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STRESS AND HEALTH: Psychological, Behavioral, and Biological Determinants

Stressors have a major influence upon mood, our sense of well-being, behavior, and health. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. However, if the threat is unremitting, particularly in older or unhealthy individuals, the long-term effects of stressors can damage health. The relationship between psychosocial stressors and disease is affected by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (i.e., genetics, constitutional factors), psychosocial resources, and learned patterns of coping. Psychosocial interventions have proven useful for treating stress-related disorders and may influence the course of chronic diseases.


Claude Bernard (1865/1961) noted that the maintenance of life is critically dependent on keeping our internal milieu constant in the face of a changing environment. Cannon (1929) called this “homeostasis.” Selye (1956) used the term “stress” to represent the effects of anything that seriously threatens homeostasis. The actual or perceived threat to an organism is referred to as the “stressor” and the response to the stressor is called the “stress response.” Although stress responses evolved as adaptive processes, Selye observed that severe, prolonged stress responses might lead to tissue damage and disease.

Based on the appraisal of perceived threat, humans and other animals invoke coping responses ( Lazarus & Folkman 1984 ). Our central nervous system (CNS) tends to produce integrated coping responses rather than single, isolated response changes ( Hilton 1975 ). Thus, when immediate fight-or-flight appears feasible, mammals tend to show increased autonomic and hormonal activities that maximize the possibilities for muscular exertion ( Cannon 1929 , Hess 1957 ). In contrast, during aversive situations in which an active coping response is not available, mammals may engage in a vigilance response that involves sympathetic nervous system (SNS) arousal accompanied by an active inhibition of movement and shunting of blood away from the periphery ( Adams et al. 1968 ). The extent to which various situations elicit different patterns of biologic response is called “situational stereotypy” ( Lacey 1967 ).

Although various situations tend to elicit different patterns of stress responses, there are also individual differences in stress responses to the same situation. This tendency to exhibit a particular pattern of stress responses across a variety of stressors is referred to as “response stereotypy” ( Lacey & Lacey 1958 ). Across a variety of situations, some individuals tend to show stress responses associated with active coping, whereas others tend to show stress responses more associated with aversive vigilance ( Kasprowicz et al. 1990 , Llabre et al. 1998 ).

Although genetic inheritance undoubtedly plays a role in determining individual differences in response stereotypy, neonatal experiences in rats have been shown to produce long-term effects in cognitive-emotional responses ( Levine 1957 ). For example, Meaney et al. (1993) showed that rats raised by nurturing mothers have increased levels of central serotonin activity compared with rats raised by less nurturing mothers. The increased serotonin activity leads to increased expression of a central glucocorticoid receptor gene. This, in turn, leads to higher numbers of glucocorticoid receptors in the limbic system and improved glucocorticoid feedback into the CNS throughout the rat’s life. Interestingly, female rats who receive a high level of nurturing in turn become highly nurturing mothers whose offspring also have high levels of glucocorticoid receptors. This example of behaviorally induced gene expression shows how highly nurtured rats develop into low-anxiety adults, who in turn become nurturing mothers with reduced stress responses.

In contrast to highly nurtured rats, pups separated from their mothers for several hours per day during early life have a highly active hypothalamic-pituitary adrenocortical axis and elevated SNS arousal ( Ladd et al. 2000 ). These deprived rats tend to show larger and more frequent stress responses to the environment than do less deprived animals.

Because evolution has provided mammals with reasonably effective homeostatic mechanisms (e.g., baroreceptor reflex) for dealing with short-term stressors, acute stress responses in young, healthy individuals typically do not impose a health burden. However, if the threat is persistent, particularly in older or unhealthy individuals, the long-term effects of the response to stress may damage health ( Schneiderman 1983 ). Adverse effects of chronic stressors are particularly common in humans, possibly because their high capacity for symbolic thought may elicit persistent stress responses to a broad range of adverse living and working conditions. The relationship between psychosocial stressors and chronic disease is complex. It is affected, for example, by the nature, number, and persistence of the stressors as well as by the individual’s biological vulnerability (i.e., genetics, constitutional factors) and learned patterns of coping. In this review, we focus on some of the psychological, behavioral, and biological effects of specific stressors, the mediating psychophysiological pathways, and the variables known to mediate these relationships. We conclude with a consideration of treatment implications.


Stressors during childhood and adolescence and their psychological sequelae.

The most widely studied stressors in children and adolescents are exposure to violence, abuse (sexual, physical, emotional, or neglect), and divorce/marital conflict (see Cicchetti 2005 ). McMahon et al. (2003) also provide an excellent review of the psychological consequences of such stressors. Psychological effects of maltreatment/abuse include the dysregulation of affect, provocative behaviors, the avoidance of intimacy, and disturbances in attachment ( Haviland et al. 1995 , Lowenthal 1998 ). Survivors of childhood sexual abuse have higher levels of both general distress and major psychological disturbances including personality disorders ( Polusny & Follett 1995 ). Childhood abuse is also associated with negative views toward learning and poor school performance ( Lowenthal 1998 ). Children of divorced parents have more reported antisocial behavior, anxiety, and depression than their peers ( Short 2002 ). Adult offspring of divorced parents report more current life stress, family conflict, and lack of friend support compared with those whose parents did not divorce ( Short 2002 ). Exposure to nonresponsive environments has also been described as a stressor leading to learned helplessness ( Peterson & Seligman 1984 ).

Studies have also addressed the psychological consequences of exposure to war and terrorism during childhood ( Shaw 2003 ). A majority of children exposed to war experience significant psychological morbidity, including both post-traumatic stress disorder (PTSD) and depressive symptoms. For example, Nader et al. (1993) found that 70% of Kuwaiti children reported mild to severe PTSD symptoms after the Gulf War. Some effects are long lasting: Macksound & Aber (1996) found that 43% of Lebanese children continued to manifest post-traumatic stress symptoms 10 years after exposure to war-related trauma.

Exposure to intense and chronic stressors during the developmental years has long-lasting neurobiological effects and puts one at increased risk for anxiety and mood disorders, aggressive dyscontrol problems, hypo-immune dysfunction, medical morbidity, structural changes in the CNS, and early death ( Shaw 2003 ).

Stressors During Adulthood and Their Psychological Sequelae

Life stress, anxiety, and depression.

It is well known that first depressive episodes often develop following the occurrence of a major negative life event ( Paykel 2001 ). Furthermore, there is evidence that stressful life events are causal for the onset of depression (see Hammen 2005 , Kendler et al. 1999 ). A study of 13,006 patients in Denmark, with first psychiatric admissions diagnosed with depression, found more recent divorces, unemployment, and suicides by relatives compared with age- and gender-matched controls ( Kessing et al. 2003 ). The diagnosis of a major medical illness often has been considered a severe life stressor and often is accompanied by high rates of depression ( Cassem 1995 ). For example, a meta-analysis found that 24% of cancer patients are diagnosed with major depression ( McDaniel et al. 1995 ).

Stressful life events often precede anxiety disorders as well ( Faravelli & Pallanti 1989 , Finlay-Jones & Brown 1981 ). Interestingly, long-term follow-up studies have shown that anxiety occurs more commonly before depression ( Angst &Vollrath 1991 , Breslau et al. 1995 ). In fact, in prospective studies, patients with anxiety are most likely to develop major depression after stressful life events occur ( Brown et al. 1986 ).


Lifetime exposure to traumatic events in the general population is high, with estimates ranging from 40% to 70% ( Norris 1992 ). Of note, an estimated 13% of adult women in the United States have been exposed to sexual assault ( Kilpatrick et al. 1992 ). The Diagnostic and Statistical Manual (DSM-IV-TR; American Psychiatric Association 2000 ) includes two primary diagnoses related to trauma: Acute Stress Disorder (ASD) and PTSD. Both these disorders have as prominent features a traumatic event involving actual or threatened death or serious injury and symptom clusters including re-experiencing of the traumatic event (e.g., intrusive thoughts), avoidance of reminders/numbing, and hyperarousal (e.g., difficulty falling or staying asleep). The time frame for ASD is shorter (lasting two days to four weeks), with diagnosis limited to within one month of the incident. ASD was introduced in 1994 to describe initial trauma reactions, but it has come under criticism ( Harvey & Bryant 2002 ) for weak empirical and theoretical support. Most people who have symptoms of PTSD shortly after a traumatic event recover and do not develop PTSD. In a comprehensive review, Green (1994) estimates that approximately 25% of those exposed to traumatic events develop PTSD. Surveys of the general population indicate that PTSD affects 1 in 12 adults at some time in their life ( Kessler et al. 1995 ). Trauma and disasters are related not only to PTSD, but also to concurrent depression, other anxiety disorders, cognitive impairment, and substance abuse ( David et al. 1996 , Schnurr et al. 2002 , Shalev 2001 ).

Other consequences of stress that could provide linkages to health have been identified, such as increases in smoking, substance use, accidents, sleep problems, and eating disorders. Populations that live in more stressful environments (communities with higher divorce rates, business failures, natural disasters, etc.) smoke more heavily and experience higher mortality from lung cancer and chronic obstructive pulmonary disorder ( Colby et al. 1994 ). A longitudinal study following seamen in a naval training center found that more cigarette smoking occurred on high-stress days ( Conway et al. 1981 ). Life events stress and chronically stressful conditions have also been linked to higher consumption of alcohol ( Linsky et al. 1985 ). In addition, the possibility that alcohol may be used as self-medication for stress-related disorders such as anxiety has been proposed. For example, a prospective community study of 3021 adolescents and young adults ( Zimmerman et al. 2003 ) found that those with certain anxiety disorders (social phobia and panic attacks) were more likely to develop substance abuse or dependence prospectively over four years of follow-up. Life in stressful environments has also been linked to fatal accidents ( Linsky & Strauss 1986 ) and to the onset of bulimia ( Welch et al. 1997 ). Another variable related to stress that could provide a link to health is the increased sleep problems that have been reported after sychological trauma ( Harvey et al. 2003 ). New onset of sleep problems mediated the relationship between post-traumatic stress symptoms and decreased natural killer (NK) cell cytotoxicity in Hurricane Andrew victims ( Ironson et al. 1997 ).

Variations in Stress Responses

Certain characteristics of a situation are associated with greater stress responses. These include the intensity or severity of the stressor and controllability of the stressor, as well as features that determine the nature of the cognitive responses or appraisals. Life event dimensions of loss, humiliation, and danger are related to the development of major depression and generalized anxiety ( Kendler et al. 2003 ). Factors associated with the development of symptoms of PTSD and mental health disorders include injury, damage to property, loss of resources, bereavement, and perceived life threat ( Freedy et al. 1992 , Ironson et al. 1997 , McNally 2003 ). Recovery from a stressor can also be affected by secondary traumatization ( Pfefferbaum et al. 2003 ). Other studies have found that multiple facets of stress that may work synergistically are more potent than a single facet; for example, in the area of work stress, time pressure in combination with threat ( Stanton et al. 2001 ), or high demand in combination with low control ( Karasek & Theorell 1990 ).

Stress-related outcomes also vary according to personal and environmental factors. Personal risk factors for the development of depression, anxiety, or PTSD after a serious life event, disaster, or trauma include prior psychiatric history, neuroticism, female gender, and other sociodemographic variables ( Green 1996 , McNally 2003 , Patton et al. 2003 ). There is also some evidence that the relationship between personality and environmental adversity may be bidirectional ( Kendler et al. 2003 ). Levels of neuroticism, emotionality, and reactivity correlate with poor interpersonal relationships as well as “event proneness.” Protective factors that have been identified include, but are not limited to, coping, resources (e.g., social support, self-esteem, optimism), and finding meaning. For example, those with social support fare better after a natural disaster ( Madakaisira & O’Brien 1987 ) or after myocardial infarction ( Frasure-Smith et al. 2000 ). Pruessner et al. (1999) found that people with higher self-esteem performed better and had lower cortisol responses to acute stressors (difficult math problems). Attaching meaning to the event is another protective factor against the development of PTSD, even when horrific torture has occurred. Left-wing political activists who were tortured by Turkey’s military regime had lower rates of PTSD than did nonactivists who were arrested and tortured by the police ( Basoğlu et al. 1994 ).

Finally, human beings are resilient and in general are able to cope with adverse situations. A recent illustration is provided by a study of a nationally representative sample of Israelis after 19 months of ongoing exposure to the Palestinian intifada. Despite considerable distress, most Israelis reported adapting to the situation without substantial mental health symptoms or impairment ( Bleich et al. 2003 ).


Acute stress responses.

Following the perception of an acute stressful event, there is a cascade of changes in the nervous, cardiovascular, endocrine, and immune systems. These changes constitute the stress response and are generally adaptive, at least in the short term ( Selye 1956 ). Two features in particular make the stress response adaptive. First, stress hormones are released to make energy stores available for the body’s immediate use. Second, a new pattern of energy distribution emerges. Energy is diverted to the tissues that become more active during stress, primarily the skeletal muscles and the brain. Cells of the immune system are also activated and migrate to “battle stations” ( Dhabar & McEwen 1997 ). Less critical activities are suspended, such as digestion and the production of growth and gonadal hormones. Simply put, during times of acute crisis, eating, growth, and sexual activity may be a detriment to physical integrity and even survival.

Stress hormones are produced by the SNS and hypothalamic-pituitary adrenocortical axis. The SNS stimulates the adrenal medulla to produce catecholamines (e.g., epinephrine). In parallel, the paraventricular nucleus of the hypothalamus produces corticotropin releasing factor, which in turn stimulates the pituitary to produce adrenocorticotropin. Adrenocorticotropin then stimulates the adrenal cortex to secrete cortisol. Together, catecholamines and cortisol increase available sources of energy by promoting lipolysis and the conversion of glycogen into glucose (i.e., blood sugar). Lipolysis is the process of breaking down fats into usable sources of energy (i.e., fatty acids and glycerol; Brindley & Rollan 1989 ).

Energy is then distributed to the organs that need it most by increasing blood pressure levels and contracting certain blood vessels while dilating others. Blood pressure is increased with one of two hemodynamic mechanisms ( Llabre et al.1998 , Schneiderman & McCabe 1989 ). The myocardial mechanism increases blood pressure through enhanced cardiac output; that is, increases in heart rate and stroke volume (i.e., the amount of blood pumped with each heart beat). The vascular mechanism constricts the vasculature, thereby increasing blood pressure much like constricting a hose increases water pressure. Specific stressors tend to elicit either myocardial or vascular responses, providing evidence of situational stereotypy ( Saab et al. 1992 , 1993 ). Laboratory stressors that call for active coping strategies, such as giving a speech or performing mental arithmetic, require the participant to do something and are associated with myocardial responses. In contrast, laboratory stressors that call for more vigilant coping strategies in the absence of movement, such as viewing a distressing video or keeping one’s foot in a bucket of ice water, are associated with vascular responses. From an evolutionary perspective, cardiac responses are believed to facilitate active coping by shunting blood to skeletal muscles, consistent with the fight-or-flight response. In situations where decisive action would not be appropriate, but instead skeletal muscle inhibition and vigilance are called for, a vascular hemodynamic response is adaptive. The vascular response shunts blood away from the periphery to the internal organs, thereby minimizing potential bleeding in the case of physical assault.

Finally, in addition to the increased availability and redistribution of energy, the acute stress response includes activation of the immune system. Cells of the innate immune system (e.g., macrophages and natural killer cells), the first line of defense, depart from lymphatic tissue and spleen and enter the bloodstream, temporarily raising the number of immune cells in circulation (i.e., leukocytosis). From there, the immune cells migrate into tissues that are most likely to suffer damage during physical confrontation (e.g., the skin). Once at “battle stations,” these cells are in position to contain microbes that may enter the body through wounds and thereby facilitate healing ( Dhabar & McEwen 1997 ).

Chronic Stress Responses

The acute stress response can become maladaptive if it is repeatedly or continuously activated ( Selye 1956 ). For example, chronic SNS stimulation of the cardiovascular system due to stress leads to sustained increases in blood pressure and vascular hypertrophy ( Henry et al. 1975 ). That is, the muscles that constrict the vasculature thicken, producing elevated resting blood pressure and response stereotypy, or a tendency to respond to all types of stressors with a vascular response. Chronically elevated blood pressure forces the heart to work harder, which leads to hypertrophy of the left ventricle ( Brownley et al. 2000 ). Over time, the chronically elevated and rapidly shifting levels of blood pressure can lead to damaged arteries and plaque formation.

The elevated basal levels of stress hormones associated with chronic stress also suppress immunity by directly affecting cytokine profiles. Cytokines are communicatory molecules produced primarily by immune cells (see Roitt et al. 1998 ). There are three classes of cytokines. Proinflammatory cytokines mediate acute inflammatory reactions. Th1 cytokines mediate cellular immunity by stimulating natural killer cells and cytotoxic T cells, immune cells that target intracellular pathogens (e.g., viruses). Finally, Th2 cytokines mediate humoral immunity by stimulating B cells to produce antibody, which “tags” extracellular pathogens (e.g., bacteria) for removal. In a meta-analysis of over 30 years of research, Segerstrom & Miller (2004) found that intermediate stressors, such as academic examinations, could promote a Th2 shift (i.e., an increase in Th2 cytokines relative to Th1 cytokines). A Th2 shift has the effect of suppressing cellular immunity in favor of humoral immunity. In response to more chronic stressors (e.g., long-term caregiving for a dementia patient), Segerstrom & Miller found that proinflammatory, Th1, and Th2 cytokines become dysregulated and lead both to suppressed humoral and cellular immunity. Intermediate and chronic stressors are associated with slower wound healing and recovery from surgery, poorer antibody responses to vaccination, and antiviral deficits that are believed to contribute to increased vulnerability to viral infections (e.g., reductions in natural killer cell cytotoxicity; see Kiecolt-Glaser et al. 2002 ).

Chronic stress is particularly problematic for elderly people in light of immunosenescence, the gradual loss of immune function associated with aging. Older adults are less able to produce antibody responses to vaccinations or combat viral infections ( Ferguson et al. 1995 ), and there is also evidence of a Th2 shift ( Glaser et al. 2001 ). Although research has yet to link poor vaccination responses to early mortality, influenza and other infectious illnesses are a major cause of mortality in the elderly, even among those who have received vaccinations (e.g., Voordouw et al. 2003 ).


Cardiovascular disease.

Both epidemiological and controlled studies have demonstrated relationships between psychosocial stressors and disease. The underlying mediators, however, are unclear in most cases, although possible mechanisms have been explored in some experimental studies. An occupational gradient in coronary heart disease (CHD) risk has been documented in which men with relatively low socioeconomic status have the poorest health outcomes ( Marmot 2003 ). Much of the risk gradient in CHD can be eliminated, however, by taking into account lack of perceived job control, which is a potent stressor ( Marmot et al. 1997 ). Other factors include risky behaviors such as smoking, alcohol use, and sedentary lifestyle ( Lantz et al. 1998 ), which may be facilitated by stress. Among men ( Schnall et al. 1994 ) and women ( Eaker 1998 ), work stress has been reported to be a predictor of incident CHD and hypertension ( Ironson 1992 ). However, in women with existing CHD, marital stress is a better predictor of poor prognosis than is work stress ( Orth-Gomer et al. 2000 ).

Although the observational studies cited thus far reveal provocative associations between psychosocial stressors and disease, they are limited in what they can tell us about the exact contribution of these stressors or about how stress mediates disease processes. Animal models provide an important tool for helping to understand the specific influences of stressors on disease processes. This is especially true of atherosclerotic CHD, which takes multiple decades to develop in humans and is influenced by a great many constitutional, demographic, and environmental factors. It would also be unethical to induce disease in humans by experimental means.

Perhaps the best-known animal model relating stress to atherosclerosis was developed by Kaplan et al. (1982) . Their study was carried out on male cynomolgus monkeys, who normally live in social groups. The investigators stressed half the animals by reorganizing five-member social groups at one- to three-month intervals on a schedule that ensured that each monkey would be housed with several new animals during each reorganization. The other half of the animals lived in stable social groups. All animals were maintained on a moderately atherogenic diet for 22 months. Animals were also assessed for their social status (i.e., relative dominance) within each group. The major findings were that ( a ) socially dominant animals living in unstable groups had significantly more atherosclerosis than did less dominant animals living in unstable groups; and ( b ) socially dominant male animals living in unstable groups had significantly more atherosclerosis than did socially dominant animals living in stable groups. Other important findings based upon this model have been that heart-rate reactivity to the threat of capture predicts severity of atherosclerosis ( Manuck et al. 1983 ) and that administration of the SNS-blocking agent propranolol decreases the progression of atherosclerosis ( Kaplan et al. 1987 ). In contrast to the findings in males, subordinate premenstrual females develop greater atherosclerosis than do dominant females ( Kaplan et al. 1984 ) because they are relatively estrogen deficient, tending to miss ovulatory cycles ( Adams et al. 1985 ).

Whereas the studies in cynomolgus monkeys indicate that emotionally stressful behavior can accelerate the progression of atherosclerosis, McCabe et al. (2002) have provided evidence that affiliative social behavior can slow the progression of atherosclerosis in the Watanabe heritable hyperlipidemic rabbit. This rabbit model has a genetic defect in lipoprotein clearance such that it exhibits hypercholesterolemia and severe atherosclerosis. The rabbits were assigned to one of three social or behavioral groups: ( a ) an unstable group in which unfamiliar rabbits were paired daily, with the pairing switched each week; ( b ) a stable group, in which littermates were paired daily for the entire study; and ( c ) an individually caged group. The stable group exhibited more affiliative behavior and less agonistic behavior than the unstable group and significantly less atherosclerosis than each of the other two groups. The study emphasizes the importance of behavioral factors in atherogenesis, even in a model of disease with extremely strong genetic determinants.

Upper Respiratory Diseases

The hypothesis that stress predicts susceptibility to the common cold received support from observational studies ( Graham et al. 1986 , Meyer & Haggerty 1962 ). One problem with such studies is that they do not control for exposure. Stressed people, for instance, might seek more outside contact and thus be exposed to more viruses. Therefore, in a more controlled study, people were exposed to a rhinovirus and then quarantined to control for exposure to other viruses ( Cohen et al. 1991 ). Those individuals with the most stressful life events and highest levels of perceived stress and negative affect had the greatest probability of developing cold symptoms. In a subsequent study of volunteers inoculated with a cold virus, it was found that people enduring chronic, stressful life events (i.e., events lasting a month or longer including unemployment, chronic underemployment, or continued interpersonal difficulties) had a high likelihood of catching cold, whereas people subjected to stressful events lasting less than a month did not ( Cohen et al. 1998 ).

Human Immunodeficiency Virus

The impact of life stressors has also been studied within the context of human immunodeficiency virus (HIV) spectrum disease. Leserman et al. (2000) followed men with HIV for up to 7.5 years and found that faster progression to AIDS was associated with higher cumulative stressful life events, use of denial as a coping mechanism, lower satisfaction with social support, and elevated serum cortisol.

Inflammation, the Immune System, and Physical Health

Despite the stress-mediated immunosuppressive effects reviewed above, stress has also been associated with exacerbations of autoimmune disease ( Harbuz et al. 2003 ) and other conditions in which excessive inflammation is a central feature, such as CHD ( Appels et al. 2000 ). Evidence suggests that a chronically activated, dysregulated acute stress response is responsible for these associations. Recall that the acute stress response includes the activation and migration of cells of the innate immune system. This effect is mediated by proinflammatory cytokines. During periods of chronic stress, in the otherwise healthy individual, cortisol eventually suppresses proinflammatory cytokine production. But in individuals with autoimmune disease or CHD, prolonged stress can cause proinflammatory cytokine production to remain chronically activated, leading to an exacerbation of pathophysiology and symptomatology.

Miller et al. (2002) proposed the glucocorticoid-resistance model to account for this deficit in proinflammatory cytokine regulation. They argue that immune cells become “resistant” to the effects of cortisol (i.e., a type of glucocorticoid), primarily through a reduction, or downregulation, in the number of expressed cortisol receptors. With cortisol unable to suppress inflammation, stress continues to promote proinflammatory cytokine production indefinitely. Although there is only preliminary empirical support for this model, it could have implications for diseases of inflammation. For example, in rheumatoid arthritis, excessive inflammation is responsible for joint damage, swelling, pain, and reduced mobility. Stress is associated with more swelling and reduced mobility in rheumatoid arthritis patients ( Affleck et al. 1997 ). Similarly, in multiple sclerosis (MS), an overactive immune system targets and destroys the myelin surrounding nerves, contributing to a host of symptoms that include paralysis and blindness. Again, stress is associated with an exacerbation of disease ( Mohr et al. 2004 ). Even in CHD, inflammation plays a role. The immune system responds to vascular injury just as it would any other wound: Immune cells migrate to and infiltrate the arterial wall, setting off a cascade of biochemical processes that can ultimately lead to a thrombosis (i.e., clot; Ross 1999 ). Elevated levels of inflammatory markers, such as C-reactive protein (CRP), are predictive of heart attacks, even when controlling for other traditional risk factors (e.g., cholesterol, blood pressure, and smoking; Morrow & Ridker 2000 ). Interestingly, a history of major depressive episodes has been associated with elevated levels of CRP in men ( Danner et al. 2003 ).

Inflammation, Cytokine Production, and Mental Health

In addition to its effects on physical health, prolonged proinflammatory cytokine production may also adversely affect mental health in vulnerable individuals. During times of illness (e.g., the flu), proinflammatory cytokines feed back to the CNS and produce symptoms of fatigue, malaise, diminished appetite, and listlessness, which are symptoms usually associated with depression. It was once thought that these symptoms were directly caused by infectious pathogens, but more recently, it has become clear that proinflammatory cytokines are both sufficient and necessary (i.e., even absent infection or fever) to generate sickness behavior ( Dantzer 2001 , Larson & Dunn 2001 ).

Sickness behavior has been suggested to be a highly organized strategy that mammals use to combat infection ( Dantzer 2001 ). Symptoms of illness, as previously thought, are not inconsequential or even maladaptive. On the contrary, sickness behavior is thought to promote resistance and facilitate recovery. For example, an overall decrease in activity allows the sick individual to preserve energy resources that can be redirected toward enhancing immune activity. Similarly, limiting exploration, mating, and foraging further preserves energy resources and reduces the likelihood of risky encounters (e.g., fighting over a mate). Furthermore, decreasing food intake also decreases the level of iron in the blood, thereby decreasing bacterial replication. Thus, for a limited period, sickness behavior may be looked upon as an adaptive response to the stress of illness.

Much like other aspects of the acute stress response, however, sickness behavior can become maladaptive when repeatedly or continuously activated. Many features of the sickness behavior response overlap with major depression. Indeed, compared with healthy controls, elevated rates of depression are reported in patients with inflammatory diseases such as MS ( Mohr et al. 2004 ) or CHD ( Carney et al. 1987 ). Granted, MS patients face a number of stressors and reports of depression are not surprising. However, when compared with individuals facing similar disability who do not have MS (e.g., car accident victims), MS patients still report higher levels of depression ( Ron & Logsdail 1989 ). In both MS ( Fassbender et al. 1998 ) and CHD ( Danner et al. 2003 ), indicators of inflammation have been found to be correlated with depressive symptomatology. Thus, there is evidence to suggest that stress contributes to both physical and mental disease through the mediating effects of proinflammatory cytokines.


The changes in biological set points that occur across the life span as a function of chronic stressors are referred to as allostasis, and the biological cost of these adjustments is known as allostatic load ( McEwen 1998 ). McEwen has also suggested that cumulative increases in allostatic load are related to chronic illness. These are intriguing hypotheses that emphasize the role that stressors may play in disease. The challenge, however, is to show the exact interactions that occur among stressors, pathogens, host vulnerability (both constitutional and genetic), and such poor health behaviors as smoking, alcohol abuse, and excessive caloric consumption. Evidence of a lifetime trajectory of comorbidities does not necessarily imply that allostatic load is involved since immunosenescence, genetic predisposition, pathogen exposure, and poor health behaviors may act as culprits.

It is not clear, for example, that changes in set point for variables such as blood pressure are related to cumulative stressors per se, at least in healthy young individuals. Thus, for example, British soldiers subjected to battlefield conditions for more than a year in World War II showed chronic elevations in blood pressure, which returned to normal after a couple of months away from the front ( Graham 1945 ). In contrast, individuals with chronic illnesses such as chronic fatigue syndrome may show a high rate of relapse after a relatively acute stressor such as a hurricane ( Lutgendorf et al. 1995 ). Nevertheless, by emphasizing the role that chronic stressors may play in multiple disease outcomes, McEwen has helped to emphasize an important area of study.


For PTSD, useful treatments include cognitive-behavioral therapy (CBT), along with exposure and the more controversial Eye Movement Desensitization and Reprocessing ( Foa & Meadows 1997 , Ironson et al. 2002 , Shapiro 1995 ). Psychopharmacological approaches have also been suggested ( Berlant 2001 ). In addition, writing about trauma has been helpful both for affective recovery and for potential health benefit ( Pennebaker 1997 ). For outpatients with major depression, Beck’s CBT ( Beck 1976 ) and interpersonal therapy ( Klerman et al. 1984 ) are as effective as psychopharmacotherapy ( Clinical Practice Guidelines 1993 ). However, the presence of sleep problems or hypercortisolemia is associated with poorer response to psychotherapy ( Thase 2000 ). The combination of psychotherapy and pharmacotherapy seems to offer a substantial advantage over psychotherapy alone for the subset of patients who are more severely depressed or have recurrent depression ( Thase et al. 1997 ). For the treatment of anxiety, it depends partly on the specific disorder [e.g., generalized anxiety disorder (GAD), panic disorder, social phobia], although CBT including relaxation training has demonstrated efficacy in several subtypes of anxiety ( Borkovec & Ruscio 2001 ). Antidepressants such as selective serotonin reuptake inhibitors also show efficacy in anxiety ( Ballenger et al. 2001 ), especially when GAD is comorbid with major depression, which is the case in 39% of subjects with current GAD ( Judd et al. 1998 ).


Patients dealing with chronic, life-threatening diseases must often confront daily stressors that can threaten to undermine even the most resilient coping strategies and overwhelm the most abundant interpersonal resources. Psychosocial interventions, such as cognitive-behavioral stress management (CBSM), have a positive effect on the quality of life of patients with chronic disease ( Schneiderman et al. 2001 ). Such interventions decrease perceived stress and negative mood (e.g., depression), improve perceived social support, facilitate problem-focused coping, and change cognitive appraisals, as well as decrease SNS arousal and the release of cortisol from the adrenal cortex. Psychosocial interventions also appear to help chronic pain patients reduce their distress and perceived pain as well as increase their physical activity and ability to return to work ( Morley et al. 1999 ). These psychosocial interventions can also decrease patients’ overuse of medications and utilization of the health care system. There is also some evidence that psychosocial interventions may have a favorable influence on disease progression ( Schneiderman et al. 2001 ).

Morbidity, Mortality, and Markers of Disease Progression

Psychosocial intervention trials conducted upon patients following acute myocardial infarction (MI) have reported both positive and null results. Two meta-analyses have reported a reduction in both mortality and morbidity of approximately 20% to 40% ( Dusseldorp et al. 1999 , Linden et al. 1996 ). Most of these studies were carried out in men. The major study reporting positive results was the Recurrent Coronary Prevention Project (RCPP), which employed group-based CBT, and decreased hostility and depressed affect ( Mendes de Leon et al. 1991 ), as well as the composite medical end point of cardiac death and nonfatal MI ( Friedman et al. 1986 ).

In contrast, the major study reporting null results for medical end points was the Enhancing Recovery in Coronary Heart Disease (ENRICHD) clinical trial ( Writing Committee for ENRICHD Investigators 2003 ), which found that the intervention modestly decreased depression and increased perceived social support, but did not affect the composite medical end point of death and nonfatal MI. However, a secondary analysis, which examined the effects of the psychosocial intervention within gender by ethnicity subgroups, found significant decreases approaching 40% in both cardiac death and nonfatal MI for white men but not for other subgroups such as minority women ( Schneiderman et al. 2004 ). Although there were important differences between the RCPP and ENRICHD in terms of the objectives of psychosocial intervention and the duration and timing of treatment, it should also be noted that more than 90% of the patients in the RCPP were white men. Thus, because primarily white men, but not other subgroups, may have benefited from the ENRICHD intervention, future studies need to attend to variables that may have prevented morbidity and mortality benefits among gender and ethnic subgroups other than white men.

Psychosocial intervention trials conducted upon patients with cancer have reported both positive and null results with regard to survival ( Classen 1998 ). A number of factors that generally characterized intervention trials that observed significant positive effects on survival were relatively absent in trials that failed to show improved survival. These included: ( a ) having only patients with the same type and severity of cancer within each group, ( b ) creation of a supportive environment, ( c ) having an educational component, and ( d ) provision of stress-management and coping-skills training. In one study that reported positive results, Fawzy et al. (1993) found that patients with early stage melanoma assigned to a six-week cognitive-behavioral stress management (CBSM) group showed significantly longer survival and longer time to recurrence over a six-year follow-up period compared with those receiving surgery and standard care alone. The intervention also significantly reduced distress, enhanced active coping, and increased NK cell cytotoxicity compared with controls.

Although published studies have not yet shown that psychosocial interventions can decrease disease progression in HIV/AIDS, several studies have significantly influenced factors that have been associated with HIV/AIDS disease progression ( Schneiderman & Antoni 2003 ). These variables associated with disease progression include distress, depressed affect, denial coping, low perceived social support, and elevated serum cortisol ( Ickovics et al. 2001 , Leserman et al. 2000 ). Antoni et al. have used group-based CBSM (i.e., CBT plus relaxation training) to decrease the stress-related effects of HIV+ serostatus notification. Those in the intervention condition showed lower distress, anxiety, and depressed mood than did those in the control condition as well as lower antibody titers of herpesviruses and higher levels of T-helper (CD4) cells, NK cells, and lymphocyte proliferation ( Antoni et al. 1991 , Esterling et al. 1992 ). In subsequent studies conducted upon symptomatic HIV+ men who were not attempting to determine their HIV serostatus, CBSM decreased distress, dysphoria, anxiety, herpesvirus antibody titers, cortisol, and epinephrine ( Antoni et al. 2000a , b ; Lutgendorf et al. 1997 ). Improvement in perceived social support and adaptive coping skills mediated the decreases in distress ( Lutgendorf et al. 1998 ). In summary, it appears that CBSM can positively influence stress-related variables that have been associated with HIV/AIDS progression. Only a randomized clinical trial, however, could document that CBSM can specifically decrease HIV/AIDS disease progression.

Stress is a central concept for understanding both life and evolution. All creatures face threats to homeostasis, which must be met with adaptive responses. Our future as individuals and as a species depends on our ability to adapt to potent stressors. At a societal level, we face a lack of institutional resources (e.g., inadequate health insurance), pestilence (e.g., HIV/AIDS), war, and international terrorism that has reached our shores. At an individual level, we live with the insecurities of our daily existence including job stress, marital stress, and unsafe schools and neighborhoods. These are not an entirely new condition as, in the last century alone, the world suffered from instances of mass starvation, genocide, revolutions, civil wars, major infectious disease epidemics, two world wars, and a pernicious cold war that threatened the world order. Although we have chosen not to focus on these global threats in this paper, they do provide the backdrop for our consideration of the relationship between stress and health.

A widely used definition of stressful situations is one in which the demands of the situation threaten to exceed the resources of the individual ( Lazarus & Folkman 1984 ). It is clear that all of us are exposed to stressful situations at the societal, community, and interpersonal level. How we meet these challenges will tell us about the health of our society and ourselves. Acute stress responses in young, healthy individuals may be adaptive and typically do not impose a health burden. Indeed, individuals who are optimistic and have good coping responses may benefit from such experiences and do well dealing with chronic stressors ( Garmezy 1991 , Glanz & Johnson 1999 ). In contrast, if stressors are too strong and too persistent in individuals who are biologically vulnerable because of age, genetic, or constitutional factors, stressors may lead to disease. This is particularly the case if the person has few psychosocial resources and poor coping skills. In this chapter, we have documented associations between stressors and disease and have described how endocrine-immune interactions appear to mediate the relationship. We have also described how psychosocial stressors influence mental health and how psychosocial treatments may ameliorate both mental and physical disorders. There is much we do not yet know about the relationship between stress and health, but scientific findings being made in the areas of cognitive-emotional psychology, molecular biology, neuroscience, clinical psychology, and medicine will undoubtedly lead to improved health outcomes.


Preparation of this manuscript was supported by NIH grants P01-MH49548, P01- HL04726, T32-HL36588, R01-MH66697, and R01-AT02035. We thank Elizabeth Balbin, Adam Carrico, and Orit Weitzman for library research.


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How Does Stress Affect Your Body? The Latest Research Shows It Can Vary

A woman is stressed in a hospital. Stress can affect the body, the brain, the organs and the immune system in varying ways.

Stress is a hell of a state of mind. Not only can it make you feel frantic, overwhelmed and on the verge of tears, but new science also shows that it can wreak some serious havoc on the body. Stress can affect your body in many different areas , some of which might not be immediately obvious.

“It is well known that stress and stressors directly affect our health, whether we want to admit it or not,”  Dr. Sherry Ross M.D. , a women’s health expert at Providence Saint John’s Health Center, tells Bustle. From your heart to your brain and immune system, stress can mess with   your body, in both short-term and more permanent ways.

Stress may seem like a good motivator to power through your to-do list, but the stakes for reducing stress are high. Decades of research tell us that stressors and anxiety can impact  our organs, our nervous system, our guts, and our brains . Carrying stress around can make you more vulnerable to illnesses and infections — or make your immune system overreact and hurt your cells. Recent research has shown how it can hurt your gut, whiten your hair, and even shrink your brain.

Here’s what stress can do to your body; be ready to grab a stress ball.

1. You Experience A Hormonal Cascade

A woman covers her eyes, leaning on a tissue box. Stress has a number of impacts on the body, research shows

The instant you begin to feel stressed, your body starts to react, Dr. Ross tells Bustle. “The first response to stress  begins in the hypothalamus in the brain,  which sends signals to the pituitary gland and the adrenal medulla. They  start a hormonal cascade ,” she says. The cascade released hormones throughout the body and includes the stress hormone cortisol. As it spreads, it causes increased heart and breathing rates, a heightened pulse, higher blood pressure, and more sweat, all of which are designed to help us cope with threats and danger.

A study published in 2019 in  Seminars In Cell & Developmental Biology  found that  this cascade even affects the microglia, a type of nerve cell in the brain and spinal cord. After the danger passes, your body is meant to reduce these hormones to normal levels, but if you’re under a lot of stress all the time, though, they stay at elevated levels constantly.

2. It Can Affect Your Immune System

Chronic stress can  damage your body’s   defenses against viruses and infections . A review of the effects of stress on the body published in  EXCLI Journal  in 2017 found that studies have linked  stress to poor immune system function,  in part because when you’re stressed, your body changes the way it secretes hormones that help the immune system. This can lead to  something called chronic immune activation , in which your immune system overreacts and starts to attack healthy cells instead of threatening ones.

It can also mean your body becomes more vulnerable to illness and recovers more slowly from diseases and infections. A  2019 study published in  Microbial Pathogenesis  found that stress can actually help bacterial growth, making infections worse.

3. Your Sleep Is Affected

A woman sleeps. Stress can disturb sleeping patterns, changing the body's reactions and memory.

Sleep deprivation from stress  can physically alter your brain,  making neurons less capable of communication and impairing your thinking processes. And this relationship goes way back; a review of the science around stress and sleep published in  Neuroscience & Biobehavioral Reviews  in 2019 found that  being stressed just after birth  can affect our sleep all the way to adulthood.

4. It Changes Your Brain

It’s not just the consequences of sleep deprivation that change the brain when you’re stressed. “For those suffering from constant and on-going stress, long term physical and mental medical complications can occur,” Dr. Ross tells Bustle. Stress over long periods can change the brain, increasing the likelihood of depression, anxiety, and other mental health issues. Research in 2018 found that stressed people showed slight brain shrinkage  compared to relaxed people, and the review in 2017 showed that  stress can physically rewire the brain , causing significant structural changes and alterations in activity.

5. It Changes Your Gut

A woman gets treatment on her stomach. Stress can change the gut microbiome and affect digestion and constipation.

If you feel gurgles in your gut whenever you’re anxious or upset, you’re not alone; the digestive system can be very sensitive to stress and other emotions. Stress can also have a serious effect on your gut health. Research published in  Frontiers in Microbiology  in 2017 found that  stress can damage the microbiome  that helps the gut function, though the effects of stress can differ widely from person to person. Everybody from  indigestion, nausea, and vomiting  to constipation can be traced to stress and its effect on the gut.

6. It Hurts Heart Health

Stress can put a lot of pressure on the heart; when you’re stressed,  your heart pumps harder  to distribute blood to make sure you’re prepared to deal with threats, and that can cause long-term damage over time. “Stress can cause high blood pressure and heartbeat irregularities,” Dr. Ross tells Bustle. Being stressed is a  risk factor for poorer heart health overall,  with stressed people more likely to  show symptoms of cardiovascular disease , heart attacks, and other heart issues over the course of their lifetimes. A study published in  Circulation  in 2019 also found that race  plays a role in the relationship between stress and heart health  in women over the course of their lives.

7. It Can Turn Your Hair White

A woman with white hair at an ATM. Hair color is one potential effect of stress on the body.

Old wives tales (not to mention David Lynch’s Twin Peaks ) often cite people whose hair turned white overnight after a huge scare or shock — and while that might not be common,  research published in  Nature  in 2020  found that there is some evidence that stress can directly cause hair-whitening in mice. According to the study, the body’s fight-or-flight system negatively impacts melanocyte stem cells, which live in hair follicles and color our hair.

Melanocyte stem cells die as we age anyway, causing gradual whitening over time, but the 2020 study found that stress accelerated the process. Stress can potentially change your hair color, but it’s hard to predict  exactly  how.

Busting stress is a good way to reduce its effects on your body and physical health. “Creating daily rituals will help reduce unwanted stress,” Dr. Ross tells Bustle. She suggests trying yoga, meditation, mindfulness, massage, psychotherapy, or a combination of approaches; you’ll probably have your own individual ways of relieving stress, whether it’s doing a few laps in a pool or sitting in the lotus position for an hour. And the results will relieve your body as well as your mind.


Studies cited:

Frank, M. G., Fonken, L. K., Watkins, L. R., & Maier, S. F. (2019). Microglia: Neuroimmune-sensors of stress.  Seminars in Cell & Developmental Biology ,  94 , 176–185. doi: 10.1016/j.semcdb.2019.01.001

Karl, J. P., Hatch, A. M., Arcidiacono, S. M., Pearce, S. C., Pantoja-Feliciano, I. G., Doherty, L. A., & Soares, J. W. (2018). Effects of Psychological, Environmental and Physical Stressors on the Gut Microbiota.  Frontiers in microbiology ,  9 , 2013. doi:10.3389/fmicb.2018.02013

Martire, V. L., Caruso, D., Palagini, L., Zoccoli, G., & Bastianini, S. (2019). Stress & sleep: A relationship lasting a lifetime.  Neuroscience & Biobehavioral Reviews . doi: 10.1016/j.neubiorev.2019.08.024

Morey, J. N., Boggero, I. A., Scott, A. B., & Segerstrom, S. C. (2015). Current Directions in Stress and Human Immune Function.  Current opinion in psychology ,  5 , 13–17. doi:10.1016/j.copsyc.2015.03.007

Peña, M. S. B., Mbassa, R. S., Slopen, N. B., Williams, D. R., Buring, J. E., & Albert, M. A. (2019). Cumulative Psychosocial Stress and Ideal Cardiovascular Health in Older Women.  Circulation ,  139 (17), 2012–2021. doi: 10.1161/circulationaha.118.033915

Sarkodie, E. K., Zhou, S., Baidoo, S. A., & Chu, W. (2019). Influences of stress hormones on microbial infections.  Microbial Pathogenesis ,  131 , 270–276. doi: 10.1016/j.micpath.2019.04.013

Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review.  EXCLI journal ,  16 , 1057–1072. doi:10.17179/excli2017-480

Zhang, B., Ma, S., Rachmin, I., He, M., Baral, P., Choi, S., … Hsu, Y.-C. (2020). Hyperactivation of sympathetic nerves drives depletion of melanocyte stem cells.  Nature ,  577 (7792), 676–681. doi: 10.1038/s41586-020-1935-3

Dr. Sherry Ross M.D.

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The impact of stress on students in secondary school and higher education

Young people report high levels of stress

Disclosure statement, additional information, review article.

Students in secondary and tertiary education settings face a wide range of ongoing stressors related to academic demands. Previous research indicates that academic-related stress can reduce academic achievement, decrease motivation and increase the risk of school dropout. The longer-term impacts, which include reduced likelihood of sustainable employment, cost Governments billions of dollars each year. This narrative review presents the most recent research concerning the impact of academic-related stress, including discussion of the impact on students’ learning capacity and academic performance, mental health problems, such as depression and anxiety, sleep disturbances and substance use.

Students in secondary and tertiary education settings face a wide range of ongoing normative stressors, which can be defined as normal day to day hassles such as ongoing academic demands. Accordingly, secondary/high school (defined here as junior/lower secondary education and senior/upper secondary education)] (UNESCO, Citation 2012 ) and tertiary (defined here as post-secondary education) (UNESCO, Citation 2012 ) students commonly self-report experiencing ongoing stress relating to their education, which we refer to as academic-related stress, such as pressure to achieve high marks and concerns about receiving poor grades. For example, the Organisation for Economic Co-operation and Development (OECD) recently conducted a survey involving 72 countries and consisting of 540,000 student respondents aged 15–16 years. On average across OECD countries, 66% of students reported feeling stressed about poor grades and 59% reported that they often worry that taking a test will be difficult. The OECD further found that 55% of students feel very anxious about school testing, even when they are well prepared. As many 37% of students reported feeling very tense when studying, with girls consistently reporting greater anxiety relating to schoolwork compared to boys (OECD, Citation 2017 ). This data demonstrates that education and academic performance are a significant source of stress to students. The impact of this ongoing academic-related stress to student outcomes and well-being has not been comprehensibly explored. Therefore, the current narrative review explores the impact of academic-related stress on students’ academic performance, mental health and well-being.

A single author (MP) searched PubMed and Google Scholar for peer-reviewed articles published at any time in English. Search terms included academic, school, university, stress, mental health, depression, anxiety, youth, young people, resilience, stress management, stress education, substance use, sleep, drop-out, physical health with a combination of any and/or all of the preceding terms. A snowball strategy allowed for examination of references in identified articles, and inclusion of additional articles as appropriate. The author reviewed all potential articles for inclusion. Articles from all countries were included in this narrative review, if a school based (secondary [as defined at grade 7 or higher] or university) population was included and the study assessed the impact of stress on student mental health, substance use, sleep, dropout rates, physical activity or academic outcomes. Articles were included regardless of study design.

Academic-related stress and mental health

Previous research indicates that self-reported stress is associated with the presentation of anxious states and lower well-being (Carter, Garber, Ciesla, & Cole, Citation 2006 ; Kessler, Citation 1997 ; Robotham & Julian, Citation 2006 ). The recent above-mentioned OECD survey reports that secondary students who self-report higher levels of academic-related stress also report lower well-being, measured using psychological, social, cognitive and physical components (OECD, Citation 2015 ). A systematic review of 13 studies showed that in individuals undertaking higher education, self-reported levels of stress are associated with poorer quality of life and well-being (Ribeiro et al., Citation 2017 ). Ongoing stress also precipitates the development of more serious mental health issues such as anxiety and depression (Kessler, Citation 1997 ; Moylan, Maes, Wray, & Berk, Citation 2013 ). The prevalence of anxiety is as high as 35% in tertiary students (Bayram & Bilgel, Citation 2008 ; Eisenberg, Gollust, Golberstein, & Hefner, Citation 2007 ; Ozen, Ercan, Irgil, & Sigirli, Citation 2010 ) and the prevalence of depression is 30% (Ibrahim, Kelly, Adams, & Glazebrook, Citation 2013 ). The reciprocal relationship between stress and depression and anxiety is well established (Dantzer, Citation 2012 ; Dantzer, O’Connor, Lawson, & Kelley, Citation 2011 ; Maes, Citation 2008 ). Indeed, major stressful life events are one of the best predictors of the onset of depression (Kendler et al., Citation 1995 ; Kessler, Citation 1997 ). Accordingly, in young people the first onset of depression is often preceded by major life stressors (Lewinsohn, Allen, Seeley, & Gotlib, Citation 1999 ).

Aside from impairing overall health and well-being, depression and anxiety symptoms can further adversely affect academic achievement (Bernal-Morales, Rodríguez-Landa, & Pulido-Criollo, Citation 2015 ). In undergraduate university students from the United States, those with higher self-reported anxiety and depression symptoms were found to achieve poorer grades on examinations (Chapell et al., Citation 2005 ; Hysenbegasi, Hass, & Rowland, Citation 2005 ). A longitudinal study of Hawaiian secondary school students showed that self-reported depressive symptoms resulted in subsequent poor academic achievement (Kessler, Citation 2012 ; McArdle, Hamagami, Chang, & Hishinuma, Citation 2014 ). This is consistent with the findings of Humensky et al. ( Citation 2010 ) who found that self-reported depressive symptoms were associated with concentration difficulties and trouble with completing school tasks, in 83 students from the United States between the ages of 14–21, and at-risk for major depression (Humensky et al., Citation 2010 ). In a sample of Finnish students aged 13–17, self-reported depression severity was associated with concentration difficulties, and poorer social relationships, self-learning, poorer academic performance, and worse reading and writing outcomes (Fröjd et al., Citation 2008 ). Therefore, it is not surprising that young people with depression, particularly males, are less likely to undertake higher education, as shown in a 15-year longitudinal study of Swedish adolescents (Jonsson et al., Citation 2010 ). Importantly, adolescent depression can also result in longer-term poor employment outcomes, as demonstrated by a 25-year longitudinal study of New Zealand children ( n = 982). This study found that people who had depression at ages 16–21 had greater rates of welfare dependence and unemployment, demonstrating that the impact of poor mental health in adolescence can have long-lasting impacts (Fergusson, Boden, & Horwood, Citation 2007 ). Enhancing support in the education setting may improve the mental health of young people. A national telephone survey of United States households showed that the incidence of depression in college students decreases if students have positive adjustments to academic life as well as adequate social support (Ross & Mirowsky, Citation 2006 ). Indeed, an Australian randomised control trial reported that a gamified online cognitive behaviour therapy intervention was effective in reducing depressive symptoms in 540 final year secondary students (Perry et al., Citation 2017 ). This study demonstrates the potential of education settings in mediating the impacts of academic-related stress on young people’s mental health.

Academic-related stress and substance use

The health and risk behaviours of young people, including substance use and abuse, are all important determinants of their current and future health and well-being status (Tountas & Dimitrakaki, Citation 2006 ; World Health Organisation, Citation 2004 ). Academic-related stress can increase substance use among young people. In a survey study of 128 Grade 11 students attending competitive private schools in the United States, students who reported experiencing high ongoing stress, particularly in relation to academic achievement and the tertiary education admissions process, also reported high rates of drug and alcohol use (Leonard et al., Citation 2015 ). The authors report that substance use was associated with a greater desire for academic achievement, higher perceived stress, less effective coping strategies, and less closeness with parents (Leonard et al., Citation 2015 ). In 7th and 8th Grade students from the United States, self-perceived stress has similarly been reported to be related to substance use. In these students, coping strategies that included information gathering, problem solving and having a positive outlook, as well as adult social support and relaxation were inversely related to substance use (Wills, Citation 1986 ). This study demonstrates the importance of protective social factors in mediating the effects of academic-related stress. In a cross-sectional study of tertiary nursing students from the United States, those with higher self-reported stress had higher incidence of substance use. Students who had higher perceptions of faculty support used fewer stimulants to assist them while studying, further demonstrating the proactive role of social factors (Boulton & O’Connell, Citation 2017 ). Finally, The Canadian Institute for Health reports that young people aged 12–19 who feel connected to their school report less anxiety and less risky behaviours, such as smoking and drinking alcohol, compared to those who do not feel connected to their schools (Canadian Institute for Health, Citation 2005 ). Collectively, the above discussed findings indicate that increased stress is associated with substance use among students and that perceived social support, including from within the education environment, may positively mediate this relationship.

Academic-related stress and sleep

Insufficient sleep in adolescents is recognised as a serious health risk by the American Medical Association and the American Academy of Sleep Medicine, who report that many young people do not get enough hours of sleep (Owens, Citation 2014 ). Stress is a contributing factor to poor sleep in young people (Bernert, Merrill, Braithwaite, Van Orden, & Joiner, Citation 2007 ; Curcio, Ferrara, & De, Citation 2006 ). Noland et al., found that 42% of 9–12 th Grade students report that stress is an impediment to good sleep, in 384 students surveyed (Noland, Price, Dake, & Telljohann, Citation 2009 ). Self-perceived stress has been shown to result in poorer sleep in female university students from the United States (Lee, Wuertz, Rogers, & Chen, Citation 2013 ; Wallace, Boynton, & Lytle, Citation 2017 ), medical students from Saudi Arabia (Almojali, Almalki, Alothman, Masuadi, & Alaqeel, Citation 2017 ), university students from Portugal (Amaral et al., Citation 2017 ) and Pakistani medical school students (Waqas, Khan, Sharif, Khalid, & Ali, Citation 2015 ), demonstrating the cross cultural impacts of stress on sleep quality and quantity tertiary education students. In a study from the United States, over 90% of 9–12 th Grade students reported that they have an inadequate number of hours of sleep on most school nights. These young people report that the impact of the loss of sleep is difficulty paying attention, lower grades, higher stress, and trouble getting along with other people. Some students reported problematic coping strategies such as taking sleeping pills, smoking cigarettes and drinking alcohol to help them sleep (Noland et al., Citation 2009 ). Sleep quality and quantity has been shown to be closely related to student learning capability and academic performance (Curcio et al., Citation 2006 ). Loss of sleep is frequently associated with poor learning (Curcio et al., Citation 2006 ). Therefore, stress-related disruption to sleep quality and quantity is an important factor contributing to poor learning and well-being among students.

Academic-related stress and physical health

The experience of high levels of academic-related stress increases the risk of young people developing preventable physical health problems later in life. A systematic review of prospective studies found that people who were stressed, such as during examination periods, were less likely to be physically active, the impact of which is associated with a plethora of potentially inter-related poor physical health outcomes (Stults-Kolehmainen & Sinha, Citation 2014 ). Stress may also lead to the development of non-communicable diseases, including metabolic syndrome, obesity and reduced insulin sensitivity, resulting from unhealthy lifestyle habits and stress system dysregulation (Pervanidou & Chrousos, Citation 2012 ). Similarly, stress has been shown to be associated with increased appetite (Dallman et al., Citation 1993 ) and higher body weight (Stephens et al., Citation 1995 ). Therefore, academic-related stress can contribute to the development of health issues, including chronic non-communicable diseases, due to decreases in physical activity and increases in unhealthy lifestyle habits.

Academic-related stress and achievement

The World Health Organisation ( Citation 1996 ) states that students must be healthy and emotionally secure to fully participate in education (World Health Organisation, Citation 1996 ). Indeed, the abovementioned OECD survey reports that anxiety about schoolwork, homework and tests has a negative impact on students’ academic performance in science, mathematics and reading. The survey highlights that top-performing girls report that the fear of making mistakes often disrupts their test performance (OECD, Citation 2015 ). Students in the bottom quarter of academic performance report feeling far more stressed compared to those in the top quarter of academic performance. As many as 63% of students in the bottom quarter of science performance report feeling anxious about tests no matter how well prepared they are, while 46% of students in the top quarter report feeling anxious (OECD, Citation 2015 ). This demonstrates that higher perceived stress levels are associated with poorer academic performance.

Previous research shows that the experience of positive and negative emotions are directly related to levels of student engagement (Reschly, Huebner, Appleton, & Antaramian, Citation 2008 ). In 293 students in Grades 7–10 from the United States, the frequency of positive emotions during classes was associated with higher student engagement. Conversely, the frequency of negative emotions was associated with lower engagement (Reschly et al., Citation 2008 ). This finding is important as engagement in learning is necessary for achievement, as illustrated by the findings of a survey conducted by the National Union of Students. This survey reported that the main factors affecting the tertiary studies of Australian university students aged 17–25 was stress (Rickwood, Telford, O’Sullivan, Crisp, & Magyar, Citation 2016 ). In an observational study of 456 German undergraduate medical students, higher perceived academic-related stress was found to predict poor academic performance (Kotter, Wagner, Bruheim, & Voltmer, Citation 2017 ). In another study of 121 medical students from Hong Kong, high self-reported stress levels were similarly related to poorer academic performance (Stewart, Lam, Betson, Wong, & Wong, Citation 1999 ). The above findings demonstrate that the academic-related stress that secondary and tertiary students experience constitutes a major factor affecting their academic achievement. Students with higher perceived stress are likely to have lower academic achievement.

Academic-related stress and dropout

Academic-related stress and burnout includes exhaustion, depersonalization, cynicism and inefficacy or reduced accomplishment (Walburg, Citation 2014 ). Academic-related stress is strongly related to decreased student academic motivation (Liu, Citation 2015 ; Liu & Lu, Citation 2011 ; Shinto, Citation 1998 ) and academic disengagement (National Centre on Addiction and Substance Abuse at Columbia University (CASA) United States of America, Citation 2003 ). The relationship between academic-related stress, motivation and dropout does not appear to be culturally specific, with similar findings shown from a number of international studies (Liu, Citation 2015 ; Liu & Lu, Citation 2011 ; Shinto, Citation 1998 ; Walburg, Citation 2014 ). In 298 Chinese secondary school students, academic-related stress in Grade 10 negatively predicted intrinsic academic motivation and positively predicted lack of motivation in Grade 12. This indicates that decreasing academic-related stress might preserve students’ ongoing intrinsic academic motivation (Liu, Citation 2015 ; Liu & Lu, Citation 2011 ). Similarly, in 495 Japanese students in junior secondary school, self-reported academic-related stress was found to negatively relate to feelings of self-growth and academic motivation (Shinto, Citation 1998 ). A recent literature review highlights how stress and burnout can also affect academic achievement by increasing the risk for school dropout (Walburg, Citation 2014 ). This was particularly true for students who experience more stressful life events of a more severe nature, as well as students who do not seek support from their parents or other family members as well as students from ethnically diverse groups (Hess & Copeland, Citation 2001 ).

School dropout is associated with a lifelong reduction in earning capacity and secure employment (Lamb & Huo, Citation 2017 ). Individuals with lower education levels report having poorer mental health and more illness than those with higher levels of education (Turrell, Stanley, de Looper, & Oldenburg, Citation 2006 ). Early dropout from school has also been reported to contribute to inter-generational issues including unemployment, poverty and less academic achievement (Black, Citation 2007 ; Lamb & Huo, Citation 2017 ; Muir, Family, Maguire, Slack-Smith, & Murray, Citation 2003 ). Academic achievement and completion of secondary school leads to greater employability, less reliance on social welfare support and a higher likelihood of participation in further education (Noble, Wyatt, McGrath, Roffey, & Rowling, Citation 2008 ). These outcomes in turn increase the likelihood of sustainable employment, adequate income and self-sufficiency (Noble et al., Citation 2008 ), which can save Governments hundreds of millions of dollars every year (Lamb & Huo, Citation 2017 ).

The current narrative review highlights that students commonly report high levels of academic-related stress, cross-culturally. The academic-related stress experienced by secondary and tertiary students’ impacts their mental and physical health and leads to a range of academic problems. Good stress-management skills have the potential to benefit young people in an ongoing manner throughout their lives, given that many long-term health-related behaviours and patterns, both positive and negative, are established during adolescence and early adulthood (Sawyer et al., Citation 2012 ). Therefore, providing opportunities to improve young people’s academic stress-related coping abilities during this highly stressful, crucial period of development is an important target (OECD, Citation 2015 ).

The OECD highlights that education settings are places where young people develop many of the social and emotional skills needed to become resilient and thrive (OECD, Citation 2015 ). Therefore, education settings can work to improve student academic related stress through the provision of programmes shown to decrease stress and increase stress management and coping. Discussion regarding the efficacy of particular school based stress management programmes to teach students to cope with stress is beyond the scope of the current review. It worth noting, however, that education-based initiatives that focus on increasing students skills and ability to cope with stress have been previously demonstrated to directly and positively influence educational achievement and decrease health risks (Hanson & Austin, Citation 2002 ; Perry et al., Citation 2017 ; Weare & Gray, Citation 2003 ). For example, a meta-analysis of 19 randomised controlled trials or quasi-experimental studies found that school programmes targeting stress management or coping skills reduced stress symptoms and improved coping skills among students (Kraag, Zeegers, Kok, Hosman, & Abu-Saad, Citation 2006 ). Schools provide access to a large number of young people, across a diverse range of backgrounds, during a formative developmental period (Sawyer et al., Citation 2012 ). As such, even if modestly effective, the population level implementation of stress management and coping skills programmes would help young people to develop healthy coping strategies in order to deal with the inevitable stressors of life. Understanding and addressing the barriers and enablers to implementation of stress management programmes in schools would support the development of effective implementation strategies (Albers & Pattuwage, Citation 2017 ; Domitrovich et al., Citation 2008 ), resulting in significant health, economic and social benefits for large numbers of young people, their families and the community.

A strength of the current review is that we have discussed studies from many countries, indicating that the academic-related stress experienced by students in education is cross-cultural and wide spread and is of international concern. We reviewed studies that demonstrated a range of negative effects of academic-related stress, highlighting the potential broad spectrum of benefits that may result from the implementation of stress-management interventions. A limitation of the current study is that we have not delineated between studies that have assessed the impact of academic-related stress during different phases of secondary and tertiary education. It is more than likely that the needs and therefore the most beneficial coping strategies may vary throughout the life span. Therefore, the most appropriate stress-management education approaches may differ between the early high school and tertiary education years.

This narrative review highlights that academic-related stress is a major concern for secondary and tertiary students. The ongoing stress relating to education has demonstrated negative impact on students’ learning capacity, academic performance, education and employment attainment, sleep quality and quantity, physical health, mental health and substance use outcomes. Increasing students’ stress-management skills and abilities is an important target for change.

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Original research article, academic stress and mental well-being in college students: correlations, affected groups, and covid-19.

research paper effects of stress

Academic stress may be the single most dominant stress factor that affects the mental well-being of college students. Some groups of students may experience more stress than others, and the coronavirus disease 19 (COVID-19) pandemic could further complicate the stress response. We surveyed 843 college students and evaluated whether academic stress levels affected their mental health, and if so, whether there were specific vulnerable groups by gender, race/ethnicity, year of study, and reaction to the pandemic. Using a combination of scores from the Perception of Academic Stress Scale (PAS) and the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), we found a significant correlation between worse academic stress and poor mental well-being in all the students, who also reported an exacerbation of stress in response to the pandemic. In addition, SWEMWBS scores revealed the lowest mental health and highest academic stress in non-binary individuals, and the opposite trend was observed for both the measures in men. Furthermore, women and non-binary students reported higher academic stress than men, as indicated by PAS scores. The same pattern held as a reaction to COVID-19-related stress. PAS scores and responses to the pandemic varied by the year of study, but no obvious patterns emerged. These results indicate that academic stress in college is significantly correlated to psychological well-being in the students who responded to this survey. In addition, some groups of college students are more affected by stress than others, and additional resources and support should be provided to them.


Late adolescence and emerging adulthood are transitional periods marked by major physiological and psychological changes, including elevated stress ( Hogan and Astone, 1986 ; Arnett, 2000 ; Shanahan, 2000 ; Spear, 2000 ; Scales et al., 2015 ; Romeo et al., 2016 ; Barbayannis et al., 2017 ; Chiang et al., 2019 ; Lally and Valentine-French, 2019 ; Matud et al., 2020 ). This pattern is particularly true for college students. According to a 2015 American College Health Association-National College Health Assessment survey, three in four college students self-reported feeling stressed, while one in five college students reported stress-related suicidal ideation ( Liu, C. H., et al., 2019 ; American Psychological Association, 2020 ). Studies show that a stressor experienced in college may serve as a predictor of mental health diagnoses ( Pedrelli et al., 2015 ; Liu, C. H., et al., 2019 ; Karyotaki et al., 2020 ). Indeed, many mental health disorders, including depression, anxiety, and substance abuse disorder, begin during this period ( Blanco et al., 2008 ; Pedrelli et al., 2015 ; Saleh et al., 2017 ; Reddy et al., 2018 ; Liu, C. H., et al., 2019 ).

Stress experienced by college students is multi-factorial and can be attributed to a variety of contributing factors ( Reddy et al., 2018 ; Karyotaki et al., 2020 ). A growing body of evidence suggests that academic-related stress plays a significant role in college ( Misra and McKean, 2000 ; Dusselier et al., 2005 ; Elias et al., 2011 ; Bedewy and Gabriel, 2015 ; Hj Ramli et al., 2018 ; Reddy et al., 2018 ; Pascoe et al., 2020 ). For instance, as many as 87% of college students surveyed across the United States cited education as their primary source of stress ( American Psychological Association, 2020 ). College students are exposed to novel academic stressors, such as an extensive academic course load, substantial studying, time management, classroom competition, financial concerns, familial pressures, and adapting to a new environment ( Misra and Castillo, 2004 ; Byrd and McKinney, 2012 ; Ekpenyong et al., 2013 ; Bedewy and Gabriel, 2015 ; Ketchen Lipson et al., 2015 ; Pedrelli et al., 2015 ; Reddy et al., 2018 ; Liu, C. H., et al., 2019 ; Freire et al., 2020 ; Karyotaki et al., 2020 ). Academic stress can reduce motivation, hinder academic achievement, and lead to increased college dropout rates ( Pascoe et al., 2020 ).

Academic stress has also been shown to negatively impact mental health in students ( Li and Lin, 2003 ; Eisenberg et al., 2009 ; Green et al., 2021 ). Mental, or psychological, well-being is one of the components of positive mental health, and it includes happiness, life satisfaction, stress management, and psychological functioning ( Ryan and Deci, 2001 ; Tennant et al., 2007 ; Galderisi et al., 2015 ; Trout and Alsandor, 2020 ; Defeyter et al., 2021 ; Green et al., 2021 ). Positive mental health is an understudied but important area that helps paint a more comprehensive picture of overall mental health ( Tennant et al., 2007 ; Margraf et al., 2020 ). Moreover, positive mental health has been shown to be predictive of both negative and positive mental health indicators over time ( Margraf et al., 2020 ). Further exploring the relationship between academic stress and mental well-being is important because poor mental well-being has been shown to affect academic performance in college ( Tennant et al., 2007 ; Eisenberg et al., 2009 ; Freire et al., 2016 ).

Perception of academic stress varies among different groups of college students ( Lee et al., 2021 ). For instance, female college students report experiencing increased stress than their male counterparts ( Misra et al., 2000 ; Eisenberg et al., 2007 ; Evans et al., 2018 ; Lee et al., 2021 ). Male and female students also respond differently to stressors ( Misra et al., 2000 ; Verma et al., 2011 ). Moreover, compared to their cisgender peers, non-binary students report increased stressors and mental health issues ( Budge et al., 2020 ). The academic year of study of the college students has also been shown to impact academic stress levels ( Misra and McKean, 2000 ; Elias et al., 2011 ; Wyatt et al., 2017 ; Liu, C. H., et al., 2019 ; Defeyter et al., 2021 ). While several studies indicate that racial/ethnic minority groups of students, including Black/African American, Hispanic/Latino, and Asian American students, are more likely to experience anxiety, depression, and suicidality than their white peers ( Lesure-Lester and King, 2004 ; Lipson et al., 2018 ; Liu, C. H., et al., 2019 ; Kodish et al., 2022 ), these studies are limited and often report mixed or inconclusive findings ( Liu, C. H., et al., 2019 ; Kodish et al., 2022 ). Therefore, more studies should be conducted to address this gap in research to help identify subgroups that may be disproportionately impacted by academic stress and lower well-being.

The coronavirus disease 19 (COVID-19) pandemic is a major stressor that has led to a mental health crisis ( American Psychological Association, 2020 ; Dong and Bouey, 2020 ). For college students, the COVID-19 pandemic has resulted in significant changes and disruptions to daily life, elevated stress levels, and mental and physical health deterioration ( American Psychological Association, 2020 ; Husky et al., 2020 ; Patsali et al., 2020 ; Son et al., 2020 ; Clabaugh et al., 2021 ; Lee et al., 2021 ; Lopes and Nihei, 2021 ; Yang et al., 2021 ). While any college student is vulnerable to these stressors, these concerns are amplified for members of minority groups ( Salerno et al., 2020 ; Clabaugh et al., 2021 ; McQuaid et al., 2021 ; Prowse et al., 2021 ; Kodish et al., 2022 ). Identifying students at greatest risk provides opportunities to offer support, resources, and mental health services to specific subgroups.

The overall aim of this study was to assess academic stress and mental well-being in a sample of college students. Within this umbrella, we had several goals. First, to determine whether a relationship exists between the two constructs of perceived academic stress, measured by the Perception of Academic Stress Scale (PAS), and mental well-being, measured by the Short Warwick-Edinburgh Mental Well-Being Scale (SWEMWBS), in college students. Second, to identify groups that could experience differential levels of academic stress and mental health. Third, to explore how the perception of the ongoing COVID-19 pandemic affected stress levels. We hypothesized that students who experienced more academic stress would have worse psychological well-being and that certain groups of students would be more impacted by academic- and COVID-19-related stress.

Materials and Methods

Survey instrument.

A survey was developed that included all questions from the Short Warwick-Edinburgh Mental Well-Being ( Tennant et al., 2007 ; Stewart-Brown and Janmohamed, 2008 ) and from the Perception of Academic Stress Scale ( Bedewy and Gabriel, 2015 ). The Short Warwick-Edinburgh Mental Well-Being Scale is a seven-item scale designed to measure mental well-being and positive mental health ( Tennant et al., 2007 ; Fung, 2019 ; Shah et al., 2021 ). The Perception of Academic Stress Scale is an 18-item scale designed to assess sources of academic stress perceived by individuals and measures three main academic stressors: academic expectations, workload and examinations, and academic self-perceptions of students ( Bedewy and Gabriel, 2015 ). These shorter scales were chosen to increase our response and study completion rates ( Kost and de Rosa, 2018 ). Both tools have been shown to be valid and reliable in college students with Likert scale responses ( Tennant et al., 2007 ; Bedewy and Gabriel, 2015 ; Ringdal et al., 2018 ; Fung, 2019 ; Koushede et al., 2019 ). Both the SWEMWBS and PAS scores are a summation of responses to the individual questions in the instruments. For the SWEMWBS questions, a higher score indicates better mental health, and scores range from 7 to 35. Similarly, the PAS questions are phrased such that a higher score indicates lower levels of stress, and scores range from 18 to 90. We augmented the survey with demographic questions (e.g., age, gender, and race/ethnicity) at the beginning of the survey and two yes/no questions and one Likert scale question about the impact of the COVID-19 pandemic at the end of our survey.

Participants for the study were self-reported college students between the ages of 18 and 30 years who resided in the United States, were fluent in English, and had Internet access. Participants were solicited through Prolific ( https://prolific.co ) in October 2021. A total of 1,023 individuals enrolled in the survey. Three individuals did not agree to participate after beginning the survey. Two were not fluent in English. Thirteen individuals indicated that they were not college students. Two were not in the 18–30 age range, and one was located outside of the United States. Of the remaining individuals, 906 were full-time students and 96 were part-time students. Given the skew of the data and potential differences in these populations, we removed the part-time students. Of the 906 full-time students, 58 indicated that they were in their fifth year of college or higher. We understand that not every student completes their undergraduate studies in 4 years, but we did not want to have a mixture of undergraduate and graduate students with no way to differentiate them. Finally, one individual reported their age as a non-number, and four individuals did not answer a question about their response to the COVID-19 pandemic. This yielded a final sample of 843 college students.

Data Analyses

After reviewing the dataset, some variables were removed from consideration due to a lack of consistency (e.g., some students reported annual income for themselves and others reported family income) or heterogeneity that prevented easy categorization (e.g., field of study). We settled on four variables of interest: gender, race/ethnicity, year in school, and response to the COVID-19 pandemic ( Table 1 ). Gender was coded as female, male, or non-binary. Race/ethnicity was coded as white or Caucasian; Black or African American; East Asian; Hispanic, Latino, or of Spanish origin; or other. Other was used for groups that were not well-represented in the sample and included individuals who identified themselves as Middle Eastern, Native American or Alaskan Native, and South Asian, as well as individuals who chose “other” or “prefer not to answer” on the survey. The year of study was coded as one through four, and COVID-19 stress was coded as two groups, no change/neutral response/reduced stress or increased stress.


Table 1 . Characteristics of the participants in the study.

Our first goal was to determine whether there was a relationship between self-reported academic stress and mental health, and we found a significant correlation (see Results section). Given the positive correlation, a multivariate analysis of variance (MANOVA) with a model testing the main effects of gender, race/ethnicity, and year of study was run in SPSS v 26.0. A factorial MANOVA would have been ideal, but our data were drawn from a convenience sample, which did not give equal representation to all groupings, and some combinations of gender, race/ethnicity, and year of study were poorly represented (e.g., a single individual). As such, we determined that it would be better to have a lack of interaction terms as a limitation to the study than to provide potentially spurious results. Finally, we used chi-square analyses to assess the effect of potential differences in the perception of the COVID-19 pandemic on stress levels in general among the groups in each category (gender, race/ethnicity, and year of study).

In terms of internal consistency, Cronbach's alpha was 0.82 for the SMEMWBS and 0.86 for the PAS. A variety of descriptors have been applied to Cronbach's alpha values. That said, 0.7 is often considered a threshold value in terms of acceptable internal consistency, and our values could be considered “high” or “good” ( Taber, 2018 ).

The participants in our study were primarily women (78.5% of respondents; Table 1 ). Participants were not equally distributed among races/ethnicities, with the majority of students selecting white or Caucasian (66.4% of responders; Table 1 ), or years of study, with fewer first-year students than other groups ( Table 1 ).

Students who reported higher academic stress also reported worse mental well-being in general, irrespective of age, gender, race/ethnicity, or year of study. PAS and SWEMWBS scores were significantly correlated ( r = 0.53, p < 0.001; Figure 1 ), indicating that a higher level of perceived academic stress is associated with worse mental well-being in college students within the United States.


Figure 1 . SWEMWBS and PAS scores for all participants.

Among the subgroups of students, women, non-binary students, and second-year students reported higher academic stress levels and worse mental well-being ( Table 2 ; Figures 2 – 4 ). In addition, the combined measures differed significantly between the groups in each category ( Table 2 ). However, as measured by partial eta squared, the effect sizes were relatively small, given the convention of 0.01 = small, 0.06 = medium, and 0.14 = large differences ( Lakens, 2013 ). As such, there were only two instances in which Tukey's post-hoc tests revealed more than one statistical grouping ( Figures 2 – 4 ). For SWEMWBS score by gender, women were intermediate between men (high) and non-binary individuals (low) and not significantly different from either group ( Figure 2 ). Second-year students had the lowest PAS scores for the year of study, and first-year students had the highest scores. Third- and fourth-year students were intermediate and not statistically different from the other two groups ( Figure 4 ). There were no pairwise differences in academic stress levels or mental well-being among racial/ethnic groups.


Table 2 . Results of the MANOVA.


Figure 2 . SWEMWBS and PAS scores according to gender (mean ± SEM). Different letters for SWEMWBS scores indicate different statistical groupings ( p < 0.05).


Figure 3 . SWEMWBS and PAS scores according to race/ethnicity (mean ± SEM).


Figure 4 . SWEMWBS and PAS scores according to year in college (mean ± SEM). Different letters for PAS scores indicate different statistical groupings ( p < 0.05).

The findings varied among categories in terms of stress responses due to the COVID-19 pandemic ( Table 3 ). For gender, men were less likely than women or non-binary individuals to report increased stress from COVID-19 (χ 2 = 27.98, df = 2, p < 0.001). All racial/ethnic groups responded similarly to the pandemic (χ 2 = 3.41, df = 4, p < 0.49). For the year of study, first-year students were less likely than other cohorts to report increased stress from COVID-19 (χ 2 = 9.38, df = 3, p < 0.03).


Table 3 . Impact of COVID-19 on stress level by gender, race/ethnicity, and year of study.

Our primary findings showed a positive correlation between perceived academic stress and mental well-being in United States college students, suggesting that academic stressors, including academic expectations, workload and grading, and students' academic self-perceptions, are equally important as psychological well-being. Overall, irrespective of gender, race/ethnicity, or year of study, students who reported higher academic stress levels experienced diminished mental well-being. The utilization of well-established scales and a large sample size are strengths of this study. Our results extend and contribute to the existing literature on stress by confirming findings from past studies that reported higher academic stress and lower psychological well-being in college students utilizing the same two scales ( Green et al., 2021 ; Syed, 2021 ). To our knowledge, the majority of other prior studies with similar findings examined different components of stress, studied negative mental health indicators, used different scales or methods, employed smaller sample sizes, or were conducted in different countries ( Li and Lin, 2003 ; American Psychological Association, 2020 ; Husky et al., 2020 ; Pascoe et al., 2020 ; Patsali et al., 2020 ; Clabaugh et al., 2021 ; Lee et al., 2021 ; Lopes and Nihei, 2021 ; Yang et al., 2021 ).

This study also demonstrated that college students are not uniformly impacted by academic stress or pandemic-related stress and that there are significant group-level differences in mental well-being. Specifically, non-binary individuals and second-year students were disproportionately impacted by academic stress. When considering the effects of gender, non-binary students, in comparison to gender-conforming students, reported the highest stress levels and worst psychological well-being. Although there is a paucity of research examining the impact of academic stress in non-binary college students, prior studies have indicated that non-binary adults face adverse mental health outcomes when compared to male and female-identifying individuals ( Thorne et al., 2018 ; Jones et al., 2019 ; Budge et al., 2020 ). Alarmingly, Lipson et al. (2019) found that gender non-conforming college students were two to four times more likely to experience mental health struggles than cisgender students ( Lipson et al., 2019 ). With a growing number of college students in the United States identifying as as non-binary, additional studies could offer invaluable insight into how academic stress affects this population ( Budge et al., 2020 ).

In addition, we found that second-year students reported the most academic-related distress and lowest psychological well-being relative to students in other years of study. We surmise this may be due to this group taking advanced courses, managing heavier academic workloads, and exploring different majors. Other studies support our findings and suggest higher stress levels could be attributed to increased studying and difficulties with time management, as well as having less well-established social support networks and coping mechanisms compared to upperclassmen ( Allen and Hiebert, 1991 ; Misra and McKean, 2000 ; Liu, X et al., 2019 ). Benefiting from their additional experience, upperclassmen may have developed more sophisticated studying skills, formed peer support groups, and identified approaches to better manage their academic stress ( Allen and Hiebert, 1991 ; Misra and McKean, 2000 ). Our findings suggest that colleges should consider offering tailored mental health resources, such as time management and study skill workshops, based on the year of study to improve students' stress levels and psychological well-being ( Liu, X et al., 2019 ).

Although this study reported no significant differences regarding race or ethnicity, this does not indicate that minority groups experienced less academic stress or better mental well-being ( Lee et al., 2021 ). Instead, our results may reflect the low sample size of non-white races/ethnicities, which may not have given enough statistical power to corroborate. In addition, since coping and resilience are important mediators of subjective stress experiences ( Freire et al., 2020 ), we speculate that the lower ratios of stress reported in non-white participants in our study (75 vs. 81) may be because they are more accustomed to adversity and thereby more resilient ( Brown, 2008 ; Acheampong et al., 2019 ). Furthermore, ethnic minority students may face stigma when reporting mental health struggles ( Liu, C. H., et al., 2019 ; Lee et al., 2021 ). For instance, studies showed that Black/African American, Hispanic/Latino, and Asian American students disclose fewer mental health issues than white students ( Liu, C. H., et al., 2019 ; Lee et al., 2021 ). Moreover, the ability to identify stressors and mental health problems may manifest differently culturally for some minority groups ( Huang and Zane, 2016 ; Liu, C. H., et al., 2019 ). Contrary to our findings, other studies cited racial disparities in academic stress levels and mental well-being of students. More specifically, Negga et al. (2007) concluded that African American college students were more susceptible to higher academic stress levels than their white classmates ( Negga et al., 2007 ). Another study reported that minority students experienced greater distress and worse mental health outcomes compared to non-minority students ( Smith et al., 2014 ). Since there may be racial disparities in access to mental health services at the college level, universities, professors, and counselors should offer additional resources to support these students while closely monitoring their psychological well-being ( Lipson et al., 2018 ; Liu, C. H., et al., 2019 ).

While the COVID-19 pandemic increased stress levels in all the students included in our study, women, non-binary students, and upperclassmen were disproportionately affected. An overwhelming body of evidence suggests that the majority of college students experienced increased stress levels and worsening mental health as a result of the pandemic ( Allen and Hiebert, 1991 ; American Psychological Association, 2020 ; Husky et al., 2020 ; Patsali et al., 2020 ; Son et al., 2020 ; Clabaugh et al., 2021 ; Lee et al., 2021 ; Yang et al., 2021 ). Our results also align with prior studies that found similar subgroups of students experience disproportionate pandemic-related distress ( Gao et al., 2020 ; Clabaugh et al., 2021 ; Hunt et al., 2021 ; Jarrett et al., 2021 ; Lee et al., 2021 ; Chen and Lucock, 2022 ). In particular, the differences between female students and their male peers may be the result of different psychological and physiological responses to stress reactivity, which in turn may contribute to different coping mechanisms to stress and the higher rates of stress-related disorders experienced by women ( Misra et al., 2000 ; Kajantie and Phillips, 2006 ; Verma et al., 2011 ; Gao et al., 2020 ; Graves et al., 2021 ). COVID-19 was a secondary consideration in our study and survey design, so the conclusions drawn here are necessarily limited.

The implications of this study are that college students facing increased stress and struggling with mental health issues should receive personalized and specific mental health services, resources, and support. This is particularly true for groups that have been disproportionately impacted by academic stress and stress due to the pandemic. Many students who experience mental health struggles underutilize college services due to cost, stigma, or lack of information ( Cage et al., 2020 ; Lee et al., 2021 ). To raise awareness and destigmatize mental health, colleges can consider distributing confidential validated assessments, such as the PAS and SWEMWBS, in class and teach students to self-score ( Lee et al., 2021 ). These results can be used to understand how academic stress and mental well-being change over time and allow for specific and targeted interventions for vulnerable groups. In addition, teaching students healthy stress management techniques has been shown to improve psychological well-being ( Alborzkouh et al., 2015 ). Moreover, adaptive coping strategies, including social and emotional support, have been found to improve the mental well-being of students, and stress-reduction peer support groups and workshops on campus could be beneficial in reducing stress and improving the self-efficacy of students ( Ruthig et al., 2009 ; Baqutayan, 2011 ; Bedewy and Gabriel, 2015 ; Freire et al., 2020 ; Green et al., 2021 ; Suresh et al., 2021 ). Other interventions that have been effective in improving the coping skills of college students include cognitive-behavioral therapy, mindfulness mediation, and online coping tools ( Kang et al., 2009 ; Regehr et al., 2013 ; Molla Jafar et al., 2015 ; Phang et al., 2015 ; Houston et al., 2017 ; Yusufov et al., 2019 ; Freire et al., 2020 ). Given that resilience has also been shown to help mediate stress and improve mental well-being during the COVID-19 pandemic, interventions focusing on enhancing resilience should be considered ( Surzykiewicz et al., 2021 ; Skalski et al., 2022 ). Telemental health resources across colleges can also be implemented to reduce stigma and improve at-risk students' access to care ( Toscos et al., 2018 ; Hadler et al., 2021 ). University campuses, professors, and counselors should consider focusing on fostering a more equitable and inclusive environment to encourage marginalized students to seek mental health support ( Budge et al., 2020 ).


While our study has numerous strengths, including using standardized instruments and a large sample size, this study also has several limitations due to both the methodology and sample. First, the correlational study design precludes making any causal relationships ( Misra and McKean, 2000 ). Thereby, our findings should be taken in the context of academic stress and mental well-being, and recognize that mental health could be caused by other non-academic factors. Second, the PAS comprised only the perception of responses to academic stress, but stress is a multi-factorial response that encompasses both perceptions and coping mechanisms to different stressors, and the magnitude of stress varies with the perception of the degree of uncontrollability, unpredictability, or threat to self ( Miller, 1981 ; Hobfoll and Walfisch, 1984 ; Lazarus and Folkman, 1984 ; Wheaton, 1985 ; Perrewé and Zellars, 1999 ; Schneiderman et al., 2005 ; Bedewy and Gabriel, 2015 ; Schönfeld et al., 2016 ; Reddy et al., 2018 ; Freire et al., 2020 ; Karyotaki et al., 2020 ). Third, the SWEMSBS used in our study and the data only measured positive mental health. Mental health pathways are numerous and complex, and are composed of distinct and interdependent negative and positive indicators that should be considered together ( Margraf et al., 2020 ). Fourth, due to the small effect sizes and unequal representation for different combinations of variables, our analysis for both the PAS and SWEMSBS included only summed-up scales and did not examine group differences in response to the type of academic stressors or individual mental health questions.

An additional limitation is that the participants in our study were a convenience sample. The testing service we used, prolific.co, self-reports a sample bias toward young women of high levels of education (i.e., WEIRD bias) ( Team Prolific, 2018 ). The skew toward this population was observed in our data, as 80% of our participants were women. While we controlled for these factors, the possibility remains that the conclusions we draw for certain groups, such as nonbinary students, ethnic/racial minorities, and men, may not be as statistically powerful as they should be. Moreover, our pre-screening was designed to recruit undergraduate level, English-speaking, 18–30-year-olds who resided in the United States. This resulted in our participant demographics being skewed toward the WEIRD bias that was already inherent in the testing service we used. Future research will aim to be more inclusive of diverse races/ethnicities, sexual orientations, languages, educational backgrounds, socioeconomic backgrounds, and first-generation college students.

Another limitation of our study is the nature of satisficing. Satisficing is a response strategy in which a participant answers a question to satisfy its condition with little regard to the quality or accuracy of the answer ( Roberts et al., 2019 ). Anonymous participants are more likely to satisfice than respondents who answer the question face-to-face ( Krosnick et al., 2002 ). We sought to mitigate satisficing by offering financial incentives to increase response rates and decrease straight-lining, item skipping, total missing items, and non-completion ( Cole et al., 2015 ). Concerns of poor data quality due to surveys offering financial incentives found little evidence to support that claim and may do the opposite ( Cole et al., 2015 ). On the other hand, social desirability bias may have influenced the participant's self-reported responses, although our anonymous survey design aimed to reduce this bias ( Joinson, 1999 ; Kecojevic et al., 2020 ).

Future Studies

Future studies should replicate our study to validate our results, conduct longitudinal cohort studies to examine well-being and perceived academic stress over time, and aim for a more representative student sample that includes various groups, including diverse races/ethnicities, sexual orientations, socioeconomic backgrounds, languages, educational levels, and first-generation college students. Additionally, these studies should consider examining other non-academic stressors and students' coping mechanisms, both of which contribute to mental health and well-being ( Lazarus and Folkman, 1984 ; Freire et al., 2020 ). Further explorations of negative and other positive indicators of mental health may offer a broader perspective ( Margraf et al., 2020 ). Moreover, future research should consider extending our work by exploring group differences in relation to each factor in the PAS (i.e., academic expectations, workload and examinations, and self-perception of students) and SWEMBS to determine which aspects of academic stress and mental health were most affected and allow for the devising of targeted stress-reduction approaches. Ultimately, we hope our research spurs readers into advocating for greater academic support and access to group-specific mental health resources to reduce the stress levels of college students and improve their mental well-being.

Utilizing two well-established scales, our research found a statistically significant correlation between the perceived academic stress of university students and their mental well-being (i.e., the higher the stress, the worse the well-being). This relationship was most apparent among gender and grade levels. More specifically, non-binary and second-year students experienced greater academic burden and lower psychological well-being. Moreover, women, non-binary students, and upper-level students were disproportionately impacted by stress related to the COVID-19 pandemic.

Studies regarding broad concepts of stress and well-being using a questionnaire are limited, but our study adds value to the understanding of academic stress as a contributor to the overall well-being of college students during this specific point in time (i.e., the COVID-19 pandemic). Competition both for admission to college ( Bound et al., 2009 ) and during college ( Posselt and Lipson, 2016 ) has increased over time. Further, selective American colleges and universities draw applicants from a global pool. As such, it is important to document the dynamics of academic stress with renewed focus. We hope that our study sparks interest in both exploring and funding in-depth and well-designed psychological studies related to stress in colleges in the future.

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics Statement

The studies involving human participants were reviewed and approved by Institutional Review Board at Rutgers University. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

GB and MB contributed to conceptualization, study design, IRB application, manuscript drafting, and revision. XZ participated in the conceptualization and design of the questionnaires. HB participated in subject recruitment and questionnaire collection. KP contributed to data analysis, table and figure preparation, manuscript drafting, and revision. XM contributed to conceptualization, study design, IRB application, supervision of the project, manuscript drafting, and revision. All authors contributed to the article and approved the submitted version.

This study was made possible by a generous donation from the Knights of Columbus East Hanover Chapter in New Jersey.

Conflict of Interest

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.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The authors wish to thank Shivani Mehta and Varsha Garla for their assistance with the study. We also thank all the participants for their efforts in the completion of the study.

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Keywords: academic stress, well-being, college students, Perception of Academic Stress, Short Warwick-Edinburgh Mental Well-Being Scale, COVID-19

Citation: Barbayannis G, Bandari M, Zheng X, Baquerizo H, Pecor KW and Ming X (2022) Academic Stress and Mental Well-Being in College Students: Correlations, Affected Groups, and COVID-19. Front. Psychol. 13:886344. doi: 10.3389/fpsyg.2022.886344

Received: 28 February 2022; Accepted: 20 April 2022; Published: 23 May 2022.

Reviewed by:

Copyright © 2022 Barbayannis, Bandari, Zheng, Baquerizo, Pecor and Ming. 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: Keith W. Pecor, pecor@tcnj.edu

† These authors have contributed equally to this work and share first authorship

This article is part of the Research Topic

Understanding Socioemotional And Academic Adjustment During Childhood And Adolescence: Volume II

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Stress effects on the body

Stress affects all systems of the body including the musculoskeletal, respiratory, cardiovascular, endocrine, gastrointestinal, nervous, and reproductive systems.

Effects of stress on the body

Our bodies are well equipped to handle stress in small doses, but when that stress becomes long-term or chronic, it can have serious effects on your body.

Musculoskeletal system

When the body is stressed, muscles tense up. Muscle tension is almost a reflex reaction to stress—the body’s way of guarding against injury and pain.

With sudden onset stress, the muscles tense up all at once, and then release their tension when the stress passes. Chronic stress causes the muscles in the body to be in a more or less constant state of guardedness. When muscles are taut and tense for long periods of time, this may trigger other reactions of the body and even promote stress-related disorders.

For example, both tension-type headache and migraine headache are associated with chronic muscle tension in the area of the shoulders, neck and head. Musculoskeletal pain in the low back and upper extremities has also been linked to stress, especially job stress.

Millions of individuals suffer from chronic painful conditions secondary to musculoskeletal disorders. Often, but not always, there may be an injury that sets off the chronic painful state. What determines whether or not an injured person goes on to suffer from chronic pain is how they respond to the injury. Individuals who are fearful of pain and re-injury, and who seek only a physical cause and cure for the injury, generally have a worse recovery than individuals who maintain a certain level of moderate, physician-supervised activity. Muscle tension, and eventually, muscle atrophy due to disuse of the body, all promote chronic, stress-related musculoskeletal conditions.

Relaxation techniques and other stress-relieving activities and therapies have been shown to effectively reduce muscle tension, decrease the incidence of certain stress-related disorders, such as headache, and increase a sense of well-being. For those who develop chronic pain conditions, stress-relieving activities have been shown to improve mood and daily function.

Respiratory system

The respiratory system supplies oxygen to cells and removes carbon dioxide waste from the body. Air comes in through the nose and goes through the larynx in the throat, down through the trachea, and into the lungs through the bronchi. The bronchioles then transfer oxygen to red blood cells for circulation.

Stress and strong emotions can present with respiratory symptoms, such as shortness of breath and rapid breathing, as the airway between the nose and the lungs constricts. For people without respiratory disease, this is generally not a problem as the body can manage the additional work to breathe comfortably, but psychological stressors can exacerbate breathing problems for people with pre-existing respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD; includes emphysema and chronic bronchitis).

Some studies show that an acute stress—such as the death of a loved one—can actually trigger asthma attacks. In addition, the rapid breathing—or hyperventilation—caused by stress can bring on a panic attack in someone prone to panic attacks.

Working with a psychologist to develop relaxation, breathing, and other cognitive behavioral strategies can help.

Cardiovascular system

The heart and blood vessels comprise the two elements of the cardiovascular system that work together in providing nourishment and oxygen to the organs of the body. The activity of these two elements is also coordinated in the body’s response to stress. Acute stress—stress that is momentary or short-term such as meeting deadlines, being stuck in traffic or suddenly slamming on the brakes to avoid an accident—causes an increase in heart rate and stronger contractions of the heart muscle, with the stress hormones—adrenaline, noradrenaline, and cortisol—acting as messengers for these effects.

In addition, the blood vessels that direct blood to the large muscles and the heart dilate, thereby increasing the amount of blood pumped to these parts of the body and elevating blood pressure. This is also known as the fight or flight response. Once the acute stress episode has passed, the body returns to its normal state.

Chronic stress, or a constant stress experienced over a prolonged period of time, can contribute to long-term problems for heart and blood vessels. The consistent and ongoing increase in heart rate, and the elevated levels of stress hormones and of blood pressure, can take a toll on the body. This long-term ongoing stress can increase the risk for hypertension, heart attack, or stroke.

Repeated acute stress and persistent chronic stress may also contribute to inflammation in the circulatory system, particularly in the coronary arteries, and this is one pathway that is thought to tie stress to heart attack. It also appears that how a person responds to stress can affect cholesterol levels.

The risk for heart disease associated with stress appears to differ for women, depending on whether the woman is premenopausal or postmenopausal. Levels of estrogen in premenopausal women appears to help blood vessels respond better during stress, thereby helping their bodies to better handle stress and protecting them against heart disease. Postmenopausal women lose this level of protection due to loss of estrogen, therefore putting them at greater risk for the effects of stress on heart disease.

Endocrine system

When someone perceives a situation to be challenging, threatening, or uncontrollable, the brain initiates a cascade of events involving the hypothalamic-pituitary-adrenal (HPA) axis, which is the primary driver of the endocrine stress response. This ultimately results in an increase in the production of steroid hormones called glucocorticoids, which include cortisol, often referred to as the “stress hormone”.

The HPA axis During times of stress, the hypothalamus, a collection of nuclei that connects the brain and the endocrine system, signals the pituitary gland to produce a hormone, which in turn signals the adrenal glands, located above the kidneys, to increase the production of cortisol.

Cortisol increases the level of energy fuel available by mobilizing glucose and fatty acids from the liver. Cortisol is normally produced in varying levels throughout the day, typically increasing in concentration upon awakening and slowly declining throughout the day, providing a daily cycle of energy.

During a stressful event, an increase in cortisol can provide the energy required to deal with prolonged or extreme challenge.

Stress and health Glucocorticoids, including cortisol, are important for regulating the immune system and reducing inflammation. While this is valuable during stressful or threatening situations where injury might result in increased immune system activation, chronic stress can result in impaired communication between the immune system and the HPA axis.

This impaired communication has been linked to the future development of numerous physical and mental health conditions, including chronic fatigue, metabolic disorders (e.g., diabetes, obesity), depression, and immune disorders.

Gastrointestinal system

The gut has hundreds of millions of neurons which can function fairly independently and are in constant communication with the brain—explaining the ability to feel “butterflies” in the stomach. Stress can affect this brain-gut communication, and may trigger pain, bloating, and other gut discomfort to be felt more easily. The gut is also inhabited by millions of bacteria which can influence its health and the brain’s health, which can impact the ability to think and affect emotions.

Stress is associated with changes in gut bacteria which in turn can influence mood. Thus, the gut’s nerves and bacteria strongly influence the brain and vice versa.

Early life stress can change the development of the nervous system as well as how the body reacts to stress. These changes can increase the risk for later gut diseases or dysfunctioning.

Esophagus When stressed, individuals may eat much more or much less than usual. More or different foods, or an increase in the use of alcohol or tobacco, can result in heartburn or acid reflux. Stress or exhaustion can also increase the severity of regularly occurring heartburn pain. A rare case of spasms in the esophagus can be set off by intense stress and can be easily mistaken for a heart attack.

Stress also may make swallowing foods difficult or increase the amount of air that is swallowed, which increases burping, gassiness, and bloating.

Stomach Stress may make pain, bloating, nausea, and other stomach discomfort felt more easily. Vomiting may occur if the stress is severe enough. Furthermore, stress may cause an unnecessary increase or decrease in appetite. Unhealthy diets may in turn deteriorate one’s mood.

Contrary to popular belief, stress does not increase acid production in the stomach, nor causes stomach ulcers. The latter are actually caused by a bacterial infection. When stressed, ulcers may be more bothersome.

Bowel Stress can also make pain, bloating, or discomfort felt more easily in the bowels. It can affect how quickly food moves through the body, which can cause either diarrhea or constipation. Furthermore, stress can induce muscle spasms in the bowel, which can be painful.

Stress can affect digestion and what nutrients the intestines absorb. Gas production related to nutrient absorption may increase.

The intestines have a tight barrier to protect the body from (most) food related bacteria. Stress can make the intestinal barrier weaker and allow gut bacteria to enter the body. Although most of these bacteria are easily taken care of by the immune system and do not make us sick, the constant low need for inflammatory action can lead to chronic mild symptoms.

Stress especially affects people with chronic bowel disorders, such as inflammatory bowel disease or irritable bowel syndrome. This may be due to the gut nerves being more sensitive, changes in gut microbiota, changes in how quickly food moves through the gut, and/or changes in gut immune responses.

Nervous system

The nervous system has several divisions: the central division involving the brain and spinal cord and the peripheral division consisting of the autonomic and somatic nervous systems.

The autonomic nervous system has a direct role in physical response to stress and is divided into the sympathetic nervous system (SNS), and the parasympathetic nervous system (PNS). When the body is stressed, the SNS contributes to what is known as the “fight or flight” response. The body shifts its energy resources toward fighting off a life threat, or fleeing from an enemy.

The SNS signals the adrenal glands to release hormones called adrenalin (epinephrine) and cortisol. These hormones, together with direct actions of autonomic nerves, cause the heart to beat faster, respiration rate to increase, blood vessels in the arms and legs to dilate, digestive process to change and glucose levels (sugar energy) in the bloodstream to increase to deal with the emergency.

The SNS response is fairly sudden in order to prepare the body to respond to an emergency situation or acute stress—short term stressors. Once the crisis is over, the body usually returns to the pre-emergency, unstressed state. This recovery is facilitated by the PNS, which generally has opposing effects to the SNS. But PNS over-activity can also contribute to stress reactions, for example, by promoting bronchoconstriction (e.g., in asthma) or exaggerated vasodilation and compromised blood circulation.

Both the SNS and the PNS have powerful interactions with the immune system, which can also modulate stress reactions. The central nervous system is particularly important in triggering stress responses, as it regulates the autonomic nervous system and plays a central role in interpreting contexts as potentially threatening.

Chronic stress, experiencing stressors over a prolonged period of time, can result in a long-term drain on the body. As the autonomic nervous system continues to trigger physical reactions, it causes a wear-and-tear on the body. It’s not so much what chronic stress does to the nervous system, but what continuous activation of the nervous system does to other bodily systems that become problematic.

Male reproductive system

The male reproductive system is influenced by the nervous system. The parasympathetic part of the nervous system causes relaxation whereas the sympathetic part causes arousal. In the male anatomy, the autonomic nervous system, also known as the fight or flight response, produces testosterone and activates the sympathetic nervous system which creates arousal.

Stress causes the body to release the hormone cortisol, which is produced by the adrenal glands. Cortisol is important to blood pressure regulation and the normal functioning of several body systems including cardiovascular, circulatory, and male reproduction. Excess amounts of cortisol can affect the normal biochemical functioning of the male reproductive system.

Sexual desire Chronic stress, ongoing stress over an extended period of time, can affect testosterone production resulting in a decline in sex drive or libido, and can even cause erectile dysfunction or impotence.

Reproduction Chronic stress can also negatively impact sperm production and maturation, causing difficulties in couples who are trying to conceive. Researchers have found that men who experienced two or more stressful life events in the past year had a lower percentage of sperm motility (ability to swim) and a lower percentage of sperm of normal morphology (size and shape), compared with men who did not experience any stressful life events.

Diseases of the reproductive system When stress affects the immune system, the body can become vulnerable to infection. In the male anatomy, infections to the testes, prostate gland, and urethra, can affect normal male reproductive functioning.

Female reproductive system

Menstruation Stress may affect menstruation among adolescent girls and women in several ways. For example, high levels of stress may be associated with absent or irregular menstrual cycles, more painful periods, and changes in the length of cycles.

Sexual desire Women juggle personal, family, professional, financial, and a broad range of other demands across their life span. Stress, distraction, fatigue, etc., may reduce sexual desire—especially when women are simultaneously caring for young children or other ill family members, coping with chronic medical problems, feeling depressed, experiencing relationship difficulties or abuse, dealing with work problems, etc.

Pregnancy Stress can have significant impact on a woman’s reproductive plans. Stress can negatively impact a woman’s ability to conceive, the health of her pregnancy, and her postpartum adjustment. Depression is the leading complication of pregnancy and postpartum adjustment.

Excess stress increases the likelihood of developing depression and anxiety during this time. Maternal stress can negatively impact fetal and ongoing childhood development and disrupt bonding with the baby in the weeks and months following delivery.

Premenstrual syndrome Stress may make premenstrual symptoms worse or more difficult to cope with and premenses symptoms may be stressful for many women. These symptoms include cramping, fluid retention and bloating, negative mood (feeling irritable and “blue”) and mood swings.

Menopause As menopause approaches, hormone levels fluctuate rapidly. These changes are associated with anxiety, mood swings, and feelings of distress. Thus menopause can be a stressor in and of itself. Some of the physical changes associated with menopause, especially hot flashes, can be difficult to cope with.

Furthermore, emotional distress may cause the physical symptoms to be worse. For example, women who are more anxious may experience an increased number of hot flashes and/or more severe or intense hot flashes.

Diseases of the reproductive system When stress is high, there is increased chance of exacerbation of symptoms of reproductive disease states, such as herpes simplex virus or polycystic ovarian syndrome. The diagnosis and treatment of reproductive cancers can cause significant stress, which warrants additional attention and support.

Stress management

These recent discoveries about the effects of stress on health shouldn’t leave you worrying. We now understand much more about effective strategies for reducing stress responses. Such beneficial strategies include:

These approaches have important benefits for physical and mental health, and form critical building blocks for a healthy lifestyle. If you would like additional support or if you are experiencing extreme or chronic stress, a licensed psychologist can help you identify the challenges and stressors that affect your daily life and find ways to help you best cope for improving your overall physical and mental well-being.

APA gratefully acknowledges the assistance of William Shaw, PhD; Susan Labott-Smith, PhD, ABPP; Matthew M. Burg, PhD; Camelia Hostinar, PhD; Nicholas Alen, BA; Miranda A.L. van Tilburg, PhD; Gary G. Berntson, PhD; Steven M. Tovian, PhD, ABPP, FAClinP, FAClinHP; and Malina Spirito, PsyD, MEd; in developing this article.

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