The perceived causal relationship between stress and control

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The Perceived Causal Relationship between

Stress and Control.

Milan Jansen

Instructor: H. Cremers

Datum: May 27, 2016

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Abstract

The current study focused on the Perceived Causal Relationship (PCR) between stress and control. A new questionnaire was developed that measured both stress and control level and that asked subjects how they perceive the causal relationship between the two. The survey was conducted among Dutch psychology students (N = 89). We found that control was negatively associated with stress. The causal relationship was bidirectional. People reported both that control affected their stress level as well as that stress affected their control level, but the reported influence of control on stress was larger than the influence of stress on control. Furthermore, people reported that high and average control levels had a negative impact on stress, but low control was neither stress inducing nor stress reducing. Conversely, high and average stress levels were reported to have a negative impact on control, but low stress was not reported as being either control inducing or reducing.

Introduction

Stress originated in our evolution as a mechanism promoting our chances of survival in hazardous situations (e.g. when we are chased by a bear). Too much stress, or stress during a prolonged period of time, however, can have negative effects on our physical health and psychological well-being (Pinquart & Sörensen, 2003; Segerstrom & Miller, 2004).

Stress is generally caused by aversive events and stimuli. But not all aversive events are perceived as stressful and people differ in which stimuli they perceive as stressful and which stimuli they do not. What causes these differences? Theorists have long argued that the controllability of stressors plays an important role. In a series of experiments with rodents, Weiss (1972) shows that the controllability of a stressor to which rodents were exposed had a considerable impact on the severity of stress induced pathology (e.g. stomach wall erosions).

Support for the idea that less control results in greater stress reactions for humans as well, comes from studies in which the amount of control participants has over an aversive

stimulus is manipulated, e.g. for one condition the intensity of a shock is dependent on test performance, while for the other condition it is fixed. In a review of numerous studies regarding the effect of behavioral control on aversive stimuli on stress, Thompson (1981)

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reports that more behavioral control does indeed lead to lower levels of self-reported anxiety as well as lower levels of physiological arousal. This effect was most clearly found during the anticipatory period of an aversive stimulus and less clearly during the aversive stimulus itself. Thompson interprets these findings by theorizing that the knowledge of having control leads people to fear the aversive stimuli less, without making the stimuli itself (e.g. receiving a shock) less stressful.

If the knowledge of having control over aversive stimuli makes people less fearful, we would expect that people who feel to have more control over aversive events in their daily lives would experience less overall stress as well. Research seems to suggest this is indeed the case. Studies on the relation between self-efficacy and stress show that people who feel more confident about their ability to complete tasks and reach goals in their lives report less stress and a higher psychological and physical well-being (Moeini 2008; Roddenberry & Renk, 2010). Self-efficacy is also found to be a mediating factor for the relationship between neuroticism and stress (Ebstrup et al., 2011). Another source of evidence for the relation between control and stress comes from research on the relation between perceived control and anxiety. In a meta-analysis of 51 studies, Gallagher (2014) finds a strong negative association between perceived control and measures of anxiety like the Penn State Worry Questionnaire (Meyer et al., 1990) and the State-Trait Anxiety Inventory (Spielberger et al., 1970), that measure a construct that is arguably quite closely linked to stress; it asks people, among other things, for feelings of tension, worry and strain.

Summarizing the reviewed literature, we can conclude that there is strong evidence for the idea that control is inversely related to stress. Although the results from early

experimental studies on the effect of behavioral control on aversive stimuli make a strong case for the idea that the relationship between stress and control is to some extent explained by the stress-inducing effect of having more control, it does not rule out the possibility that it works in the opposite direction too. Research that investigates the causal effect of stress on control proves to be very limited tough. Some support for the idea that stress might affect control as well can be found in a study by Maciejewski et al. (2000). In this study on the effect of stressful life events on self-efficacy, the researchers found that people who experienced more stressful life events had lower levels of self-efficacy, which gives rise to the idea that in this case stress might have led to lower control.

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To better understand the causal link between stress and control, research that addresses both the effect of control on stress as well as the effect of stress on control is needed. Setting up a design that measures the causal relation is difficult though, especially when one wants to investigate the causal relationship between control and stress in people’s daily lives. One possibility would be to conduct longitudinal research in which one would assess people’s stress level and their perceived control at succeeding moments in time and see whether low levels of control indeed predict high stress levels later on and vice-versa. Such a design requires substantial financial resources and is time consuming though and another problem lies in the fact that it is difficult to determine the time interval at which a causal relation could be measured.

A new method to investigate causal relationships in clinical disorders has been developed by Frewen (2012). It consists of asking people to what extent, in their personal experience, symptom A causes symptom B and vice-versa. An example would be to ask people to what extent their feelings of depression are caused by their feelings of anxiety. Although it might look surprisingly simple at first sight, initial research has shown that the method is capable of pointing out causal relationships between symptoms that are expected to exist based on the theories about the disorders. People suffering from PTSD do for example report re-experiencing of traumatic memories to be a cause of emotional disturbance more than vice-versa and the same is true for anxiety being more often perceived as cause for depressive symptoms than the other way around (Frewen, 2012; Frewen, 2013).

The present study focused on stress and control levels in people’s daily lives and the perceived causal relationship between the them. Firstly, we expected that control levels would be inversely related with stress levels. Secondly, we expected that people would report that their control level has an effect on their stress level. Thirdly, because of the limited availability of supportive data for the effect of stress on control in contrast to the rather extensive support for an effect of control on stress, we hypothesized that the influence of control on stress would be reported as being larger than the influence of stress on control. Lastly, we expected that people will report that high control levels have a stress reducing effect, whereas low control levels will be perceived as having a stress inducing effect. Due to the limited existing research, no predictions were made about either the existence or the direction of the effect of stress on control.

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Method

Participants and Procedure

The research was conducted as a part of a broader program in which all first year psychology students at the University of Amsterdam participate. The program consists of the online administration of several questionnaires. The collected data is used for different studies that are conducted at the University of Amsterdam, one of which was the present study. In total 91 students completed our survey. The mean age was 20.93 year (SD = 3.84), 71 were woman, 20 were male.

Measures

To measure participants’ perceived causal relationship between stress and control we developed a new 30-item long questionnaire based on the Perceived Stress Scale (PSS) (Cohen, Kamarck & Mermelstein, 1983). The first part of our survey consisted of the 10 items of the PSS that were translated to Dutch. The second part of the survey consisted of 20 items questioning to what extent the phenomenon expressed in one item of the PSS was the cause for the phenomenon expressed in another item. To clarify this mechanism, take item 3, 8, 24 as an example. Item 3 was “In the last month, how often have you felt nervous or stressed? (Hoe vaak voelde u zich de afgelopen maand nerveus of gespannen?)”. Item 8 was “In the last month, how often have you felt that you were on top of things? (Hoe vaak had u de afgelopen

maand het gevoel dat u alles onder controle had?)”. Answer options for both questions ranged

from “Never (Nooit)” to “Very Often (Heel vaak)”.

Say someone answered “Very Often” to item 3 and “Never” to item 8. Item 24 would then be formulated as follows: “In the last month you never felt that you were on top of things and you very often felt nervous and stressed. Please indicate how these things influenced each other. Because I never felt on top of things, I felt … nervous and stressed. (U had de

afgelopen maand nooit het gevoel dat u alles onder controle had en u voelde zich heel vaak nerveus of gespannen. Geef aan in welke mate dit elkaar beïnvloedde. Doordat ik nooit alles onder controle had, was ik … nerveus of gespannen)” Answer options ranged from “A lot less (Veel minder)” to “A

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Not all items of the PSS proved to be suitable for formulating the follow-up questions. Feedback from a test group that completed an initial version of the questionnaire led us to only include items that concerned a main construct (i.e. anger or control), since follow-up questions that were based on items concerning a broader concept as “being able to cope with all the things you have to do”, proved to be hard to interpret. We also chose to only use item 8 for formulating follow-up questions about control, since item 2 was formulated negatively which would lead to double negatives. We ended up using item 1, 3, 7, 8 and 9 to formulate the items about the PCR’s.

Only items 2, 3, 8, 17 and 24 served the purpose of answering the main hypothesis of this research by assessing participants’ level of stress (item 3), their level of control (item 2 & 8), the perceived influence of their stress level on their level of control (item 17) and the

perceived influence on their level of control on their level of stress (item 24). The other items were left in for exploratory purposes.

A full version of the questionnaire used in this research is included in Appendix A.

Data Analysis

The possible scores for the first 10 questions of the questionnaire ranged from 1 to 5. Item 4, 5, 7 & 8 were reversed. The next 20 items about PCR’s had scores ranging from -2 which stood for a strong negative effect, to positive 2 which stood for a strong positive effect.

Since the results were measured at the ordinal level, all correlations were calculated using the Spearman’s rho.

In order to check whether people were consistent in reporting their control level, a

Spearman’s rho between item 8 and 2 was calculated, because both items measured control a significant positive correlation was expected.

To test if control was negatively correlated with stress we calculated the Spearman’s rho between the average of item 8 and 2 an item 3. Item 8 was reversed and item 2 was

formulated negatively, so a low average score of item 2 & 8 stood for high control, therefore a significant positive correlation was expected.

In order to test if people reported an effect of control level on stress level, we conducted a one-sample t-test to test if the absolute value of item 24 differed significantly from 0. A significant difference was expected. We also analyzed whether the absolute value of item 17

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differed significantly from 0 in order to test if people report an effect of stress level on control level.

To test if the reported effect of control of stress was larger than the reported effect of stress on control, we conducted a paired-samples t-test in which we compared the absolute value of item 17 with the absolute value of item 24. We expected the absolute value of item 24 to be significantly larger.

The direction of the effect of control on stress was analyzed in two ways. First we

calculated the Spearman’s rho between item 8 and item 24, to test if control level was related to the reported effect of control level on stress. Since item 8 was reversed, we expected a significant positive correlation. To test if high control did indeed reduce stress levels and if low control did indeed increase stress levels, we split our subjects into three groups based on their score on item 8. All subjects with a score lower than 3 were assigned to the high control group, whereas all subjects with a score higher than 3 were assigned to the low control group. Subjects with a score of 3 were assigned to the average control group. We then conducted three one-sample t-tests to determine whether the scores on item 24 differed significantly from 0. For the high control group, we expected the score on item 24 to be significantly lower than 0 (i.e. indicating that their high control lowered their stress level). For the low control group, we expected the score to be significantly higher than 0 (i.e. indicating that their low control increased their stress level). We had no expectations about the average control group.

We also analyzed the effect of stress on control. A Spearman’s rho was calculated between item 3 and item 17 to test if stress level was related to the reported effect of stress on control. We then assigned subjects to groups based on their scores on item 3. Subjects who scored lower than 3, equal to 3 or higher than 3, were respectively assigned to the low, average and high stress group. The scores on item 17 were subsequently compared with 0 to determine the influence of low, high and average stress levels on control.

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Results

Two of the 91 participants were excluded from the analyses, because they gave the same answer to all of the questions of the second part of our survey. The most probable

explanation is that these participants wanted to finish the survey quickly and that they did not make an effort to provide a thoughtful answer. Exclusion of these participants did not change the conclusions of the study.

The mean and standard deviation of the items that were used to answer our hypothesis as well as the total PSS score are outlined in table 1.

Table 1:

Mean (M) and Standard Deviation (SD) of Item 2, 3, 8, 17, 24 and Total PSS Score.

Measure N M SD

Item 2 (Lack of Control) 89 2.49 1.09

Item 3 (Stress) 89 3.07 0.89

Item 8 (Control) * 89 2.70 0.86

Item 17 (Effect of Reported Stress on Control) 89 -0.29 0.88 Item 24 (Effect of Reported Control on Stress) 89 -0.65 0.96

Total PSS Score 89 25.64 6.18

* Item 8 is reversed, a high score represents a low level of control.

Item 2 and 8 were significantly positively correlated, indicating a consistency in the participant’s reporting of control level rho = .521, p < .001. Item 3 and the mean of item 2 & 8 were also significantly positively correlated, indicating a negative relationship between control and stress level rho = .492, p < .001 (the correlation is positive, because the items measuring control level were reversed).

Both the absolute value of item 24 (M = .944, SD = .663) as well as the absolute value of item 17 (M = .697, SD = .611) differed significantly form 0, t(88) = 12.423, p < .001; t(88) =

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10.763, p < .001, indicating people reported both an effect of control on stress as well as an effect of stress on control. The absolute value of item 24 was significantly larger than the absolute value of item 17, t(88) = 3.353, p = 0.001, indicating that people reported the effect of control on stress as being larger than the effect of stress on control.

There was a significant positive correlation between item 8 and item 24, rho = .397, p < .001, indicating that the level of control was negatively related to the effect of control on stress (the correlation is positive, because item 8 was reversed). The mean and standard deviation for the scores on item 24 for people who scored either high, average or low on control are outlined in table 2. Both in the high as well as in the average control group, the score on item 24 was significantly lower than 0, t(38) = -10.68, p < .001; t(37) = -4.04, p < .001, indicating that high and average control reduced stress levels. In the low control group, the score on item 24 did however not differ significantly from 0, t(13) = .611, p = .551. People did not report that low control increased their stress level. In explorative fashion we investigated if the absolute value of item 24 in the low control group differed significantly from 0. This was the case t(13) = 5.491; p < .001. So people in the low control group did report an effect of control on stress, although on average the effect was neither increasing nor decreasing. For a visual representation of the relation between control level and the effect of control on stress see graph 1.

Table 2:

Descriptives for the Score on Item 24 (Effect of Reported Control on Stress Level) for People with Low, High or Average Control.

Control Level N Min Max M SD

Low (Item 8 > 3) 14 -2 2 0.21 1.311

Average (Item 8 = 3) 37 -2 2 -0.59 0.896

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A significant negative correlation was found between item 3 and item 27, rho = -.430, p < .001, indicating that the level of stress was negatively related with the effect of stress on control. The mean and standard deviation on item 17 for people who scored either low, average or high on stress are outlined in table 3. Both in the average and high stress group the score on item 17 was significantly lower than 0, t(42) = -3.532, p = .001; t(26) = -6.750, p < .001, indicating that average and high stress reduced control levels. In the low stress group the score on item 17 did not differ significantly from 0, t(18) = 1.761, p = .095. In an

explorative fashion we also analyzed whether the absolute value of item 17 did differ significantly from 0 in the low stress group. This was the case, t(18) = 5.848, p < .001. So people in the low control group did report an effect of stress on control, although on average the effect was neither increasing nor decreasing. For a visual representation of the relation between stress level and the effect of stress on control see graph 2.

Table 3:

Descriptives for the Score on Item 17 (Effect of Reported Stress on Control Level) for People with Low, High or Average Stress.

Stress Level N Min Max M SD

Low (Item 3 < 3) 19 -2 2 0.47 1.172

Average (Item 3 = 3) 43 -1 2 -0.37 0.691

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Discussion

The purpose of the present study was to examine how people perceive the relationship between control and stress. Consistent with our expectations we found that people who report to have a high level of control over their daily lives, report lower stress levels. With regard to the causality of this relationship, we found that people reported both that their level of control affects their stress level as well as that their stress level affects their control level, but consistent with our expectations we found that the reported effect of control on stress was larger than the reported effect of stress on control.

With regard to the direction of the effect of control on stress we found that people with a high control level reported that this control level reduced their stress level, which was in line with our hypothesis. People with an average control level also indicated that this control

Graph 1:

The Reported Effect of Control on Stress for Low, Average and High Control Groups.

Graph 2:

The Reported Effect of Stress on Control for Low, Average and High Stress Groups.

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level reduced their stress level. The results for participants with a low control level did however not concur with our expectations. Although they did report to perceive an effect of control level on stress level, this effect was not predominantly stress increasing or reducing.

For the direction of the effect of stress on control we found a similar pattern. High and average stress levels were reported as having a negative effect on control, whereas the effect of low stress was not predominantly control increasing or decreasing.

A couple of conclusions can be drawn from these findings. The first one being that people perceive the causal relationship between stress and control as strongly bidirectional. Which is to some extent surprising, since most of the existing research and theories mainly focus on how control affects stress and not how stress affects control. One possible explanation for how stress affects control can however be found in the neurological effects of stress. When people are stressed their body’s cortisol level is increased, which results (among other things) in a temporal impairment of the functioning of the prefrontal cortex (Arnsten, 2009). The PFC is particularly important for cognitive processes like planning, attention and problem solving. It is not difficult to see how impairment of these functions might reduce one’s sense of control over situations. The results of the current study should be seen as an encouragement to develop and test hypothesis about how stress affects control.

Another interesting finding is that although people with a low stress level reported that their control level has an effect on their stress level, this effect was not consistently being reported as being either stress inducing or stress reducing. This difference in how the direction of the effect of control on stress was reported seems to be found in other studies as well. In a review about the earlier discussed experiments on the effect of behavioral control over an aversive stimulus, Folkman (1984) elaborates on the finding that in most of the studies a minor but significant portion of the participants show an opposite effect; for them more control actually increases stress. Folkman suggested that personality might play a key role. Some people might favor coping styles such as avoidance or dependence that don’t play well with having more control. This theory is to some extent supported by research showing that people who prefer to repress feelings about a stressful event instead of acknowledging and expressing them, showed more stress when they were allowed to exercise control over a stressful event (Shipley et. al., 1978). One personality trait that has often been associated with an avoidant comping style is neuroticism (Kardum & Krapić,

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2001; Connor-Smith & Flachsbart, 2007). Research that investigates the moderating role of personality traits and coping style in the relationship between control and stress is needed to better understand why some people perceive control as stress-inducing whereas others perceive stress as stress-reducing.

Although the previous paragraph provides us with a psychological explanation of how the differences in the directionality of the effect of low control on stress can be explained, similar differences were also found in the reporting of the directionality of the effect of low stress on control. It should be noted that due to how the questions about the effect of low control and stress were formulated, some people might have misinterpreted them, which could have also led to this result. When someone did for example report to be almost never in control, the subsequent question would be about the effect of almost never being in control on stress. Some participants might have missed the double negative and they might have just answered what the effect of control on stress was, which would have led to an opposite answer.

Another important point that should be taken into consideration when interpreting the results of the current study is the limited reliability of the measures. Stress level was assessed by the score on just one item, control was measured by the average score of two items, but for the follow-up questions only the answer to one item was used. Furthermore, the effect of stress on control and vice-versa were also both measured by just one item. Further research that uses more extensive questionnaires to measure stress and control are needed in order to gather more reliable results.

Finally, it should of course be pointed out that the results of the present study only show how people perceive the causal relationship between stress and control. In reality under laying mechanisms may work quite differently. Apart from the fact that this point can be made about any self-measurement tool, previous studies have shown that results of PCR’s often closely match existing theories and results from longitudinal studies (Frewen, 2012; Frewen, 2013). It is therefore at the very least surprising that the strong bidirectionally that was reported about the relationship between stress and control is currently

underrepresented in existing theories about the relationship between stress and control. The results of the current study should be seen as an encouragement to formulate new theories and conduct research about the relationship between stress and control that do take this

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bidirectionally into account. This will ultimately lead to a better understanding of how the two are related, which can be used for developing better strategies and treatments to prevent and reduce excessive stress in our lives.

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Appendix A: The Questionnaire Used in This Research.

Item 1-10: The PSS translated to Dutch. Answer options were: “Nooit”, “Bijna nooit”,

“Soms”, “Vaak” and “Heel vaak”.

1. Hoe vaak was u de afgelopen maand van streek omdat er iets onverwachts

gebeurde?

2. Hoe vaak had u de afgelopen maand het gevoel dat u geen controle had over de

belangrijke dingen in uw leven?

3. Hoe vaak voelde u zich de afgelopen maand nerveus of gespannen?

4. Hoe vaak heeft u zich de afgelopen maand zeker gevoeld over uw vermogen om

met persoonlijke problemen om te kunnen gaan?

5. Hoe vaak had u de afgelopen maand het gevoel dat de dingen verliepen zoals u

wilde?

6. Hoe vaak had u de afgelopen maand het gevoel dat u niet om kon gaan met alle

dingen die u moest doen?

7. Hoe vaak was u de afgelopen maand in staat om irritaties in uw leven onder

controle te houden?

8. Hoe vaak had u de afgelopen maand het gevoel dat u alles onder controle had? 9. Hoe vaak was u de afgelopen maand boos om dingen die buiten uw controle

lagen?

10. Hoe vaak had u de afgelopen maand het gevoel dat problemen zich zo hoog

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Item 11-30: The follow-up questions about PCR’s. Answer options were: “Veel minder”,

“Minder”, “Niet meer of minder”, “Meer”, “Veel meer”.

11. U voelde zich de afgelopen maand [ antwoord op vraag 1 ] van streek omdat er iets onverwachts gebeurde en u voelde zich [ antwoord op vraag 3 ] nerveus of

gespannen.

Geef aan in welke mate dit elkaar beïnvloedde.

Doordat ik [ antwoord op vraag 1 ] van streek was, was ik ... nerveus of gespannen.

12. U voelde zich de afgelopen maand [ antwoord op vraag 1 ] van streek omdat er iets onverwachts gebeurde en u was [ antwoord op vraag 8 ] in staat om irritaties in uw leven onder controle te houden.

Doordat ik [ antwoord op vraag 1 ] van streek was, was ik ... geïrriteerd.

13. U voelde zich de afgelopen maand [ antwoord op vraag 1 ] van streek omdat er iets onverwachts gebeurde en u had [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had.

Doordat ik [ antwoord op vraag 1 ] van streek was, was ik ... alles onder controle.

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14. U voelde zich de afgelopen maand [ antwoord op vraag 1 ] van streek omdat er iets onverwachts gebeurde en u was [ antwoord op vraag 9 ] boos over dingen die buiten uw controle lagen.

Doordat ik [ antwoord op vraag 1 ] van streek was, was ik ... boos.

15. U voelde zich de afgelopen maand [ antwoord op vraag 3 ] nerveus of gespannen en u was [ antwoord op vraag 1] van streek omdat er iets onverwachts gebeurde.

Doordat ik [ antwoord op vraag 3 ] nerveus of gespannen was, was ik ... van streek.

16. U voelde zich de afgelopen maand [ antwoord op vraag 3 ] nerveus of gespannen en u was [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden.

Doordat ik [ antwoord op vraag 3 ] nerveus of gespannen was, was ik ... geïrriteerd.

17. U voelde zich de afgelopen maand [ antwoord op vraag 3 ] nerveus of gespannen en u had [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had.

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Doordat ik [ antwoord op vraag 3 ] nerveus of gespannen was, had ik ... alles onder controle.

18. U voelde zich de afgelopen maand [ antwoord op vraag 3 ] nerveus of gespannen en was [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen.

Doordat ik [ antwoord op vraag 3 ] nerveus of gespannen was, was ik ... boos.

19. U was de afgelopen maand [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden en u was [ antwoord op vraag 1 ] van streek omdat er iets onverwachts gebeurde.

Doordat ik [ antwoord op vraag 7 ] geïrriteerd was, was ik ... van streek.

20. U was de afgelopen maand [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden en u voelde zich [ antwoord op vraag 3 ] nerveus of gespannen.

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gespannen.

21. U was de afgelopen maand [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden en u had [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had.

Doordat ik [ antwoord op vraag 7 ] geïrriteerd was, had ik ... alles onder controle.

22. U was de afgelopen maand [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden en u was [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen.

Doordat ik [ antwoord op vraag 7 ] geïrriteerd was, was ik ... boos.

23. U had de afgelopen maand [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had en u was [ antwoord op vraag 1 ] van streek omdat er iets onverwachts gebeurde.

Doordat ik [ antwoord op vraag 1 ] alles onder controle had, was ik ... van streek.

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24. U had de afgelopen maand [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had en u voelde zich [ antwoord op vraag 3 ] nerveus of gespannen.

Doordat ik [ antwoord op vraag 8 ] alles onder controle had, was ik ... nerveus of gespannen.

25. U had de afgelopen maand [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had en u was [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden.

Doordat ik [ antwoord op vraag 8 ] alles onder controle had, was ik ... geïrriteerd.

26. U had de afgelopen maand [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had en u was [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen.

Doordat ik [ antwoord op vraag 8 ] alles onder controle had, was ik ... boos.

27. U was de afgelopen maand [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen en u was [ antwoord op vraag 1 ] van streek omdat er iets

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Doordat ik [ antwoord op vraag 9 ] boos was, was ik ... van streek.

28. U was de afgelopen maand [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen en u was [ antwoord op vraag 3 ] nerveus of gespannen.

Doordat ik [ antwoord op vraag 9 ] boos was, was ik ... nerveus of gespannen.

29. U was de afgelopen maand [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen en u was [ antwoord op vraag 7 ] in staat om irritaties in uw leven onder controle te houden.

Doordat ik [ antwoord op vraag 9 ] boos was, was ik ... geïrriteerd.

30. U was de afgelopen maand [ antwoord op vraag 9 ] boos om dingen die buiten uw controle lagen en u had [ antwoord op vraag 8 ] het gevoel dat u alles onder controle had.

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