnerability to stress

• Vaz Serra et al. (1991) suggest that the
  individuals with poor coping strategies tend to
  see a problem in everything or making a
  problem out of everything.
• The prominence of hassles, chronic stress and
  macro stressors in individuals with higher 23 QVS
  values suggests that they use inadequate
  strategies in dealing with their everyday
  problems.

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Air traffic controllers

• In a study of 155 air traffic controllers, Isabel
  Mota (2002) used the PRI, the 23 QVS and an
  analogical scale of stress perceived under work
  conditions.
• The average value of 23 QVS for the group
  equalled 30, which makes us admit that their
  elements were not particularly vulnerable to
  stress.

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Air traffic controllers

• Having undertaken a logistical regression for the
  study of stress perceived under work conditions,
  she found a significant effect connected to
  gender and factors 1, 3, 4 and 7 of the 23 QVS.
• According to Isabel Mota the odds ratio showed
  that a womans probability of having a higher
  stress perception than a man under the same work
  conditions is 4.3 times higher.

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Air traffic controllers

• The personal characteristics indicating
• Perfectionism and intolerance to frustration
  (F1).
• Lack of social support (F3).
• Existence of adverse life conditions (F4) and
• Deprivation of affection and rejection (F7)
• are associated to higher levels of perceived
  stress .
• A unit by unit increase of the scores of each of
  the above factors increases between 2 and 3 times
  the risk of belonging to a group of higher
  perceived stress.

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Stress in hotel industry

• José P. Cruz and Helena Costa (2002) made a study
  about stress in the hotel industry in 135
  individuals working for a major chain of hotels
  in the Algarve region.
• By using the 23 QVS, they found a positive and
  highly significant correlation (r .520 p lt
  .001) between that scale and the stress mentioned
  by the respondents.

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War stress in Marine troops

• Monteiro Ferreira (2002) studied 196 former
  Special Marines of the Portuguese Navy who were
  engaged in combat in Angola, Mozambique and
  Guinea-Bissau.
• They were designated for particularly complex and
  dangerous missions.
• The number of years as Marines spanned between 2
  and 11, with a median of 6 years.

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War stress in Marine troops

• The 196 subjects of the sample were individually
  submitted to an interview which consisted of a
  simplified form of CAPS - Clinician Administered
  PTSD Scale (Blake et al., 1995) and also replied
  to 23 QVS.

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War stress in Marine troops

• Two groups of veterans were identified .
• With suspicion of PTSD (N116 59,2 of the
  sample).
• Without suspicion of PTSD (N80 40,8 of the
  sample).

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War stress in Marine troops

• The two groups showed no statistically
  significant differences as regards age and
  educational level.
• Nearly all elements of both groups were married.
• The next slide shows the results which were
  obtained.

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War stress in Marine troops
PTSD N116
No PTSD N80
p
Means
23 QVS
53.41
37.81
.000
F1
3.52
2.88
.000
F2
1.51
0.76
.000
F3
0,93
0.80
N.S.
F4
1.54
1.22
.05
F5
2.27
1.91
.05
F6
1.96
1.11
.000
F7
1.21
0,32
.000
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War stress in Marine troops

• Following a study of sensitivity and specificity,
  it was noted that the 23 QVS scale correctly
  identified
• 85 of those affected by PTSD and
• 83 of those not affected by PTSD.
• It thus proved to be a scale with good
  sensitivity and specificity.

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Quality of life in patients with Multiple
Sclerosis
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Quality of life in patients with MS

• Multiple Sclerosis is a CNS disease which begins
  in ones late teens or early adult life. It shows
  recurrent episodes of dysfunction of the upper
  spinal cord, brain stem, cerebellum, optical
  nerves and the brain, resulting from foci of
  destruction of mielinised fibres (Adams, Victor
  and Ropper, 1998).
• Mohr and Cox (2001) mention that there is a
  relation between the way in which people deal
  with life events and the episodes of remission
  and aggravation of the disease.

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Quality of life in patients with MS

• Sofia Cruz et al. (2004) made a study about the
  influence of resilience and vulnerability to
  stress on the quality of life of Multiple
  Sclerosis patients.
• Being a disease with a low prevalency the authors
  could built up a sample of 34 patients 15
  female and 19 male.

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Quality of life in patients with MS

• Quality of life was evaluated with FAMS
  (Functional Assessment of Multiple Sclerosis -
  Cella et al., 1996).
• Resilience to stress was measured with Aaron
  Antonowskys The Sense of Coherence
  Questionnaire, (SCQ).
• The 23 QVS was used to evaluate the vulnerability
  to stress.

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Quality of life in patients with MS

• Aida Mendes et al. (2004) found these results
• A correlation of -.63 (plt.00) between 23 QVS and
  FAMS.
• Utilising 43 as a cut-off point for the 23 QVS
  they found that the individuals above that value
  mentioned a worse quality of life (p.004).
• A positive correlation (plt.000) between SCQ and
  FAMS.
• A negative correlation of -.683 (plt.000) between
  23 QVS and SCQ.

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Quality of life in patients with MS

• They came to the following conclusions
• The quality of life of Multiple Sclerosis
  patients is inversely related to their
  vulnerability to stress.
• There is a negative and highly significant
  correlation between resilience and vulnerability
  to stress.

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Mental schemas

• Mental schemas are a generalised representation
  of the experiences that regularly appeared to a
  given individual. Once developed, they can
  persist throughout ones entire life.
• They become organisers of principles for the
  individuals emotional and behavioural
  performance.
• They can induce an adequate and adaptative
  behaviour, or an inadequate and maladaptative
  behaviour.

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Mental schemas

• The mental schemas organise the experience in the
  various contexts an individual goes through, and
  enable him to give it a significance.
• They define what is expected to be seen, heard or
  remembered.
• When an individual enters a given situation, he
  will decode it according to his previous
  experiences, which will indicate him what he can
  expect from it and how he should act.

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In brief
Mental Schemas
Information processing

-
Attitudes and behaviour
Attitudes and behaviour
Adaptatives
Maladaptatives
Vulnerability to stress
No vulnerability to stress
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Early Maladaptive Schemas

• Jeffrey Young (1990) mentions that early
  maladaptive schemas are extremely stable and
  enduring themes that develop during childhood and
  are elaborated upon throughout an individuals
  lifetime.
• Schemas are unconditional beliefs about oneself
  in relation to the environment.

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Early Maladaptive Schemas

• They are self-perpetuating and resistant to
  change they are the core of the individuals
  self-concept.
• They are disfunctional in some significant and
  recurring manner.
• They are usually activated by events in the
  environment, relevant to the particular schema.
• Once they are triggered, they are closely tied to
  high levels of negative affect.

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Early Maladaptive Schemas

• Vaz Serra (2005) correlated the 23 QVS to the
  Schema Questionnaire by Young and Brown, 1989.
• The sample comprised 180 indivíduals 90 were
  under treatment due to anxiety disorders (Social
  Phobia, Panic Disorder, GAD, PTSD, Specific
  phobias, OCD, etc.) and 90 were normals, matched
  to the sample of patients.

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Early Maladaptive Schemas
Patients (90)
Normals (90)
p
N180
Age
Mean
31.067
31.244
N.S
S.D.
9.455
10.274
23 QVS total
50.722
31.756
0.000
Mean
S.D.
11.144
7.291
Young total
Mean
336.078
207.422
0.000
S.D.
98.568
48.132
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Early Maladaptive Schemas
23 QVS total
N180
Young total
.803
P .000 for all
Correlations
Schemas
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Early Maladaptive Schemas

• A stepwise regression, with the total value of
  the 23 QVS as the dependent variable, selected
  the following variables
• The Young total score, the following schemas and
  D (being or not being patient)
• Y(1), Y (2), Y (3), Y (5), Y (6), Y (10), Y (15)
  and D.

Df 9 170
F-ratio 57.601
p .000
Squared multiple R .753
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Meaning of the Schemas
Domain
These schemas mean

• Y(1) Dependence

Autonomy

• Y(2) Subjugation/Lack of Individuation

• Y(3) Vulnerability to Harm and Illness

Connectedness
Worthiness

• Y(10) Social Undesirability

Expectations and Limits

• Y(15) Entitlement/Insufficient Limits

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Conclusions

• There are reasons to admit the existence of
  individual differences as regards vulnerability
  to stress.
• The psychological vulnerabilities may be
  understood according to the influence that the
  mental schemas have on the way in which each
  individual processes the information from the
  environment, which then influences attitudes and
  behaviours.
• 23 QVS proved to be a sensitive instrument in
  detecting vulnerability to stress and
  distinguishing between a large variety of
  psychopathological conditions.

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Future research topics

• To make a prospective study in the general
  population in order to know the association
  between vulnerability to stress, social support
  and illness.
• To perform more clinical research with larger
  samples in order to know what are the predominant
  profiles within the vulnerability to stress
  dimensions.

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References
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References

• Adams,R.D., Victor,M e Ropper,A.H. (1998) 6.ª
  edição do Compêndio de Neurologia McGraw Hill.
• Beck,A.T. e Emery,G. (1985) Vulnerability The
  Core of Anxiety Disorders pp. 67-81 in Anxiety
  Disorders and Phobias A Cognitive Perspective -
  U.S.A. Basic Books.
• Brown,G.W. (1993) The role of life events in
  the aetiology of depressive and anxiety disorders
  pp. 23-50 in STRESS From Synapse to
  Syndrome, S.C. Stanford e P. Salmon (eds.)
  Hartcourt Brace Company, Publishers Academic
  Press.
• Coyne,J.C. e Whiffen,V.E. (1995) Issues in
  personality as diathesis for depression the case
  of sociotrophy-dependency and autonomy-self-critic
  ism Psychological Bulletin, 118 358-378.
• Cruz,S., Almeida,A., Ferreira,S. e Mendes,A.C.
  (2004) - Qualidade de vida em doentes com
  Esclerose Múltipla estudo da influência da
  vulnerabilidade e da resiliência ao stress na sua
  avaliação Psiquiatria Clínica, 25(2) 107-114.

78
References

• Kessler,R.C. e Magee,W.J. (1994) The
  disaggregation of vulnerability to depression as
  a function of the determinants of onset and
  recurrence Cap. 9, pp. 239-258 in Stress and
  Mental Health Contemporary Issues and Prospects
  for the Future, W. R. Avison e I. H. Gotlib
  (eds.) - New York Plenum Press.
• Leighton,A.H. (1998) A Perspective on
  Adversity, Stress and Psychopathology - Cap. 28,
  pp. 506-520 in Adversity, Stress and
  Psychopathology, B.P. Dohrenwend (ed.) New
  York, Oxford Oxford University Press.
• Mohr and Cox (2001) Multiple Sclerosis
  Empirical Literature for the Clinical Health
  Psychologist Journal of Clinical Psychology, 57
  479-499.
• Mota,I. M. P. S. (2002) - Percepção de Stress em
  Controladores de Tráfego Aério tese de mestrado
  apresntada à Universidade Fernando Pessoa.
• Vaz-Serra,A., Firmino,H., Pocinho,F.,
  Figueiredo,A.M. (1991) - Coping Mechanisms and
  Stressful Life Events Acta Psiquiátrica
  Portuguesa, 37 5-12
• Vaz-Serra,A. (1999) O stress na vida de todos
  os dias Edição de autor Coimbra
  Distribuidora Dinapress.

79
References

• Vaz-Serra,A. (2000) - Construção de uma escala
  para avaliar a vulnerabilidade ao stress a 23
  QVS - Psiquiatria Clínica, 20 (4) 279-308.
• Vaz-Serra,A. (2005) Esquemas Mentais e
  Vulnerabilidade ao Stress Psiquiatria Clínica
  (aguarda publicação).
• Young,J. (1994) Cognitive Therapy for
  Personality Disorders A Schema-Focused Approach
  (Revised edition) Sarasota, Florida
  Professional Resource Press.
• Young,J., Klosko,J.S. And Weishaar,M.E. (2003)
  Schema Therapy A Practitioners Guide New
  York, London The Guilford Press.