Stress and control

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Bachelorproject: Stress and Control

Femke Heemskerk

26 mei 2016

Studentnumber: 10365877

University of Amsterdam

Guided by: Henk Cremers

Words: 3574

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The Perceived Relation Between Stress and Control (A Network Approach)

Femke Heemskerk

University of Amsterdam

26 mei 2016 Introduction

Stress has long been of interest in many different fields of research because of its implications for health. Many people perceive stress as a change in emotional and physical functioning, such as irritations and frustrations, sometimes even resulting in physical problems such as flu, sore throats, headaches, and backaches (DeLongis, Folkman & Lazarus (1988) or psychological problems such as anxiety and depression (Lazarus, 1999; Zautra, 2003 both cited in Almeida, 2005). There are many situations (stressors) that can cause people to experience stress. Daily stressors, for example, could be concerns of work, caring for other people, and commuting between work and home (Almeida, 2005).

Control can be defined as the belief that someone has the opportunity of influencing the aversiveness of an event (Thompson, 1981). Averill (1973) discovered that control could have stress-‐inducing or stress-‐reducing properties, distinguishing three main types of control: (a) behavioural (direct action on the environment), (b) cognitive (the interpretation of events), and (c) decisional (having a choice among alternative courses of action). Averill (1973) concluded that the stress-‐inducing or stress-‐reducing properties of personal control depend upon the experience of control (e.g., too many response options may lead to conflict and feelings of helplessness, or a person of limited competence might still experience considerable control provided that his goals were not set beyond his capabilities). Research of Diehl and Hay (2010) shows that control can be a mediating factor in coping with daily stress: not only do individuals report higher negative affect

on days that they experience more stress than usual, they also do so on days that they experience less control than usual. The results of both studies are interesting because they suggest that one could reduce the negative effects of stress by increasing control.

The biological mechanism of stress possibly gives one more understanding of the effects of perceived control on stress. For example subject A is being stressed by event B. Event B activates the stress response system (SRS), a complex, integrated biological network of central neural and hormonal responses (Ellis, Jackson & Boyce, 2006). This network plays an important role in multiple adaptive functions that prepare subject A (the organism) for the challenge or threat (event B) by directing the body’s energy, resulting in changes in affect, motivation and cognition (Boyce & Ellis, 2005; Ellis, Jackson & Boyce, 2006; Del Giudice, Ellis & Shirtcliff, 2011; Greenberg, Carr & Summers, 2002). Two important stress structures that are activated during stressful events will be discussed below.

The first structure activated by stressful situations is the hypothalamic-‐pituitary-‐ adrenocortical (HPA) axis, regulating the release of cortisol, an important hormone associated with psychological, physiological, and physical health functioning (Dickerson & Kemeny, 2004). The HPA axis is helpful in threatening situations; when activated for an extended period of time, however, it can have serious health implications (McEwen, 199; Heim & Nemeroff, 1999; Wingenfeld & Wolf, 2011). Hence stress can result in physical and psychological problems; it would therefore be of interest to research ways the negative consequences of stress can be reduced.

Both psychological and biological researchers have argued that there is a relationship between stress and control. It is yet unclear whether this relationship can be perceived and if so, how people perceive this relation. The present study developed a novel (Dutch) psychological questionnaire based on the Perceived Stress Scale (PSS) 10 item inventory for measuring the Perceived Causal Relations (PCR) between stress and control. 91 Psychology students of the University of Amsterdam participated (19 male, 67 female). The results indicate that people perceive a causal relation between stress and control: control leads to a decrease in stress and stress leads to a decrease of control. The network analysis shows that the PCR between control and stress is stronger than the PCR between stress and control. Control has indeed a stress-‐reducing effect. Future research should focus on a more diverse sample group, keeping into account age, life phase and educational level. It is also possible to link psychological to biological research and to develop a longitudinal research design.

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As mentioned before, multiple researchers have discovered that control can have stress-‐reducing properties. These findings are in line with biological research of Dickerson and Kemeny (2004) showing that cortisol activation can be effected by perceived loss of control (i.e. loss of control can have negative physiological and psychological effects; Frazier, Berman & Steward, 2002; Hofmann, 2005).

The second structure affected by stressful situations is the ventromedial prefrontal cortex (vmPFC). The vmPFC is a brain region that plays an important role in cognitive control (Dedovic, Duchesne, Andrews, Engert & Pruessner, 2009; McKlveen, Myers & Herman, 2015; Miller & Cohen, 2001) regulating emotion, thought and behaviour under non-‐stress conditions (Arnsten, 2009). Under conditions of stress the higher-‐order abilities of the vmPFC are impaired, resulting in uncontrolled and rapid emotional responses (Arnsten, 2009).

Research of Maier and Watkins (2010) suggests vmPFC plasticity; it appears that the experience of control alters the vmPFC in such a way that later uncontrollable stressors now activate the vmPFC circuitry, leading to stressor resistance, i.e. control would result in a decrease of stress. This finding could have positive implications for further research. It could be possible to increase our sense of control, which would offer protection against the negative effects of stress.

Overall psychological and biological research shows that there is a relation between stress and control; some suggesting that stress has a negative effect on control and others arguing that control has a positive effect on stress. Due to the fact that up to the present there has been no scientific research on the perceived causal relation (PCR) between stress and control, it is unclear if and how people perceive this relation. The present study examines whether people perceive a causal relation between stress and control. When a PCR is present a network is visualized. Based on the research mentioned above we hypothesize that stressful situations cause people to experience a loss of control, resulting in an increase in stress. It is expected that perceived loss of control causes a rise in the perception of stress, or stated differently, that perceived control causes a decrease of stress.

Method Participants

91 psychology (19 men and 67 women) students from the University of Amsterdam in the Netherlands completed our questionnaire in a battery of questionnaires as part of a broader research program that all first year students have to participate in. The ethical commission has approved this study.

Instruments

Perceived Stress Scale (PSS). The PSS (Cohen, Kamarck & Mermelstein, 1983) is a diagnostic questionnaire used to measure perceived stress. The PSS 10 item inventory is translated to Dutch and extended with 20 follow-‐up questions, as the present study examines the perceived causal relation between stress and control.

Perceived Causal Relations (PCR) Scaling. The series of follow-‐up questions is developed based on the systematic approach from Frewen, Allen, Lanius and Neufeld (2012) known as Perceived Causal Relation scaling (PCR). First, a person indicates on the PSS which of the thoughts and feelings were present during the last month. Secondly, each combination of presents thoughts and feelings (i,j) is combined in a question that assesses whether i caused j (Borsboom & Cramer, 2013). Answers on the first ten questions (the PSS) were included in the follow-‐up questions, so that the formulation became evident. For example; when people report they have been ‘fairly often’ upset in the last month and they have ‘almost never’ felt like they were in control, they would be asked in the follow-‐up question to report the extent in which the first influenced the latter selecting an answer scaling from ‘much less’ to ‘much more’ (e.g., ‘because I have been upset ‘fairly often’ I felt ‘much less’ like I was in control’).

The items used in questions one to ten were assigned to either the construct ‘stress’ or ‘control’ Items 1, 3 and 7 were assigned to ‘stress’ as they reflect emotional reactions; item 8 was assigned to ‘control’. Follow-‐up questions based on items 4, 5, 6, 9, and 10 were excluded, as it was not possible to assign these to either variables ‘stress’ or ‘control’ due to ambiguities in formulation (for further information see Appendix A and B).

Network Analysis. Due to the use of the use of PCR it was possible to build a matrix of the self-‐reported relations between all items. In this way a network analysis emerges that represents the causal structure of stress and control. A network analysis can be of value to discover and visualize the most important PCRs.

Measures. The scores for the first 10 questions are obtained by scaling the answers on a 5-‐point Likert scale (e.g., 0 = never, 1 = almost never, 2 = sometimes, 3 = fairly often, 4 = very often). The scores of the 20 follow-‐up questions are also obtained on a 5-‐point Likert scale (e.g., -‐2 = much less, -‐1 = less, 0 = not more or less, 1 = more, 2 = much more).

Procedure

Participants were tested in a university computer hall. The time required to complete the questionnaire was approximately 5-‐10 minutes. Participants were asked to fill in informed consent and were debriefed following completion.

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Statistical procedure

The hypothesis has been tested using one-‐sample and independent-‐samples T tests, allowing to (a) compare whether the PCRs we found were significantly greater than zero, and (b) to simultaneously check for effects of sex. A significance level of 0.05 is used.

Three different analyses have been used in order to examine whether perceived control causes a decrease of stress. First, a one-‐sample T test is used to analyse the PCRs between the two most relevant items (‘nervous/stress’ and ‘control’). Second, a one-‐ sample T test is used to analyse the PCRs between the three main stress-‐related items (‘upset’, ‘nervous/stress’ and ‘irritable’) and control. Third, the PCRs between stress and control items were presented in a network analysis. No correction is performed for multiple comparisons.

Results

The results from 86 participants were used in the statistical analysis. Five participants have been excluded; one participant due to old age (age 52.8), two participants due to missing values and two participants due to a deviation of zero when answering question 11 to 30. Age is relevant to compare the total PSS score of the Dutch questionnaire used with the norm table (age 18-‐29) for the PSS 10 item inventory. Checking the variation within the answers is important to analyse whether there was honest participation (i.e., participants not reporting the same answer to every question due to lack of motivation).

Table 1 presents descriptive statistics of the between-‐person variables (i.e., sex, age and total PSS score). Calculating age is important because of the use of the norm table (age 18-‐29) of the PSS 10 item inventory. In this way the total PSS score of the Dutch translation (M = 15.56, SD = 6.22) can be compared with the total PSS score from the norm table (M = 14.2, SD = 6.2). This is required when checking whether the Dutch questionnaire measures the same construct (stress) as the original PSS 10 item inventory. The results of a independent-‐samples T test show that women score significantly higher on

the PSS 10 inventory than men, t(84) = -‐2.57, p = 0.012, 95% CI [-‐7.14, -‐0.91]. As the total PSS score is only used as a reference to the PSS 10 item inventory, these results will not obstruct further analysis. They are, however, a reminder to evaluate differences of sex throughout the rest of the statistical analysis.

First, the PCR between the two most relevant items, ‘nervous/stressed’ and ‘control’, are analysed. Figure 1 presents the mean score on question 17 (the PCR between ‘nervous/stressed’ and ‘control’) and the mean score on question 24 (the PCR between ‘control’ and ‘nervous/stressed’).

Results of a one-‐sample T test show participants reported a significant negative PCR between ‘nervous/stressed’ and ‘control’, M = -‐0.28, SD = 0.89, t(85) = -‐2.91, p= 0.005, 95% CI [-‐0.47, -‐0.09]. They also reported a significant negative PCR between ‘control’ on ‘nervous/stressed’, M = -‐0.65, SD = 0.97, t(85) = -‐6.24, p < 0.001, 95% CI [-‐0.86, -‐0.44]. There was no significant difference between men and women on both questions (Q17: t(84) = 1.56, p = 0.122, 95% CI [-‐0.10, 0.81]; Q24: t(84) = .10, p = 0.921, 95% CI [-‐0.48, 0.53]). These results indicate that there is a PCR between stress and control; stress results in a loss of control and control results in a reduction of stress.

Second, two other stress related items, ‘upset’ and ‘irritable’, were included, as stress can be experienced in different ways. A new variable ‘mean_stress’ was computed for the mean PCR between the three most relevant stress related items (‘upset’, ‘nervous/stressed’ and ‘irritable’) and ‘control’. A second variable mean_control’ was computed for the mean PCRs between ‘control’ and the three stress items.

Results of a one-‐sampe T test show that participants reported a significant negative PCR between ‘mean_stress’ and ‘mean_control’, M = -‐0.14, SD = 0.60, t(85) = -‐2.08, p = 0.040, 95% CI [-‐0.27, -‐ 0.01]. There was a significant difference between men and women, t(84) = 2.01, p = 0.048, 95% CI [0.003, 0.62]. Women reported a negative PCR between ‘mean_stress’ and ‘mean_control’ (M = -‐0.20, SD = 0.58), while men reported a positive PCR between ‘mean_stress’ and ‘mean_control’ (M = 0.11,

Table&1. Descriptive*statistics*men*and*women N Mean&age SD&age Mean&total& PSS&score SD&total&PSS& score Men 19 21,775 2,204 12,4211 6,18525 Women 67 20,3686 1,294 16,4478 5,98048 Total 86 20,679 1,635 15,5581 6,22066 Sex Figure'1. PCR'between'stress'and'control. M = -‐0.65, SD = 0.97 M = -‐0.28, SD = 0.89

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SD = 0.63). Participants also reported a significant negative PCR between ‘mean_control’ and ‘mean_stress’, M = -‐0.64, SD = 0.89, t(84) = -‐6.64, p < 0.001, 95% CI [-‐0.83, -‐0.45]. There was no significant difference between men and women, t(84) = 0.33, p = 0.740. 95% CI [-‐0.39, 0.54].

The results above provide additional support for our hypotheses: people perceive a causal relation between stress and control. Stress causes a decrease of control and control causes a decrease of stress.

To examine whether an increase in stress causes people to experience a greater loss of control, and if an increase of control results in a greater reduction in stress, the results were plotted in graphs (see figure 2 and 3; the item score is placed on the x-‐axis and the PCR on the y-‐axis).

Figure 2 suggests that when participants report a higher level of ‘nervous/stresses’, they perceive a stronger negative relation between stress and control. When participants report a low level of ‘nervous/stressed’, they report a positive relation between stress and control. These results indicate that when people experience a low level of stress, they feel like they have more control, and when they experience a high level of stress, they feel like they have less control (Spearman’s rho = -‐0.42, p < 0.001, 95% CI [-‐0.60, -‐0.21]).

Figure 3 shows that when participants report a low level of control, they perceive a negative relation between control and stress. When they report a high level of control, participants perceive a slightly positive relation between control and stress. When people experience less control, they experience more stress, and when they feel like they have more control, they experience less stress (Spearman’s rho = 0.41, p > 0.001, 95% CI [0.18, 0.61]).

Third, a network analysis is shown to detect and visualize the most important PCRs and the most central item. The descriptive statistics and the results of a one-‐sample T test are presented in table 2. The results of the T test for questions related to item 9 (angry) were not significant so these PCRs have not been included in the network.

Qgraph for ‘R’, developed by S. Epskamp (2016), was used to plot a network from the correlations presented in table 3 (i.e., the PCR between ‘upset’, ‘nervous/stressed’, ‘irritable’, and ‘control’). Figure 4 presents the network analysis. Participants report the strongest PCR between control and stress; ‘control’ has the strongest adverse effect on all other items.

This network, together with the correlation matrix in table 3, also shows the importance of ‘irritable’. Interestingly there is a small positive effect of ‘upset’ on ‘control’. It is possible that people experience more control when they are less upset, resulting in a positive PCR.

Figure'2. Correlation'between'the'score'on'nervous/stressed' and'the'PCR'between'nervous/stressed'and'control. Figure'3. Correlation'between'the'score'on'control'and'the' PCR'between'control'and'nervous/stressed.'''''' Note:&the'score'on'Q8'is'recoded,'ranging'from''0'=' 'fairly'often''and'4'=''almost'never'. Table&3. Perceived(relations(between(stress(and(control(items

Upset Nervous/Stressed Irritated Control

Upset 1 :0,38 :0,42 0,22

Nervous/Stressed 0,25 1 0,28 :0,28

Irritated 0,28 0,26 1 :0,37

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Discussion

The present study focused on one objective. The PCR between stress and control was examined,

hypothesizing that perceived control causes a decrease of stress. Results show that people perceive a causal relation between stress and control; more stress results in a decrease of control, more control results in a decrease of stress. These findings are consistent with previous psychological research (Averill, 1973; Diehl & Hay, 2010) and biological research (Dickerson & Kemeny, 2004; Maier & Watkins, 2010) suggesting that perceived control could offer protection against the negative effects of stress. It is important to keep in mind that perceived causal relations have been analysed therefore the conclusions are based on self-‐reports. Actual causality (and the role of the HPA-‐axis and the vmPFC) cannot be determined.

Implications

The results of the current study are of value due to implications specified below. As is mentioned in the introduction, stress can be helpful for an organism, but prolonged stress can have negative physical and psychological consequences. The conducted research shows that perceived control could have stress-‐reducing properties. Biological conclusions cannot be drawn, but the results of this research can possibly link psychological with biological research.

First, Dickerson and Kemeny (2004) show that cortisol activation can be effected by perceived loss of control. It is therefore possible that an increase of perceived control results in a decrease of cortisol; control could work as a protection mechanism

Ups N/S

Irr Cnt

Figure'4.

Network of the perceived relation between control (Cnt), Irritable (Irr), Nervous/Stressed (N/S) and Upset (Ups).

Note. (a) The edges represent the relations. The bigger

the effect, the thicker the edge. (b) The colour of the edge represent the direction of the perceived relation, red is negative,'green'is'positive.'

Table&2.

Discriptive*statistics*and*one/sample*T*test*for*the*PCRs.

Question Mean Std.&Deviation t df Sig.&(25tailed) &95%&Confidence&Interval&of&the&Difference Lower Upper Q11:&PCR&between&upset&and&nervous/stressed 5.41 1.182 53.193 85 .002 5.66 5.15 Q12:&PCR&between&upset&and&irritable 5.44 1.102 53.719 85 .000 5.68 5.21 Q13:&PCR&between&upset&and&control .24 .957 2.366 85 .020 .04 .45 Q14:&PCR&between&upset&and&angry 5.43 1.069 53.733 85 .000 5.66 5.20 Q15:&PCR&between&nervous/stressed&and&upset .24 .993 2.280 85 .025 .03 .46 Q16:&PCR&between&nervous/stressed&and&irritable .28 1.144 2.262 85 .026 .03 .52 Q17:&PCR&between&nervous/stressed&and&control 5.28 .890 52.908 85 .005 5.47 5.09 Q18:&PCR&between&nervous/stressed&and&angry .21 .922 2.106 85 .038 .01 .41 Q19:&PCR&between&irritable&and&upset .28 .903 2.866 85 .005 .09 .47 Q20:&PCR&between&irritable&and&nervous/stressed .26 .843 2.815 85 .006 .08 .44 Q21:&PCR&between&irritable&and&control 5.37 .736 54.686 85 .000 5.53 5.21 Q22:&PCR&between&irritable&and&angry .38 .856 4.155 85 .000 .20 .57 Q23:&PCR&between&control&and&upset 5.58 .951 55.667 85 .000 5.79 5.38 Q24:&PCR&between&control&and&nervous/stressed 5.65 .967 56.243 85 .000 5.86 5.44 Q25:&PCR&between&control&and&irritable 5.69 .936 56.795 85 .000 5.89 5.49 Q26:&PCR&between&control&and&angry 5.59 .845 56.505 85 .000 5.77 5.41 Q27:&PCR&between&angry&and&upset 5.19 1.035 51.667 85 .099 5.41 .04 Q28:&PCR&between&angry&and&nervous/stressed 5.13 .918 51.292 85 .200 5.32 .07 Q29:&PCR&between&angry&and&irritable 5.16 1.105 51.367 85 .175 5.40 .07 Q30:&PCR&between&angry&and&control 5.02 .958 5.225 85 .822 5.23 .18

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against the negative health implications of extended HPA axis activation.

Second, research of Maier and Watkins (2010) suggests plasticity of the vmPFC; it appears that the experience alters the vmPFC. This could suggest that developing a stronger sense of control would offer protection against the negative effects of stress. A relevant subsequent research may look at the possibilities to train our sense of control. Longitudinal brain imaging could map possible changes in the vmPFC structures in order to confirm plasticity.

Limitations

Four limitations are discussed below. First, the sample group lacked diversity in terms of age and background. Only psychology students with a mean age of 20.70 (SD = 1.64) participated. Because of such a select sample group it is difficult to extrapolate the results to the whole of society. Below is argued why. (a) The number of male participants was much smaller than the number of female participants. This difference can have an effect on the PCR between stress and control. Women, for example, report that they experience more stress than men. (b) It is possible that students experience less stress than people in another phase of life. Students could perceive a different causal relation between stress and control. For example reporting a stronger PCR between control and stress (e.g., they may report more control because they can plan their study-‐time according to their own schedule). On the other hand, may it be possible that the PCR between stress and control is fairly weak for retirees, as they might not experience as much stress as businessmen and students. (c) The educational level of the participants is above average, possibly resulting in higher reflection skills (Dochy, Segers & Sluijsmans, 1999; Mann, Gordon & MacLeod, 2009). Accordingly they can have more knowledge about the relation between their thoughts, actions and emotions, which can result in a clearer PCR than when people don’t have these abilities. (d) It is possible the students are biased as they might already have some psychological and biological knowledge about stress and control. It is possible that psychology students therefore report a stronger PCR more often, resulting in significant results. People without psychological background might not have this knowledge and can therefore report a weaker PCR or no PCR at all. Future research could best gather a group of participants with approximately as much men as women to minimize the effects of sex. It is also important to include people of different ages, life phases, educational levels and fields of profession, to reduce these possible biases.

Second, the (English) PSS 10 item inventory formed the base of the novel Dutch questionnaire. A lot of the terms used in the English PSS were difficult

to translate to Dutch. Due to these uncertainties it is not entirely sure whether the same construct was measured or whether our follow up questions were correct. Future research may use an official Dutch translation of the PSS 10 item inventory or can enable assistance from Dutch and English translators to ensure measuring the right construct.

Third, the participants were explicitly asked to report the strength of the PCR between stress and control. The formulation of the questions might have directed the participant subconsciously into reporting a PCR while they otherwise might not have noticed this relation. Future research may use a longitudinal design: participants would be asked to report whether they perceive different stress-‐ and control-‐related emotions and feelings each day for an extended period of time. Based on the perceived emotions and feelings a relation between stress and control may be visualized.

Fourth, the questionnaire was conducted at a set time, most likely when the participants experienced a low level of stress. Hence they had to recall stressful events from the last month and re-‐evaluate whether they experienced stress and/or control and in what extend these influenced each other. As time has passed, it is possible the memory of the experienced level of stress and control has faded; therefore making it more difficult to precisely report the PCRs. Future research could use a longitudinal design to tackle this limitation also by asking participants to report the PCR between stress and control right after a stressful event took place.

Conclusion

Using a novel (Dutch) psychological questionnaire based on the Perceived Stress Scale (PSS) 10 item inventory, the present study examined the PCR between stress and control. The results are in line with psychological a biological research indicating a relationship between stress and control; when people experience control, they experience less stress, and when people experience stress, they experience less control. A network analysis visualized these results and concluded that the effect of control on stress is stronger than the effect of stress on control. However, due to limitations further research is needed to support these findings and in order to extrapolate the results to the whole of society. In summary, the findings from this study suggest that people perceive a causal relation between control and stress.

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APPENDIX A: Dutch questionnaire used in the study

Q1: Hoe vaak was u de afgelopen maand van streek omdat er iets onverwachts gebeurde?

Q2: Hoe vaak had u de afgelopen maand het gevoel dat u geen controle had over de belangrijke dingen in uw leven?

Q3: Hoe vaak voelde u zich de afgelopen maand nerveus of gespannen?

Q4: Hoe vaak heeft u zich de afgelopen maand zeker gevoeld over uw vermogen om met persoonlijke problemen om te kunnen gaan?

Q5: Hoe vaak had u de afgelopen maand het gevoel dat de dingen verliepen zoals u wilde?

Q6: Hoe vaak had u de afgelopen maand het gevoel dat u niet om kon gaan met alle dingen die u moest doen?

Q7: Hoe vaak was u de afgelopen maand in staat om irritaties in uw leven onder controle te houden? Q8: Hoe vaak had u de afgelopen maand het gevoel dat u alles onder controle had? Nooit Bijna nooit Soms Q9: Hoe vaak was u de afgelopen maand boos om dingen die buiten uw controle lagen?

Q10: Hoe vaak had u de afgelopen maand het gevoel dat problemen zich zo hoog opstapelde dat u ze niet aan kon?

Q11: U voelde zich de afgelopen maand … van streek omdat er iets onverwachts gebeurde en u voelde zich … nerveus of gespannen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … van streek was, was ik ... nerveus of gespannen.

Q12: U voelde zich de afgelopen maand … van streek omdat er iets onverwachts gebeurde en u was … in staat om irritaties in uw leven onder controle te houden. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … van streek was, was ik ... geïrriteerd.

Q13: U voelde zich de afgelopen maand … van streek omdat er iets onverwachts gebeurde en u had … het gevoel dat u alles onder controle had. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … van streek was, had ik ... alles onder controle.

Q14: U voelde zich de afgelopen maand … van streek omdat er iets onverwachts gebeurde en u was … boos om dingen die buiten uw controle lagen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … van streek was, was ik ... boos.

Q15: U voelde zich de afgelopen maand … nerveus of gespannen en u was … van streek omdat er iets onverwachts gebeurde. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … nerveus of gespannen was, was ik ... van streek.

Q16: U voelde zich de afgelopen maand … nerveus of gespannen en u was … in staat om irritaties in uw leven onder controle te houden. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … nerveus of gespannen was, was ik ... geïrriteerd.

Q17: U voelde zich de afgelopen maand … nerveus of gespannen en u had … het gevoel dat u alles onder controle had. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … nerveus of gespannen was, had ik ... alles onder controle.

Q18: U voelde zich de afgelopen maand … nerveus of gespannen en u was … boos omdat dingen buiten uw controle lagen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … nerveus of gespannen was, was ik ... boos.

Q19: U was de afgelopen maand … in staat om irritaties in uw leven onder controle te houden en u was … van streek omdat er iets onverwachts gebeurde. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … geïrriteerd was, was ik ... van streek.

Q20: U was de afgelopen maand … in staat om irritaties in uw leven onder controle te houden en u voelde zich … nerveus of gespannen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … geïrriteerd was, was ik ... nerveus of gespannen.

Q21: U was de afgelopen maand … in staat om irritaties in uw leven onder controle te houden en u had … het gevoel dat u alles onder controle had. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik …

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geïrriteerd was, had ik ... alles onder controle.

Q22: U was de afgelopen maand … in staat om irritaties in uw leven onder controle te houden en u was … boos om dingen die buiten uw controle lagen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … geïrriteerd was, was ik ... boos.

Q23: U had de afgelopen maand … het gevoel dat u alles onder controle had en u … van streek omdat er iets onverwachts gebeurde. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … alles onder controle had, was ik ... van streek.

Q24: U had de afgelopen maand … het gevoel dat u alles onder controle had en u voelde zich … nerveus of gespannen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … alles onder controle had, was ik ... nerveus of gespannen.

Q25: U had de afgelopen maand … het gevoel dat u alles onder controle had en u was … in staat om

irritaties in uw leven onder controle te houden. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … alles onder controle had, was ik ... geïrriteerd.

Q26: U had de afgelopen maand … het gevoel dat u alles onder controle had en u was … boos om dingen die buiten uw controle lagen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … alles onder controle had, was ik ... boos.

Q27: U was de afgelopen maand … boos om dingen die buiten uw controle lagen en u was … van streek omdat er iets onverwachts gebeurde. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … boos was, was ik ... van streek.

Q28: U was de afgelopen maand … boos om dingen die buiten uw controle lagen en u was … nerveus of gespannen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … boos was, was ik ... nerveus of gespannen.

Q29: U was de afgelopen maand … boos om dingen die buiten uw controle lagen en u was … in staat om irritaties in uw leven onder controle te houden. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … boos was, was ik ... geïrriteerd.

Q30: U was de afgelopen maand … boos om dingen die buiten uw controle lagen en u had … het gevoel dat u alles onder controle had. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik … boos was, had ik ... alles onder controle.

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APPENDIX B: Englisch translation of the items used in the Dutch questions

Q1: Upset. Q2: No control.

Q3: Nervous and “stressed”

Q4: Able to handle personal problems. Q5: Feeling things were going your way.

Q6: Not able to cope wit hall the things that had to be done. Q7: Irritable.

Q8: Control. Q9: Angered.

Q10: Could not overcome difficulties.

Q11: PCR between upset and nervous/stressed. Q12: PCR between upset and irritable.

Q13: PCR between upset and control. Q14: PCR between upset and angry.

Q15: PCR between nervous/stressed and upset. Q16: PCR between nervous/stressed and irritable. Q17: PCR between nervous/stressed and control. Q18: PCR between nervous/stressed and angry. Q19: PCR between irritable and upset.

Q20: PCR between irritable and nervous/stressed. Q21: PCR between irritable and control.

Q22: PCR between irritable and angry. Q23: PCR between control and upset.

Q24: PCR between control and nervous/stressed. Q25: PCR between control and irritable.

Q26: PCR between control and angry. Q27: PCR between angry and upset.

Q28: PCR between angry and nervous/stressed. Q29: PCR between angry and irritable.

Q30: PCR between angry and control.