research article about stress

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

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

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

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

16k Accesses

41 Citations

Metrics details

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

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

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

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

Peer Review reports

Introduction

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

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

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

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

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

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

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

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

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

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

Aims of the study

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

Methods and materials

Study design and setting.

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

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

Study participants and sampling

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

Study instruments

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

Perceived Stress Scale (PSS)

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

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

Ways of Coping Questionnaire (WCQ)

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

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

Short Health Anxiety Inventory (SHAI)

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

Data analyses

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

Ethical considerations

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

Sociodemographic characteristics of respondents

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

Perceived stress, anxiety, and coping styles

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

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

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

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

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

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

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

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

Perceived stress differences between coping strategies among the Hungarian students

Health anxiety differences between coping strategies among the Hungarian students

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

Perceived stress differences between coping strategies among the international students

Health anxiety differences between coping strategies among the international students

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

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

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

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

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

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

Comparisons between domestic and international students

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

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

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

Relationship between health anxiety and perceived stress

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

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

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

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

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

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

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

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

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

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

Availability of data and materials

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

Abbreviations

Centers for Disease Control and Prevention

Coronavirus Disease 2019

Perceived Stress Scale

Short Health Anxiety Inventory

Middle East Respiratory Syndrome

Severe Acute Respiratory Syndrome

Ways of Coping Questionnaire

World Health Organization

World Health Organization. Advice for the public on COVID-19. [Online]. 2020. https://www.who.int/emergencies/diseases/novel-coronavirus-2019/advice-for-public . Accessed 9 Sep 2020.

National Center for Public Health. Opportunities to reduce contact numbers—Community events in relation to COVID-19 virus infection. [Online]. 2020. https://www.nnk.gov.hu/index.php/koronavirus-tajekoztato/549-opportunities-to-reduce-contact-numbers-community-events-in-relation-to-covid-19-virus-infection . Accessed 20 Sep 2020.

GardaWorld. Crisis24 News Alert. [Online]. 2020. https://www.garda.com/crisis24/news-alerts?search_api_fulltext=&na_countries%5B%5D=1431&field_news_alert_categories=All&field_news_alert_crit=All&items_per_page=20 . Accessed 20 Sep 2020.

Tanne JH, Hayasaki E, Zastrow M, Pulla P, Smith P, Rada AG. Covid-19: how doctors and healthcare systems are tackling coronavirus worldwide. Br Med J. 2020;368:m1090.

Article   Google Scholar  

Sohrabi C, Alsafi Z, O’Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). Int J Surg. 2020;76:71–6.

Rosenbaum L. Facing Covid-19 in Italy—ethics, logistics, and therapeutics on the epidemic’s front line. N Engl J Med. 2020;382:1873–5. https://doi.org/10.1056/NEJMp2005492 .

Article   PubMed   Google Scholar  

Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate Psychological Responses and Associated Factors during the Initial Stage of the 2019 Coronavirus Disease (COVID-19) epidemic among the general population in China. Int J Environ Res Public Health. 2020;17:1729.

Akour A, Al-Tammemi AB, Barakat M, Kanj R, Fakhouri HN, Malkawi A, et al. The impact of the COVID-19 pandemic and emergency distance teaching on the psychological status of university teachers: a cross-sectional study in Jordan. Am J Trop Med Hyg. 2020;103:2391–9.

Al-Tammemi AB, Akour A, Alfalah L. Is it just about physical health? An online cross-sectional study exploring the psychological distress among university students in Jordan in the Midst of COVID-19 Pandemic. Front Psychol. 2020;11:562213.

Roddenberry A, Renk K. Locus of control and self-efficacy: potential mediators of stress, illness, and utilization of health services in college students. Child Psychiatry Hum Dev. 2010;41:353–70.

Racic M, Todorovic R, Ivkovic N, Masic S, Joksimovic B, Kulic M. Self- perceived stress in relation to anxiety, depression and health-related quality of life among health professions students: a cross-sectional study from Bosnia and Herzegovina. Slov J Public Heal. 2017;56:251–9.

Görgen SM, Hiller W, Witthöft M. Health anxiety, cognitive coping, and emotion regulation: a latent variable approach. Int J Behav Med. 2014;21:364–74.

Abramowitz JS, Braddock A. Psychological treatment of health anxiety and hypochondriasis: a biopsychosocial approach. Boston: Hogrefe Publishing; 2008.

Google Scholar  

Taylor S, Asmundson GJG. Treating health anxiety: a cognitive-behavioral approach. 1st ed. New York: Guilford Press; 2004.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders,(DSM-5). 5th edition. Washington, DC: American Psychiatric Association; 2013.

Wheaton MG, Abramowitz JS, Berman NC, Fabricant LE, Olatunji BO. Psychological predictors of anxiety in response to the H1N1 (swine flu) pandemic. Cognit Ther Res. 2012;36:210–8.

Asmundson GJG, Taylor S. How health anxiety influences responses to viral outbreaks like COVID-19: What all decision-makers, health authorities, and health care professionals need to know. J Anxiety Disord. 2020;71:102211.

Taha SA, Matheson K, Anisman H. The 2009 H1N1 influenza pandemic: the role of threat, coping, and media trust on vaccination intentions in Canada. J Health Commun. 2013;18:278–90.

Phua DH, Tang HK, Tham KY. Coping responses of emergency physicians and nurses to the 2003 severe acute respiratory syndrome outbreak. Acad Emerg. 2005;12:322–8.

Teasdale E, Yardley L, Schlotz W, Michie S. The importance of coping appraisal in behavioural responses to pandemic flu. Br J Health Psychol. 2012;17:44–59.

Sim K, Huak Chan Y, Chong PN, Chua HC, Wen SS. Psychosocial and coping responses within the community health care setting towards a national outbreak of an infectious disease. J Psychosom Res. 2010;68:195–202.

Lazarus RS. Stress and emotion: a new synthesis. London: Free Association Books; 1999.

Lazarus RS, Folkman S. Stress, appraisal, and coping. New York: Springer; 1984.

Lazarus RS, Folkman S. Transactional theory and research on emotions and coping. Eur J Pers. 1987;1:141–69.

Cai H, Tu B, Ma J, Chen L, Fu L, Jiang Y, et al. psychological impact and coping strategies of frontline medical staff in hunan between January and March 2020 during the Outbreak of Coronavirus Disease 2019 (COVID-19) in Hubei. China Med Sci Monit. 2020;26:e924171.

PubMed   Google Scholar  

Chua SE, Cheung V, Cheung C, McAlonan GM, Wong JWS, Cheung EPT, et al. Psychological effects of the SARS outbreak in Hong Kong on high-risk health care workers. Can J Psychiatry. 2004;49:391–3. https://doi.org/10.1177/070674370404900609 .

Flesia L, Monaro M, Mazza C, Fietta V, Colicino E, Segatto B, et al. Predicting perceived stress related to the Covid-19 outbreak through stable psychological traits and machine learning models. J Clin Med. 2020;9:3350.

Khalid I, Khalid TJ, Qabajah MR, Barnard AG, Qushmaq IA. Healthcare workers emotions, perceived stressors and coping strategies during a MERS-CoV outbreak. Clin Med Res. 2016;14:7–14.

Gee S, Skovdal M. The role of risk perception in willingness to respond to the 2014–2016 West African Ebola outbreak: a qualitative study of international health care workers. Glob Heal Res Policy. 2017;2:21.

Gerhold L. COVID-19: Risk perception and Coping strategies. Results from a survey in Germany. PsyArXiv Prepr. 2020.

Auerbach RP, Alonso J, Axinn WG, Cuijpers P, Ebert DD, Green JG, et al. Mental disorders among college students in the World Health Organization World Mental Health Surveys. Psychol Med. 2016;46:2955–70.

Bíró É. Studies on the mental health of students in higher education. University of Debrecen; 2014. https://dea.lib.unideb.hu/dea/handle/2437/195979 . Accessed 15 Feb 2021.

The University of Debrecen. Facts and Figures. [Online]. 2020. https://www.edu.unideb.hu/page.php?id=28 . Accessed 25 Dec 2020.

Cohen S. Perceived stress in a probability sample of the United States. In: The social psychology of health. Thousand Oaks: Sage Publications, Inc; 1988. p. 31–67.

Strauder A, Thege BK. Az Észlelt Stressz Kérdőív (PSS) Magyar Verziójának Jellemzői. Mentálhigiéné És Pszichoszomatika. 2006;7:203–16.

Sørlie T, Sexton HC. The factor structure of “The Ways of Coping Questionnaire” and the process of coping in surgical patients. Pers Individ Dif. 2001;30:961–75.

Rózsa S, Purebl G, Susánszky É, Kő N, Szádóczky E, Réthelyi J, et al. Dimensions of coping: Hungarian adaptation of the Ways of Coping Questionnaire. Mentálhigiéné És Pszichoszomatika. 2008; 217–241.

Salkovskis PM, Rimes KA, Warwick HMC. The Health Anxiety Inventory: development and validation of scales for the measurement of health anxiety and hypochondriasis. Psychol Med. 2002;32:843.

Alberts NM, Hadjistavropoulos HD, Jones SL, Sharpe D. The Short Health Anxiety Inventory: a systematic review and meta-analysis. J Anxiety Disord. 2013;27:68–78.

Köteles F, Simor P, Bárdos G. Validation and psychometric evaluation of the Hungarian version of the Short Health Anxiety Inventory (SHAI). Mentálhigiéné és Pszichoszomatika. 2011;12:191–213.

Artino AR. Regulation of Emotion. In: Encyclopedia of Child Behavior and Development. Boston, MA: Springer US; 2011. p. 1236–8.

Gross JJ. The emerging field of emotion regulation: an integrative review. Rev Gen Psychol. 1998;2:271–99.

Kaczkurkin AN, Foa EB. Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues Clin Neurosci. 2015;17:337–46.

Jungmann SM, Witthöft M. Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: Which factors are related to coronavirus anxiety? J Anxiety Disord. 2020;73:102239.

Taha S, Matheson K, Cronin T, Anisman H. Intolerance of uncertainty, appraisals, coping, and anxiety: the case of the 2009 H1N1 pandemic. Br J Health Psychol. 2014;19:592–605.

Umucu E, Lee B. Examining the impact of COVID-19 on stress and coping strategies in individuals with disabilities and chronic conditions. Rehabil Psychol. 2020;65:193–8.

Main A, Zhou Q, Ma Y, Luecken LJ, Liu X. Relations of SARS-related stressors and coping to Chinese college students’ psychological adjustment during the 2003 Beijing SARS epidemic. J Couns Psychol. 2011;58:410–23.

Özdin S, Bayrak ÖŞ. Levels and predictors of anxiety, depression and health anxiety during COVID-19 pandemic in Turkish society: the importance of gender. Int J Soc Psychiatry. 2020;66:504–11.

Taylor S, Landry CA, Paluszek MM, Fergus TA, McKay D, Asmundson GJG. COVID stress syndrome: concept, structure, and correlates. Depress Anxiety. 2020;37:706–14.

Gamonal Limcaoco RS, Mateos EM, Fernández JM, Roncero C. Anxiety, worry and perceived stress in the world due to the COVID-19 pandemic, March 2020. Preliminary results. MedRxiv Prepr. 2020.

Abouammoh N, Irfan F, AlFaris E. Stress coping strategies among medical students and trainees in Saudi Arabia: a qualitative study. BMC Med Educ. 2020;20:124.

Gade S, Chari S, Gupta M. Perceived stress among medical students: to identify its sources and coping strategies. Arch Med Health Sci. 2014;2:80–6.

Leszko M, Iwański R, Jarzębińska A. The relationship between personality traits and coping styles among first-time and recurrent prisoners in Poland. Front Psychol. 2020;10:2969.

Centers for Disease Control and Prevention. Mental Health and Coping During COVID-19 Pandemic. [Online]. 2020. https://www.cdc.gov/coronavirus/2019-ncov/daily-life-coping/managing-stress-anxiety.html . Accessed 9 Sep 2020.

Download references

Acknowledgments

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

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

Author information

Authors and affiliations.

Doctoral School of Health Sciences, University of Debrecen, Debrecen, Hungary

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

Department of Psychiatry, Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Szabolcs Garbóczy

Department of Personality and Clinical Psychology, Institute of Psychology, University of Debrecen, Debrecen, Hungary

Anita Szemán-Nagy

Faculty of Medicine, University of Debrecen, Debrecen, Hungary

Mohamed S. Ahmad & Viktor Rekenyi

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

Dorottya Ocsenás

Doctoral School of Human Sciences, University of Debrecen, Debrecen, Hungary

Department of Family and Occupational Medicine, Faculty of Medicine, University of Debrecen, Móricz Zs. krt. 22, Debrecen, 4032, Hungary

Ala’a B. Al-Tammemi & László Róbert Kolozsvári

You can also search for this author in PubMed   Google Scholar

Contributions

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

Corresponding author

Correspondence to László Róbert Kolozsvári .

Ethics declarations

Ethics approval and consent to participate.

Ethical permission was obtained from the Hungarian Ethical Review Committee for Research in Psychology (Reference number: 2020-45). All methods were carried out following the institutional guidelines and conforming to the ethical standards of the declaration of Helsinki. All participants were informed about the study and written informed consent was obtained before completing the survey.

Consent for publication

Not Applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

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

Download citation

Received : 07 January 2021

Accepted : 26 March 2021

Published : 06 April 2021

DOI : https://doi.org/10.1186/s40359-021-00560-3

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Health anxiety
• Perceived stress
• Coping styles
• University students

BMC Psychology

ISSN: 2050-7283

• General enquiries: [email protected]

Transforming stress through awareness, education and collaboration.

Stress Research

“The difficulty in science is often not so much how to make the discovery but rather to know that one has made it.” – J.D. Bernal

2022 Stress Statistics

Two years after the World Health Organization declared COVID-19 a global pandemic, inflation, money issues and the war in Ukraine have pushed U.S. stress to alarming levels, according to polls conducted for the American Psychological Association .

A late-breaking poll, fielded March 1-3 by The Harris Poll on behalf of APA, revealed striking findings, with more adults rating inflation and issues related to the invasion of Ukraine as stressors than any other issue asked about in the 15-year history of the Stress in America TM  poll. This comes on top of money stress at the highest recorded level since 2015, according to a broader Stress in America poll fielded last month.

Top sources of stress were the rise in prices of everyday items due to inflation (e.g., gas prices, energy bills, grocery costs, etc.) (cited by 87%), followed by supply chain issues (81%), global uncertainty (81%), Russia’s invasion of Ukraine (80%) and potential retaliation from Russia (e.g., in the form of cyberattacks or nuclear threats) (80%).

Adults also reported separation and conflict as causes for straining and/or ending of relationships. Half of adults (51%, particularly essential workers at 61%) said they have loved ones they have not been able to see in person in the past two years as a result of the COVID-19 pandemic. Strikingly, more than half of all U.S. adults (58%) reported experiencing a relationship strain or end as a result of conflicts related to the COVID-19 pandemic, including canceling events or gatherings due to COVID-19 concerns (29%); difference of opinion over some aspect of vaccines (25%); different views of the pandemic overall (25%); and difference of opinion over mask-wearing (24%).

Key Stress Statistics

Americans are one of the most stressed out in the world. The current stress level experienced by Americans is 20 percentage points higher than the global average. The country’s rate is similar to Louisiana’s, the most stressed state. Globally, Greece has the highest reported stress level at 59%.

• 55% of Americans are stressed during the day.
• The global average of the number of stressed people out of 143 countries is 35%.
• Paraguay is the country with the highest positive experience index.
• Afghanistan is the least positive country in the world with a positive experience index of 43% lower than its score in the previous year.
• Stress causes 57% of US respondents to feel paralyzed.
• 63% of US workers are ready to quit their job to avoid work-related stress.
• Chronic stress is commonplace at work with 94% of workers reporting feeling stress at work.
• 59% of Greeks have reported experiencing stress in the previous day.
• Montana is the least stressed US state with a total stress score of 26.81 while Louisiana the most stressed with 59.94.

Causes and Sources of Stress

Living conditions, the political climate, financial insecurity, and work issues are some stressors US adults cite as the cause of their stress. Ineffective communications increase work stress to the point of frustration that workers want to quit.  These stressors, unfortunately, are not something people can just ignore. Quitting a job would result in debt and financial instability which, in turn, would be added stressors.

• 35% of workers say their boss is a cause of their workplace stress.
• 80% of US workers experience work stress because of ineffective company communications.
• 39% of North American employees report their workload the main source of the work stress.
• 49% of 18 – 24 year olds who report high levels of stress felt comparing themselves to others is a stressor.
• 71% of US adults with private health insurance say the cost of healthcare causes them stress while 53% with public insurance say the same.
• 54% of Americans want to stay informed about the news but following the news causes them stress.
• 42% of US adults cite personal debt as a source of significant stress.
• 1 in 4 American adults say discrimination is a significant source of stress.
• Mass shootings are a significant source of stress across all races; 84% of Hispanic report this, the highest among the races.

Stress and Relationships

People under stress admit to taking out their frustration on other people. Targets for venting out include strangers and those they have personal relationships with. Men and women report different levels of how work stress affects their relationships with their spouses.

• 76% of US workers say their workplace stress has had a negative impact on their personal relationships.
• Seven in 10 adults report work stress affects their personal relationships.
• 79% of men report work stress affects their personal relationship with their spouse compared to 61% for women.
• 36% of adults reported experiencing stress caused by a friend or loved one’s long-term health condition.

Stress Management Statistics

A look at the stress management techniques employed by US adults to deal with their stress, an overwhelming majority are self-care practices. Though very helpful, it does not address the stressor at the root of the problem. Stress management programs would be beneficial not only for employees but for the company in the long run.

• 30% of Us adults eat comfort food “more than the usual” when faced with a challenging or stressful event.
• 51% of US adults engage in prayer—a routine activity—when faced with a challenge or stressful situation.
• Coping mechanisms of Gen Z and Millenials experiencing stress in the US 44% of Gen Z and 40% of Millenials sleep in while exercising counts for 14% and 20% respectively.
• 49% of US adults report enduring stressful situations as a coping behavior to handle stress.
• Less than 25% of those with depression worldwide have access to mental health treatments.

CompareCamp

American Psychological Association

Cardiac Coherence and Post-traumatic Stress Disorder in Combat Veterans

Jay P. Ginsberg, Ph.D.; Melanie E. Berry, M.S.; Donald A Powell, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010;16 (4):52-60. PDF version of the complete paper: Cardiac Coherence and PTSD in Combat Veterans

Abstract-PTSD

Background: The need for treatment of posttraumatic stress disorder (PTSD) among combat veterans returning from Afghanistan and Iraq is a growing concern. PTSD has been associated with reduced cardiac coherence (an indicator of heart rate variability [HRV]) and deficits in early-stage information processing (attention and immediate memory) in different studies. However, the co-occurrence of reduced coherence and cognition in combat veterans with PTSD has not been studied before.

Primary Study Objective: A pilot study was undertaken to assess the covariance of coherence and information processing in combat veterans. An additional study goal was an assessment of the effects of HRV biofeedback (HRVB) on coherence and information processing in these veterans.

Methods/Design: A two-group (combat veterans with and without PTSD), a pre-post study of coherence and information processing was employed with baseline psychometric covariates.

Setting: The study was conducted at a VA Medical Center outpatient mental health clinic.

Participants: Five combat veterans from Iraq or Afghanistan with PTSD and five active-duty soldiers with comparable combat exposure who were without PTSD.

Intervention: Participants met with an HRVB professional once weekly for 4 weeks and received visual feedback in HRV patterns while receiving training in resonance frequency breathing and positive emotion induction.

Primary Outcome Measures: Cardiac coherence, word list learning, commissions (false alarms) in go—no go reaction time, digits backward.

Results: Cardiac coherence was achieved in all participants, and the increase in coherence ratio was significant post-HRVB training. Significant improvements in the information processing indicators were achieved. Degree of increase in coherence was the likely mediator of cognitive improvement.

Conclusion: Cardiac coherence is an index of the strength of control of parasympathetic cardiac deceleration in an individual that has cardinal importance for the individual’s attention and affect regulation.

The Effect of a Biofeedback-based Stress Management Tool on Physician Stress: A Randomized Controlled Clinical Trial

Jane B. Lemaire, Jean E. Wallace, Adriane M. Lewin, Jill de Grood, Jeffrey P. Schaefer

Open Medicine 2011; 5(4)E154. PDF version of the complete paper: physician-stress-randomized-controlled-clinical-trial

Abstract- Biofeedback-based Stress Management

Background: Physicians often experience work-related stress that may lead to personal harm and impaired professional performance. Biofeedback has been used to manage stress in various populations.

Objective: To determine whether a biofeedback-based stress management tool, consisting of rhythmic breathing, actively self-generated positive emotions and a portable biofeedback device, reduces physician stress.

Design: Randomized controlled trial measuring the efficacy of a stress-reduction intervention over 28 days, with a 28-day open-label trial extension to assess effectiveness.

Setting: Urban tertiary care hospital.

Participants: Forty staff physicians (23 men and 17 women) from various medical practices (1 from primary care, 30 from a medical specialty and 9 from a surgical specialty) were recruited by means of electronic mail, regular mail and posters placed in the physicians’ lounge and throughout the hospital.

Intervention: Physicians in the intervention group were instructed to use a biofeedback-based stress management tool three times daily. Participants in both the control and intervention groups received twice-weekly support visits from the research team over 28 days, with the intervention group also receiving re-inforcement in the use of the stress management tool during these support visits. During the 28-day extension period, both the control and the intervention groups received the intervention, but without intensive support from the research team.

Main outcome measure: Stress was measured with a scale developed to capture short-term changes in global perceptions of stress for physicians (maximum score 200).

Results: During the randomized controlled trial (days 0 to 28), the mean stress score declined significantly for the intervention group (change -14.7, standard deviation [SD] 23.8; p = 0.013) but not for the control group (change -2.2, SD 8.4; p = 0.30). The difference in mean score change between the groups was 12.5 (p = 0.048). The lower mean stress scores in the intervention group were maintained during the trial extension to day 56. The mean stress score for the control group changed significantly during the 28-day extension period (change -8.5, SD 7.6; p < 0.001).

Conclusion: A biofeedback-based stress management tool may be a simple and effective stress-reduction strategy for physicians.

Coherence Training In Children With Attention-Deficit Hyperactivity Disorder: Cognitive Functions and Behavioral Changes

Anthony Lloyd, Ph.D.; Davide Brett, B.Sc.; Ketith Wesnes, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010; 16 (4):34-42

PDF version of the complete paper: coherence-training-in-children-with-adhd

Abstract-ADHD

Attention-deficit hyperactivity disorder (ADHD) is the most prevalent behavioral diagnosis in children, with an estimated 500 000 children affected in the United Kingdom alone. The need for an appropriate and effective intervention for children with ADHD is a growing concern for educators and childcare agencies. This randomized controlled clinical trial evaluated the impact of the HeartMath self-regulation skills and coherence training program (Institute of HeartMath, Boulder Creek, California) on a population of 38 children with ADHD in academic year groups 6, 7, and 8. Learning of the skills was supported with heart rhythm coherence monitoring and feedback technology designed to facilitate self-induced shifts in cardiac coherence. The cognitive drug research system was used to assess cognitive functioning as the primary outcome measure. Secondary outcome measures assessed teacher and student reposted changes in behavior. Participants demonstrated significant improvements in various aspects of cognitive functioning such as delayed word recall, immediate word recall, word recognition, and episodic secondary memory. Significant improvements in behavior were also found. The results suggest that the intervention offers a physiologically based program to improve cognitive functioning in children with ADHD and improve behaviors that is appropriate to implement in a school environment.

Coherence and Health Care Cost – RCA Actuarial Study: A Cost-Effectiveness Cohort Study

Woody Bedell; Mariette Kaszkin-Bettag, Ph.D.

Alternative Therapies in Health and Medicine, A Peer-Reviewed Journal, 2010;16 (4):26-31. PDF version of the complete paper: rca-actuarial-study-coherence-and-health-care

Abstract-Health and Medicine

Chronic stress is among the most costly health problems in terms of direct health costs, absenteeism, disability, and performance standards. The Reformed Church in America (RCA) identified stress among its clergy as a major cause of higher-than-average health claims and implemented HeartMath (HM) to help its participants manage stress and increase physiological resilience. The 6-week HM program Revitalize You! was selected for the intervention including the emWave Personal Stress Reliever technology.

From 2006 to 2007, completion of a health risk assessment (HRA) provided eligible clergy with the opportunity to participate in the HM program or a lifestyle management program (LSM). Outcomes for that year were assessed with the Stress and Well-being Survey. Of 313 participants who completed the survey, 149 completed the Revitalize You! The program and 164 completed the LSM. Well-being, stress management, resilience, and emotional vitality were significantly improved in the HM group as compared to the LSM group.

In an analysis of the claims costs data for 2007 and 2008, 144 pastors who had participated in the HM program were compared to 343 non-participants (control group). Adjusted medical costs were reduced by 3.8% for HM participants in comparison with an increase of 9.0% for the control group. For the adjusted pharmacy costs, an increase of 7.9% was found compared with an increase of 13.3% for the control group. Total 2008 savings as a result of the HM program are estimated at $585 per participant, yielding a return on investment of 1.95:1. These findings show that HM stress-reduction and coherence-building techniques can reduce health care costs.

View my collection, “Stress and Cardiovascular Disease” from NCBI

View my collection, “Stress and Cancer” from NCBI

View my collection, “Stress and Diabetes” from NCBI

View my collection, “Post Traumatic Stress Disorder” from NCBI

View my collection, “Stress and Aging” from NCBI

View my collection, “Stress in Adolenscents” from NCBI

View my collection, “Stress and Meditation” from NCBI

View my collection, “Stress and Yoga” from NCBI

View my collection, “Workplace Stress” from NCBI

Want to receive the latest news and info from AIS? Sign up to receive our enewsletter.

What about our FREE magazines?

Contentment Magazine Combat Stress Magazine

• Reference Manager
• Simple TEXT file

People also looked at

Editorial article, editorial: the impact of stress on cognition and motivation.

• 1 Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
• 2 ICVS-3Bs PT Government Associate Laboratory, Guimarães, Portugal

Editorial on the Research Topic The Impact of Stress on Cognition and Motivation

Stress is usually defined as an actual or anticipated threat or disruption of organism homeostasis, which usually leads to an acute stress response allowing for adaptation to the new condition. Conversely, chronic stress usually leads to maladaptive responses in various organs and systems, activating pathophysiological mechanisms such as psychiatric disturbances, neurologic disorders, cardiovascular diseases and metabolic dysregulation ( Sousa, 2016 ). The impact of chronic stress in cognition and motivation has been extensively described in the literature. In this Research Topic of Frontiers in Behavioral Neuroscience, a host of new empirical findings on the impact of stress on cognition and motivation was presented in a translational perspective from rodents to humans.

The detrimental impact of stress on behavior can be established early in development, including from exposure before birth. Usually described as programming effects, these are well described after strongly stressful experiences during pregnancy. In one of the papers of this series, Soares-Cunha and co-workers extend our understanding of programming effects by showing that even mild stressful events during this critical period can lead to long-lasting structural and neurochemical alterations and anxious- and depressive-like behaviors in the offspring ( Soares-Cunha et al. ).

Social stress is also known to induce depressive-like behaviors. Using tests based on association learning, Kúkel'ová et al. show that chronic social stress (CSS) can lead to reductions in reward salience and effort valuation in mice, decision-making deficits that can also be observed in patients depression and schizophrenia ( Kúkel'ová et al. ), adding to the external validity of the model. Moreover, in another paper of the series, by Yang and collaborators, CSS induced spatial-working and contextual-fear memory deficits were related with decreased levels of N-methyl-D-aspartate receptor subunit 2B (NR2B), impaired long term potentiation (LTP) and NMDA receptor-mediated excitatory postsynaptic currents in the hippocampus ( Yang et al. ). Importantly, both memory impairments and electrophysiological alterations were attenuated by antidepressant treatment with the NMDA-antagonist ketamine ( Yang et al. ), adding further evidence to support a role for glutamate excitotoxicity in such stress-related deficits.

Although post-traumatic stress disorder (PTSD) is a widely recognized and often devastating consequence of exposure to intense stress, the biochemical mechanisms underlying the creation of the fear memory remain poorly understood. In a very interesting paper in this regard, Han and co-workers show that the behavioral consequences of exposure to a stress protocol designed to mimic a PTSD like-condition [single prolonged stress (SPS) protocol and immobilization-stress (IM)] are associated with decreased LTP as well as decreased stathmin and increased Rin1 expression in the hippocampus and the amygdala ( Han et al. ). Of note, both regions are implicated in the regulation of fear memory, further stressing the significance of these findings.

The serotoninergic system has been involved in both anxiety state and trait, particularly through the activity of 5-HT2A receptors. To assess how anxiety trait can modulate the role of 5-HT2A in stress-induced anxiety, León and collaborators treated animals with high and low freezing responses to contextual cues previously associated with footshock with ketanserin, a preferential 5-HT2A receptor blocker. Their finding of an opposite effect of the drug on the two lines highlights and adds insight into the relevance of genetic variability in the establishment of stress responses ( León et al. ).

Like serotonin, glial-derived neurotrophic factor (GDNF) has been implicated in the regulation of stress responses. Specifically, it was previously recognized that up-regulation of GDNF expression is associated with increased stress resilience. In a paper in the present Research Topic, Buhusi and co-authors extend this findings by showing that the opposite is also true: GDNF-deficient mice are more vulnerable to stress, failing to express latent inhibition (LI) which results in slower learning of new conditioning associations ( Buhusi et al. ). Moreover, this LI impairment was associated with a decreased neuronal activation in the nucleus accumbens shell and increased activation in the nucleus accumbens core.

Decision-making processes are among the cognitive-related dimensions widely affected by stress. Work from ours and other groups has shown that chronic stress promotes a switch from a flexible and contextualized goal directed system of responses to a more rigid habit based system ( Dias-Ferreira et al., 2009 ). In line with this, a paper by Maran and colleagues in the present series shows that high arousal states disturb spatial and sequence learning, discrimination of spatial positions and learning of associative sequences, which could all reflect a reduced involvement of the flexible cognitive systems responsible for the sensitivity for contextual details ( Maran et al. ).

We have previously shown that risk-based decision making is also impacted by chronic stress exposure ( Morgado et al., 2015 ). In the present Research Topic, Simonovic and colleagues translate our findings to humans, showing that stress exposure impairs performance in the Iowa Gambling Task (IGT), delaying the avoidance of the disadvantageous decks ( Simonovic et al. ). In the same vein, Starcke and colleagues show that the exposure to unsolvable anagrams also induces more disadvantageous decisions on the IGT ( Starcke et al. ), an effect particularly observed in male participants.

Given the vast consequences of stress exposure and its ubiquitous presence in our everyday lives, research on attenuating measures is of high clinical and even societal relevance. In a very interesting paper of this series, DiMenichi and co-authors show that writing about past failures before experiencing a stressor attenuated subsequent stress responses and reduced their physiological and behavioral effects ( DiMenichi et al. ), a finding that can be easily transposed to practice.

Altogether, the findings put forward in this research topic contribute to a better understanding of how stress impacts on cognition and motivation, providing a broad range of insights from the molecular and cellular processes that underlie behavioral alterations to new interventions that can ameliorate stress-induced impairments.

Author Contributions

PM and JJC wrote this article and approved it for publication.

This work was supported by FEDER funds, through the Competitiveness Factors Operational Programme (COMPETE), and by National funds, through the Foundation for Science and Technology (FCT), under the scope of the project POCI-01-0145-FEDER-007038. This article has been developed under the scope of the project NORTE-01-0145-FEDER-000013, supported by the Northern Portugal Regional Operational Programme (NORTE 2020), under the Portugal 2020 Partnership Agreement, through the European Regional Development Fund (FEDER), and the BIAL foundation, Porto, Portugal (grant number PT/FB/BL-2016-206).

Conflict of Interest Statement

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

Dias-Ferreira, E., Sousa, J. C., Melo, I., Morgado, P., Mesquita, A. R., Cerqueira, J. J., et al. (2009). Chronic stress causes frontostriatal reorganization and affects decision-making. Science 325, 621–625. doi: 10.1126/science.1171203

PubMed Abstract | CrossRef Full Text | Google Scholar

Morgado, P., Marques, F., Ribeiro, B., Leite-Almeida, H., Pego, J. M., Rodrigues, A. J., et al. (2015). Stress induced risk-aversion is reverted by D2/D3 agonist in the rat. Eur. Neuropsychopharmacol. 25, 1744–1752. doi: 10.1016/j.euroneuro.2015.07.003

Sousa, N. (2016). The dynamics of the stress neuromatrix. Mol. Psychiatry 21, 302–312. doi: 10.1038/mp.2015.196

Keywords: cognition, stress, motivation, behavior, decision-making

Citation: Morgado P and Cerqueira JJ (2018) Editorial: The Impact of Stress on Cognition and Motivation. Front. Behav. Neurosci. 12:326. doi: 10.3389/fnbeh.2018.00326

Received: 02 December 2018; Accepted: 11 December 2018; Published: 21 December 2018.

Reviewed by:

Copyright © 2018 Morgado and Cerqueira. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Pedro Morgado, [email protected]

This article is part of the Research Topic

The Impact of Stress on Cognition and Motivation

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• 15 January 2020

Stress, anxiety, harassment: huge survey reveals pressures of scientists’ working lives

• Alison Abbott

You can also search for this author in PubMed   Google Scholar

A survey of more than 4,000 scientists has painted a damning picture of the culture in which they work, suggesting that highly competitive and often hostile environments are damaging the quality of research.

Access options

Access Nature and 54 other Nature Portfolio journals

Get Nature+, our best-value online-access subscription

24,99 € / 30 days

cancel any time

Subscribe to this journal

Receive 51 print issues and online access

185,98 € per year

only 3,65 € per issue

Rent or buy this article

Prices vary by article type

Prices may be subject to local taxes which are calculated during checkout

Nature 577 , 460-461 (2020)

doi: https://doi.org/10.1038/d41586-020-00101-9

Reprints and permissions

Related Articles

• Institutions

CERN’s impact goes way beyond tiny particles

Spotlight 17 APR 24

Exclusive: official investigation reveals how superconductivity physicist faked blockbuster results

News 06 APR 24

Larger or longer grants unlikely to push senior scientists towards high-risk, high-reward work

Nature Index 25 MAR 24

Breaking ice, and helicopter drops: winning photos of working scientists

Career Feature 23 APR 24

Londoners see what a scientist looks like up close in 50 photographs

Career News 18 APR 24

Dad always mows on summer Saturday mornings

Futures 17 APR 24

Postdoctoral Research Fellow

Description Applications are invited for a postdoctoral fellow position at the Lunenfeld-Tanenbaum Research Institute, Sinai Health, to participate...

Toronto (City), Ontario (CA)

Sinai Health

Postdoctoral Research Associate - Surgery

Memphis, Tennessee

St. Jude Children's Research Hospital (St. Jude)

Open Rank Faculty Position in Biochemistry and Molecular Genetics

The Department of Biochemistry & Molecular Genetics (www.virginia.edu/bmg) and the University of Virginia Cancer Center

Charlottesville, Virginia

Biochemistry & Molecular Genetics

Postdoctoral Position - Synthetic Cell/Living Cell Spheroids for Interactive Biomaterials

Co-assembly of artificial cells and living cells to make co-spheroid structures and study their interactive behavior for biomaterials applications.

Mainz, Rheinland-Pfalz (DE)

University of Mainz

2024 Recruitment notice Shenzhen Institute of Synthetic Biology: Shenzhen, China

The wide-ranging expertise drawing from technical, engineering or science professions...

Shenzhen,China

Shenzhen Institute of Synthetic Biology

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Cell Stress
• v.5(6); 2021 Jun

The evolution of the concept of stress and the framework of the stress system

1 Center for Aging Biomedicine, Key Laboratory of Protein Chemistry and Developmental Biology of Fish of Ministry of Education, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China.

2 National & Local Joint Engineering Laboratory of Animal Peptide Drug Development, College of Life Sciences, Hunan Normal University, Changsha, Hunan 410081, China.

3 Key Laboratory of Hunan Province for Model Animal and Stem Cell Biology, School of Medicine, Hunan Normal University, Changsha, Hunan 410081, China.

Stress is a central concept in biology and has now been widely used in psychological, physiological, social, and even environmental fields. However, the concept of stress was cross-utilized to refer to different elements of the stress system including stressful stimulus, stressor, stress response, and stress effect. Here, we summarized the evolution of the concept of stress and the framework of the stress system. We find although the concept of stress is developed from Selye's “general adaptation syndrome”, it has now expanded and evolved significantly. Stress is now defined as a state of homeostasis being challenged, including both system stress and local stress. A specific stressor may potentially bring about specific local stress, while the intensity of stress beyond a threshold may commonly activate the hypothalamic-pituitary-adrenal axis and result in a systematic stress response. The framework of the stress system indicates that stress includes three types: sustress (inadequate stress), eustress (good stress), and distress (bad stress). Both sustress and distress might impair normal physiological functions and even lead to pathological conditions, while eustress might benefit health through hormesis-induced optimization of homeostasis. Therefore, an optimal stress level is essential for building biological shields to guarantee normal life processes.

INTRODUCTION

Over the past decades, the concepts of stress have evolved and expanded significantly. Although the current concept of stress is developed from the pioneering contributions of Claude Bernard [ 1 ], Walter B. Cannon [ 2 ], and Hans Selye [ 3 ], stress no longer specifically refers to the acute activation of hypothalamic-pituitary-adrenal (HPA) axis and a series of compensatory sympathoadrenal responses when homeostasis is threatened [ 2 , 3 ]. It is now clear that even lower organisms or isolated tissues and cells also have stress responses [ 4 , 5 ]. Meanwhile, with the specifying of the concept of homeostasis, the concept of stress is becoming more and more specific. For instance, oxidative stress specifically refers to a disruption of redox signaling and control [ 6 , 7 ], and endoplasmic reticulum stress refers to the stress induced by the accumulation of unfolded proteins in the endoplasmic reticulum [ 8 ]. With the extension of the concept of homeostasis, the concept of stress has permeated our culture in many aspects, it has become a core concept in the field of biology and medicine, and has been widely used in psychological, physiological, social, and environmental fields.

The implications of stress have expanded greatly. It now includes not only the negative aspects such as “general adaptation syndrome (GAS)” defined by Selye, threats to health and life, but also the positive aspects such as adapting to the existing environment and anticipating future challenges. Therefore, even Selye also suggests that it should be better to categorize stress into “eustress” meaning good stress, and “distress” meaning bad stress [ 9 ]. However, many scientists still use Selye's “GAS” to define stress, and simply interpret stress as a threat to health. An important reason for this is that the concept of stress itself has not been uniform. As Selye said, the concept of stress is often confused with the concept of stressful stimulus, stressor, stress response, and stress effect [ 9 ].

Therefore, this paper will first construct the basic framework of the stress system, and then summarize the key developments that have contributed to shaping the framework. Through this way, we hope the mature framework of the stress system will help to integrate stress-related concepts from disparate fields of science and medicine, and allow the concept of stress to be common across different fields.

THE BASIC FRAMEWORK OF THE STRESS SYSTEM

Many scientists have noticed that the stress system contains several elements, such as stressful stimulus, stressor, and stress response [ 4 , 5 , 9 ]. Considering that the process of stress acting on the body is generally similar to other signal transduction processes, it should also include stimuli, receptors, and cascades. Therefore, we suggest the framework of the stress system should comprise five basic elements: stressful stimulus, stressor, stress, stress response, and stress effect ( Figure 1A ). In this framework, the stressful stimulus is the starting point, the effect is the end point, and stressor, stress, and stress response are cascades.

(A) The basic framework of the stress system. (B) The developing framework of the stress system. (C) The mature framework of the stress system.

According to this framework, we may easily differentiate each element of the stress system. Taking oxidative stress as an example, reactive oxygen species (ROS) are stressors, the factors that stimulate the generation of ROS are stressful stimuli, a disruption of redox signaling and control caused by ROS is oxidative stress, the response that the body attempts to restore redox homeostasis is an oxidative stress response, and the resulting biological consequence is the effect of this stress.

Although the concept of stress is still confusing and controversial in many scientific pieces of literature, this framework may help readers to know the real meaning of stress in literatures. For instance, Selye defined “GAS” [ 3 ] is, in fact, both stress response and stress effect: the activation of the HPA axis is a systematic stress response, while physical and mental disorders produced by prolonged stress are stress effects. All treatments he used including heat, cold, and other noxious agents, are stressful stimuli. Since this paper has not revealed whether these stimuli are directly transferred into specific stressors, or induce the generation of specific stressors, it cannot be defined in which stress they have originally resulted in. But as Selye noticed, all these treatments caused a similar HPA activation-related stress response. To explain this phenomenon, Selye suggests that the stress is nonspecific and shared response, regardless of the nature of causative agents, or stressors [ 3 , 9 ]. Later, this view of nonspecific stress response has been widely challenged [ 4 , 10 , 11 ]. This nonspecific stress response is not universal, especially it does not exist in isolated cells and tissues [ 4 , 10 ]. However, as the HPA axis is an “alarm system” for higher animals, in a sense, all stresses, once their intensity exceeds a certain threshold, may potentially cause HPA axis-related systematic stress response [ 5 , 12 ].

THE CONCEPTS OF STRESS

Notably, the above basic framework of the stress system still has no “sensor”, thus it is difficult to determine which stressors may result in stress and which may not. Fortunately, in the 1920s, Cannon coined “homeostasis [ 13 ]” referring to the tendency of a system to maintain the stability of milieu intérieur [ 1 ], and found a wide variety of threats to homeostasis causing a similar sympathoadrenal response that he termed “fight-or-flight” response [ 14 , 15 ], which we now know is a typical stress response. Therefore, homeostasis might be the candidate “sensor” of the stress system. Cannon defined stress as threats to homeostasis [ 2 ]. Selye also found the activation of HPA axis was a common response to diverse nocuous agents or sublethal doses of intoxications, and defined stress as the “nonspecific response of the body to any demand upon it” [ 3 , 16 , 17 ].

Obviously, according to the above framework, stress defined by Cannon is stressor, and Selye's stress and Cannon's “fight-or-flight” response are stress responses. However, through introducing homeostasis into the concept of stress, their works promote the evolution of the stress system, as homeostasis endows the framework of the stress system with the ability to sense stressors and judge whether they are threats or not ( Figure 1B ). With the help of homeostasis, it is easy to understand that not all stressors inevitably cause stress, but the stressors that threaten homeostasis do [ 5 ].

It is now clear that stress should be a state rather than a stressor or response [ 5 ], which has also been mentioned by Selye [ 9 ]. Based on homeostasis, all elements of the stress system can be clearly defined ( BOX 1 ). Stressors are factors with the potential to directly challenge homeostasis. Stress is a state of homeostasis being challenged. Stressful stimuli are agents that can induce the formation of stressors or transfer to stressors. Stress response is a compensatory process aimed to restore homeostasis. Stress effects are biological consequences resulting from the struggle with stressors, which may include re-establishing homeostasis that promotes health (positive effects), or causing damage to the body or even diseases (negative effects).

EXTENSION AND SPECIFICITY OF THE CONCEPT OF STRESS

Initially, the term homeostasis coined by Cannon was a purely physiological concept in animals. Later, the concept was extended to the field of psychology, and cumulating evidence suggested that the activation of the HPA axis was more sensitive to emotional activities than physiological ones ( Table 1 ). Therefore, stress was categorized into physiological stress and psychological stress [ 10 ]. Subsequent studies revealed that although different psychological activities could commonly activate the HPA axis, the phenotypes and mechanisms of corresponding stress were different from each other. Therefore, psychological stress was further classified into four main types according to specific functions ( Table 2 ), that is, emotional stress [ 18 ], cognitive stress [ 19 ], perceptual stress [ 20 ], and psychosocial stress [ 21 ], and each type was sometimes further classified according to specific psychological stressors or stimuli, such as social defeat stress [ 21 , 22 ], post-traumatic stress [ 23 – 25 ], and pandemic stress [ 26 , 27 ].

Summary of stress responsive system.

Unlike psychological stress, which is mainly system stress, physiological stress includes both system stress and local stress. Therefore, only the specificity of systematic physiological stress is similar to that of psychological stress, that is, termed by specific stimuli or stressors ( Table 2 ), such as oxidative stress [ 28 ], nutrient stress [ 29 ], heat stress [ 30 ], thermal stress [ 31 ], shear stress [ 32 ], drought stress [ 33 ], osmotic stress [ 34 ], mechanical stress [ 35 ], genotoxic stress [ 36 ], and so on. However, the specificity of most local physiological stress is termed according to the sites where stressors are produced ( Table 2 ). For instance, cardiac stress [ 37 ], dopamine neuron-specific stress [ 38 ], cytoskeletal stress [ 39 ], mitochondrial stress [ 40 , 41 ], endoplasmic reticulum stress [ 8 , 42 ], and telomere stress [ 43 ] are stresses taking place only in specific cellular or subcellular sites. Besides, some physiological stresses are also classified by functions ( Table 2 ), such as metabolic stress [ 44 ], replication stress [ 45 ], and neurodegenerative stress [ 46 ].

The summary of stress types.

Notably, the concept of stress was also used in filamentous fungi [ 47 ] and plants [ 48 ]. Although these stresses mainly belonged to physiological stress, they were specifically termed as environmental stress and abiotic stress ( Table 2 ), respectively. The subtypes of both environmental stress and abiotic stress were classified mainly according to stimuli ( Table 2 ).

Besides, owing to the implications of homeostasis have extended to social and environmental science, the concept of stress has also expanded to related fields. Therefore, some specific stress concepts in social and environmental science have also been coined by related scientists [ 26 , 47 , 49 , 50 ].

STRESS, HORMESIS, SUSTRESS, EUSTRESS, DISTRESS, HOMEOSTASIS AND ALLOSTASIS

For many scientists, the word stress is still closely associated with Selye defined “GAS” [ 3 ], and it seems all stress responses are negative for health. But over the last 80 years, science has expanded the concept of stress along many dimensions. Particularly, accumulating evidence illustrates that most stressors display a biphasic dose-dependent effect on health, that is, while high-level exposures to stressors could be detrimental to health, low-level exposures would be beneficial [ 51 ]. These biphasic dose responses have been defined as “hormesis” ( BOX 1 ) [ 52 ], and the low dose adaptive response is considered to be the result of compensatory biological processes to restore homeostasis perturbed by stressors [ 52 ]. A typical example is ROS-induced oxidative stress [ 53 – 56 ]. ROS are reactive molecules with the potential to damage proteins, lipids, nucleic acids, and other biomolecules [ 55 ]. Early studies suggested that ROS contributed to the pathogenesis of many diseases, and even promoted the aging process [ 57 ]. However, it is now clear that although excessive ROS may cause damage to biomolecules, maintenance of an optimal level of ROS is essential for modulating life processes [ 28 , 55 , 58 , 59 ]. Therefore, more and more researchers have come to realize that an optimal stress level is crucial for health, while an excessive or inadequate stress level might impair development, growth, and body composition, and lead to pathological conditions [ 5 ]. In this context, stress has to be divided into eustress, distress, and sustress ( Figure 1C , BOX 1 ). Here, eustress means good stress, that is, homeostasis has been mildly challenged by moderate levels of stressors (for instance, the levels of stressors within the “hermetic zone” [ 60 ]). Eustress might induce a mild stress response, enhance the buffering capacity of homeostasis [ 61 ], and benefit health. Distress means bad stress, that is, homeostasis has been strongly challenged by high levels of stressors, which might induce a severe stress response, impair homeostasis, and endanger health. Sustress is coined from the Latin ‘sus' (an assimilated form of the Latin “sub-” before “-s-”) meaning ‘less than normal' and ‘stress' to mean ‘no or inadequate stress'. Sustress might shrink the buffering capacity of homeostasis [ 61 ] and threaten health [ 5 , 58 ]. The above “GAS” [ 3 ] only represents the responses and effects resulting from distress, but not eustress and sustress.

In this framework of the stress system ( Figure 1C ), homeostasis likes a ‘commander', which senses different stressors and directs subsequent stress responses and effects. Notably, although the concept of homeostasis has still been widely used, its original meaning of ‘maintenance of dynamic stability of milieu intérieur through constancy' ( Figure 2 ) has been challenged, because the baseline of homeostasis might be dynamic rather than constant. Accumulating evidence indicates that many physiological indexes and activities including blood pressure, body temperature, the secretion of hormones, and the expression of proteins and genes, display a typical circadian rhythm. Therefore, in 1988, Sterling and Eyer coined a new term ‘allostasis' ( BOX 1 ) from the Greek ‘allo' meaning ‘variable', and ‘stasis' meaning ‘stable', to represent ‘‘remaining stable by being variable' [ 62 ]. As illustrated in Figure 2 , the only difference between these two concepts is that the baseline of allostasis is variable, while that of homeostasis is constant. Most of the dynamic equilibrium of milieu intérieur should be allostasis rather than homeostasis. In this context, McEwen coined the term “allostatic load” to describe the stress process [ 63 , 64 ].

Blue solid line represents the baseline, orange line represents dynamic equilibrium, and blue dot line represents the boundary of dynamic equilibrium.

SUMMARY AND PERSPECTIVES

Stress is a state of homeostasis being challenged. Along with the concept of homeostasis extending to the fields of physiology, psychology, and even environmental science, the concept of stress has evolved dramatically. It is now clear that stress might take place systematically through activating the HPA axis (system stress) or take place only at the site where stressors are induced or generated (local stress). Since any stressor may be sensed by existing homeostasis and potentially trigger responses at molecular, cellular, and systemic levels to preserve the homeostasis and induce adaptation, the concept of stress has been specified according to different stressful stimuli, stressors, sites, or functions, such as emotional stress, oxidative stress, mitochondrial stress, metabolic stress, and so on. As research continues, many more specific stresses will emerge.

Stress functions through the stress system, and it contains three basic types: distress, eustress, and sustress. While distress may impair normal physiological function, eustress plays a critical role in the adaptive process of assessing and disposing of stressors, and endowing the individual to prepare for and survive future challenges [ 65 ], and sustress may weaken the basal activity and responsiveness of the stress system [ 5 ]. Therefore, more and more researchers have come to realize that an optimal stress level is essential for building biological shields through hormesis to guarantee normal life processes [ 5 , 66 ].

The word of stress has permeated our culture in many dimensions, while the stress concept is still confusing and controversial. We hope this framework of the stress system will help distinguish the true meaning of the stress concept appearing in different pieces of literature, integrate stress-related concepts from disparate fields of science and medicine, and allow the concept of stress to be common across different fields.

AUTHOR CONTRIBUTIONS

G.L. and S.L. wrote the manuscript, and F.W. and G.L. revised the manuscript.

Acknowledgments

G.L. was supported by the National Natural Science Funds of China (31871198, 31741070), Cooperative Innovation Center of Engineering and New Products for Developmental Biology of Hunan Province (20134486), and the Opening Fund of The National & Local Joint Engineering Laboratory of Animal Peptide Drug Development (Hunan Normal University), National Development and Reform Commission. F.W. was supported by the National Natural Science Funds of China (81903138), and the Natural Science Funds of Hunan Province (2019JJ50778). The funding sponsors had no role in the writing of the manuscript, and in the decision to submit the manuscript for publication.

Abbreviatons: