Medical error is the third leading cause of death in the United States, with surgery being a critical area for improvement. Of particular interest for this dissertation is understanding and mitigating the impact of acute stress experienced by surgeons. Previous research demonstrates the detrimental effects mismanaged acute stress can have on cognitive performance integral in optimal surgical practice. Biofeedback consists of objectively monitoring signs of stress, presenting physicians with their own physiological output in real time. Introducing appropriate, targeted coping mechanisms when they are most needed may facilitate behavioral adjustments in the face of acute stress. The goal of this dissertation research was to evaluate the potential benefit of biofeedback and coping instructions, measured by reduced perceived and physiological stress, and improved task performance. In the first study, college students participated in a first-person shooter videogame while receiving visual coping instructions. Instructions that were presented at moments of elevated stress improved downstream physiology compared to randomly administered instruction, and the presence of coping instructions was more beneficial than their absence at highly stressful times. In the second study, I adapted and validated a computer-based task to focus on components of workload experienced by physicians. This study yielded one high-stress and one-low stress version of a more demographic-appropriate task. In the final study, medical students and residents completed this task. The independent variables tested included a visual biofeedback interface, intermittent auditory coping instructions, and/or brief training on stress management and emotional intelligence. Results from this study showed that despite high cognitive workload experienced by participants receiving both biofeedback and coping instructions, performance across stress levels was indistinguishable, and physiological indicators of stress immediately following discrete coping instructions was reflective of decreased stress. Taken together, the results of these studies validate the generation of a new lab-based task to induce stress among healthcare providers, and the physiological and performance benefits associated with physiologically-based coping instructions. Future work should investigate how these concepts can be tailored towards surgical workflow with feedback modality in mind, extended to teams, and/or scaled up to higher levels of fidelity to better capture the work environment. / Ph. D. / Medical error is the third leading causing of death in the United States, with surgery being a critical area for improvement. Many medical errors are preventable, and previous research has shown that inappropriately managed acute stress is responsible for many errors. Biofeedback is one way to externalize stress states, enabling individuals to monitor their own stress, even as it is changing. With rapid advancement in technological functionality, sensors hold promise not only for personal body data, but also active interventions such as biofeedback. Biofeedback is the process of actively monitoring physiology on an external device, and updating behaviors based on that physiology. Its role as a stress management tool is growing. Commercially available sensor devices are widespread, and are generating and archiving thousands of data points every day. Rather than simply archiving this data, we can use sensor technology to inform us of our current physiological and cognitive states in real time, and use that information to alter our response to stressful stimuli to achieve more favorable outcomes. This concept can be applied specifically to address how to cope when experiencing high levels of stress. For individuals working in high-stakes environments on a daily basis, such as surgeons, using physiological data to manage stress could have the added benefit of improving performance that might otherwise suffer due to mismanaged stress. The goal of this dissertation research is to explore the potential benefit of using biofeedback and specific coping strategies to reduce stress and improve performance among healthcare providers. This research consisted of different studies, all using experimental psychology approaches and all geared towards evaluating different conditions of either visual coping instructions, training on emotional intelligence concepts as they relate to coping under stress, visual biofeedback, and/or auditory coping instructions. The results of these studies validate the generation of a new lab-based task to induce stress among healthcare providers, support the benefit of introducing coping instructions in response to elevated physiological signs of stress, and support the need for future assessments.

Stress can have influence on pain sensitivity, but the direction of its effects remains unclear. Previous research has reported both increased and decreased pain sensitivities under stress with different sensory tasks. The aim of the current study was to investigate the effect of stress on pain sensitivity using multiple psychological stressors in a relatively large sample of young men and women. Sixty-two participants were included, and pain thresholds, tolerance, and temporal summation were tested using thermal, mechanical, and dynamic tasks before and after stress. A condition of stress was induced by the Stroop task and a mental arithmetic task. On average, there were no significant differences between stress and no stress conditions. Although not significant, pressure thresholds and tolerance had a tendency to decrease under stress conditions, and thermal thresholds and tolerance had a tendency to increase under stress conditions. Temporal summation did not change regardless of condition. These findings suggest that individual differences in response to stress and type of task being completed may play a role in how stress affects pain sensitivity. / 2021-06-17T00:00:00Z

Do person by situation effects influence physiological stress response? Despite being relatively uncontested since being theorized nearly 80 years ago, the fight-or-flight model of stress response has suffered criticism for its one-size-fits-all approach in light of the historical gender bias in the literature. In contrast, the tend-and-befriend model of stress response argues that females are driven to care for their offspring (tend) and band together with others (befriend) in response to stress. Despite evidence suggesting the importance individual differences in the effect of affiliation and social support on stress, past research has generally overlooked markers of individual difference and personality. The major aim of this dissertation was to identify and examine potential person by situation effects on stress physiology, illuminating under what conditions and for whom affiliation and social support may buffer against the stress response and aid recovery in the wake of a stressor. Two studies were conducted to evaluate the role of individual difference factors of gender and personality (i.e., person effects) and the availability of affiliation with a similar other (study 1) or a trusted friend (study 2) compared with no available affiliation (i.e., social situation effects) on stress response and recovery. Study 1 revealed that availability of affiliation with a similar other did not have a protective influence on stress physiology in general. However, personality (openness to experience) and gender together, along with availability of affiliation, were important predictors of stress physiology over time. Study 2 indicated that the availability of affiliation with a trusted friend had a protective effect on stress physiology across each time point. Further, extraversion, conscientiousness, and openness to experience each appear to be important predictors of the influence of availability of affiliation with a close friend on stress physiology over time. In sum, this dissertation found evidence of person by situation effects on stress physiology across two studies. In both studies, the effect of the availability of affiliation differed based on individual difference factors of personality, not on gender. As such, tend-and-befriend may be better conceptualized not as a uniquely female response, but rather a stress response that depends on individual difference characteristics of personality. Further, future stress response models and research should consider personality as an important marker of individual difference in physiological stress response. / text

The current study examined the psychological effects of recurring earthquake aftershocks in the city of Christchurch, New Zealand, which began in September 2010. Although it has been identified that exposure to ongoing adverse events such as continuing terrorist attacks generally leads to the development of increasing symptomology over time, differences in perceived controllability and blame between man-made and natural adverse events may contribute to differences in symptom trajectories. Residents of two Christchurch suburbs differentially affected by the earthquakes (N = 128) were assessed on measures of acute stress disorder, generalised anxiety, and depression, at two time points approximately 4-5 months apart, in order to determine whether symptoms intensified or declined over time in the face of ongoing aftershocks. At time 1, clinically significant levels of acute stress were identified in both suburbs, whereas clinical elevations in depression and anxiety were only evident in the most affected suburb. By time 2, both suburbs had fallen below the clinical range on all three symptom types, identifying a pattern of habituation to the aftershocks. Acute stress symptoms at time 2 were the most highly associated with the aftershocks, compared to symptoms of generalised anxiety and depression which were identified by participant reports to be more likely associated with other earthquake-related factors, such as insurance troubles and less frequent socialisation. The finding that exposure to ongoing earthquake aftershocks leads to a decline in symptoms over time may have important implications for the assessment of traumatic stress-related disorders, and provision of services following natural, as compared to man-made, adverse events.

Although the impact of cannabinoids (CBs) on anxiety has been thoroughly studied, current research paradigms fail to incorporate acute stressors. The present study investigated the synthetic CB HU-210’s anxiolytic potential in an acute stress CD1 male mouse model, where the animals were subject to a 10-minute Forced Swimming (FS) test between treatment and behavioral tests. Surprisingly, HU-210 did not show anxiolytic action in the Open Field (OFT) and Elevated-Plus Maze (EPM) stressed mice as previously reported in the naïve model literature. The combination of acute stress and high HU-210 doses produced severe locomotor impairments in ambulatory movement that were not previously observed in unstressed mice. It is hypothesized that this anxiogenic phenotype results from the summation of exogenous CB treatment and stress-induced endocannabinoid (eCB) release. Subsequently, the impact of the eCB signaling on anxiety behaviors was examined. Systemic administration of KML29, the selective inhibitor of 2-AG degradative enzyme, returned stress-induced anxiety-like behaviors to baseline levels, without significantly affecting locomotion. KML29’s anxiolyticism was abolished when combined with the cannabinoid receptor antagonist AM281, implying this is a CB receptor-mediated process. A GABAA receptor agonist muscimol was co-administered with KML29 in order to pharmacologically investigate the role of GABAergic neurotransmission in this anxiolytic phenomenon, but it did not alter KML29’s effects. Collectively, these findings suggest that exogenous CBs and acute stress act synergistically in an anxiogenic manner, but that enhanced 2-AG signaling in response to stress demonstrates anxiolytic potential.

Working memory (WM) is a crucial component of cognitive function that affects learning, reasoning, and problem solving, all of which are important for daily functioning. Therefore, addressing factors that can impact working memory, such as stress, are incredibly relevant to understanding WM efficiency. WM is an important component of higher order cognitive function and high WM capacity has been shown to be important for academic and occupational performance. Thus, understanding the relationship between stress-related factors and WM could aid in identifying strategies to mitigate the deleterious effects of stress on working memory. Although some previous research has indicated a negative impact of acute stress on WM, other research has indicated no impact or even a positive impact of stress on WM. As the relationship between acute stress and WM is mixed, examining other stress-related factors may provide further insight into the relationship. The current study examines how adverse childhood experiences (ACEs) and acute stress influence WM, and how frontal theta and alpha activity are affected by WM task demands. Participants completed a working memory task while their EEG was recorded. Participants then completed the PANAS to assess their current emotional state. Following the PANAS, participants viewed a stressful or neutral video as an acute stress induction, followed by a second PANAS to ensure effectiveness of stress induction. Participants then completed the WM task a second time. Finally, the participants completed the ACEs questionnaire. Bayesian linear mixed effects models were used to examine the relationships between ACEs, acute stress, WM, and frontal theta and alpha frequencies. Findings suggest there is not enough evidence to support a relationship between acute stress, ACEs, WM, and WM-related theta and alpha. While the current study did not reveal a relationship, future research should explore how acute stress and exposure to specific stressors during childhood could explain individual differences in WM.

We present an evidence-based review of post-trauma interventions used to prevent posttraumatic stress disorder (PTSD). Literature search of PubMed from 1988 to March 2016 using keywords “Early Intervention AND Prevention of PTSD” yielded 142 articles, of which 52 intervention studies and 6 meta-analyses were included in our review. Trauma-focused cognitive behavioral therapy and modified prolonged exposure delivered within weeks of a potentially traumatic event for people showing signs of distress have the most evidence in the treatment of acute stress and early PTSD symptoms, and the prevention of PTSD. Even though several pharmacological agents have been tried, only hydrocortisone prior to high-risk surgery, severe traumatic injury, or during acute sepsis has adequate evidence for effectiveness in the reduction of acute stress symptoms and prevention of PTSD. There is an urgent need to determine the best targets for interventions after trauma to accelerate recovery and prevent PTSD.

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