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Adjustment Disorders as a Stress-Related Disorder: A

Longitudinal Study of the Associations among Stress,
Resources, and Mental Health
Ru¨ya-Daniela Kocalevent1*, Annett Mierke2, Gerhard Danzer2, Burghard F. Klapp2
1 Institute and Policlinic for Medical Psychology, University Medical Center, Hamburg-Eppendorf, Germany, 2 Department of Psychosomatic Medicine, Charite´ University
Medicine, Berlin, Germany

Objective: Adjustment disorders are re-conceptualized in the DSM-5 as a stress-related disorder; however, besides the
impact of an identifiable stressor, the specification of a stress concept, remains unclear. This study is the first to examine an
existing stress-model from the general population, in patients diagnosed with adjustment disorders, using a longitudinal

Methods: The study sample consisted of 108 patients consecutively admitted for adjustment disorders. Associations of
stress perception, emotional distress, resources, and mental health were measured at three time points: the outpatients’
presentation, admission for inpatient treatment, and discharge from the hospital. To evaluate a longitudinal stress model of
ADs, we examined whether stress at admission predicted mental health at each of the three time points using multiple
linear regressions and structural equation modeling. A series of repeated-measures one-way analyses of variance (rANOVAs)
was performed to assess change over time.

Results: Significant within-participant changes from baseline were observed between hospital admission and discharge
with regard to mental health, stress perception, and emotional distress (p,0.001). Stress perception explained nearly half of
the total variance (44%) of mental health at baseline; the adjusted R2 increased (0.48), taking emotional distress (i.e.,
depressive symptoms) into account. The best predictor of mental health at discharge was the level of emotional distress
(i.e., anxiety level) at baseline (b = 20.23, R2corr = 0.56, p,0.001). With a CFI of 0.86 and an NFI of 0.86, the fit indices did not
allow for acceptance of the stress-model (Cmin/df = 15.26; RMSEA = 0.21).

Conclusions: Stress perception is an important predictor in adjustment disorders, and mental health-related treatment
goals are dependent on and significantly impacted by stress perception and emotional distress.

Citation: Kocalevent R-D, Mierke A, Danzer G, Klapp BF (2014) Adjustment Disorders as a Stress-Related Disorder: A Longitudinal Study of the Associations
among Stress, Resources, and Mental Health. PLoS ONE 9(5): e97303. doi:10.1371/journal.pone.0097303
Editor: Gabriel S. Dichter, UNC Chapel Hill, United States of America
Received October 30, 2013; Accepted April 17, 2014; Published May 13, 2014
Copyright: ß 2014 Kocalevent et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: No current funding sources for this study.
Competing Interests: The authors have declared that no competing interests exist.
* E-mail:

Introduction This unresolved specification of the stress construct in diagnosed
ADs is also reflected in the high variance of prevalence rates.
Adjustment disorders (ADs) have recently been defined as a Maercker and colleagues [1] reported a 12-month AD prevalence
stress response syndrome [1]. This new diagnostic concept was of 0.9–2.3% in Germany, depending on whether functional
addressed in the preparation of the DSM-5 and the ICD-11. impairments were taken into account. An estimated prevalence of
Stressful events or continuing unpleasant circumstances are the 0.5% was derived using data from the European Outcome of
primary and overriding causal factors of ADs, and this disorder Depression International Network study [3]. The prevalence of
does not occur without such effects [2]. Specifically, ‘‘The ADs in China is ,1% [4]. A representative study of ADs among
disorders in this section can thus be regarded as maladaptive 65- to 96-year-olds from Switzerland yielded a prevalence of 2.3%
responses to severe or continued stress, in that they interfere with [5]. In a cross-sectional study on primary care and psychiatric
successful coping mechanisms and therefore lead to problems of outpatients over the age of 60 with anxiety symptoms alone, ADs
social functioning’’ [2]. While the impact of stressors in this new yielded a high prevalence of 3.7% [6]. The prevalence of ADs in
conceptualization of ADs is well specified, there is a lack of primary care was 2.9% in a representative cross-sectional study
empirical data examining the associations among stress percep- [7]. ADs continue to be diagnosed in a clinical setting range, with
tion, resources, and emotional distress on mental health in ADs. up to 12% of referrals in consultation-liaison psychiatry [8].
Maercker and colleagues [1] required new empirical data when
Empirical data concerning the specification of the stress
preparing the DSM-5 and the ICD-11 diagnostic nomenclature
construct in ADs are scarce. Previous cross-sectional empirical
for ADs as a stress-related disorder.

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specific treatment modules centered on stress regulation (for in patients diagnosed with adjustment disorders.’’ Expectations of self-efficacy were defined as a source of generalized problem solving. operationalization of different aspects of stress is used to specifically refer to resources. we assessed stress perception. and the mental health dimension of quality of life among patients clinically diagnosed with ADs. major stressors) were associated with ADs Berlin approved this study. would predict mental health in people with ADs.9]. Structural equation modeling was used to test for the stress-model To date. in which intrusion. The BRCS is a 4-item questionnaire with a five-point rating scale that aims to identify individuals in need of resilient coping skill interventions [19]. These so-called cognitive models of persisting Methods stress seek to explain three forms of cognitive stress processing: a) successful completion. which reflects an Figure 1. individual’s sense of his or her own competency and ability.’’ ‘‘most likely true.18]. questionnaires that were displayed on personal digital assistants (PDAs). aspects [17. stress response syndromes are limited to post-traumatic stress disorders [10–12].0097303. massage. treatment covered general treatment modules (different group The purpose of this longitudinal study was to examine an therapies and psychoeducation for all patients) and disorder- existing cross-sectional stress-model from the general population. where 1 means the statement does not describe you at all and 5 means it describes you very well. Written informed consent was according to a postulated stress-response model of ADs [13. Postulated stress model.79) [21].’’ ‘‘most likely not true. and failure to adapt to the life-events are the central Sample processes and symptoms [14]. at admission to the inpatient department [17. We life in people with ADs was higher than in those with other mental hypothesized that stress. Instruments In the study design. and so on. (dis)stress response syndrome. The questionnaire is composed of 9 items with four possible response categories: ‘‘not true. the mental dimension of quality of quality of life. The inpatient health (T3) and the indirect effect mediated via stress (T1). b) chronic cognitive processing.18].. and mental health. emotional distress. sauna. Germany between 01/ Lazarus and Folkman’s hypothesis was confirmed in the general 2007 and 02/2013 were analyzed. with 2 May 2014 | Volume 9 | Issue 5 | e97303 .plosone. Questionnaire on self-efficacy and optimism (SWOP). The treatment lasted 2–14 days. avoidance of reminders. available resources [15. see Figure 2). Longitudinal Study on Adjustment Disorders findings indicate higher self-perceived stress scores among patients tion. and the mental health dimension of mental disorders. The SWOP evaluates self-efficacy and optimism. and all clinical investigations were conducted according The proposed model described ADs as particular forms of the to the principles expressed in the Declaration of Helsinki. with ADs compared with those with anxiety disorders or other resources. The directions for the items are worded as follows: ‘‘Consider how well the following statements describe your behavior from 1 to 5.1371/journal. Furthermore. individuals who with ADs and treated at the psychosomatic inpatient department perceive stress examine present. among patients clinically diagnosed with ADs. Resources Brief resilient coping scale (BRCS).16]. The data from 108 consecutive patients who were diagnosed According to a transactional model of stress. stress percep- behavioral therapy with a strong physiotherapeutic emphasis on single-person therapy. and at discharge (T3.’’ The BRCS is considered to be sufficiently valid and reliable (Cronbach’s a = . theoretical model assumptions of the processes within (Figure 1) in ADs. stress comprises of personal resources. A recent study explored whether The institutional review board of Charite´ University Medicine severe life-events (i. and at least to be decomposed into the direct effect of resources (T1) on mental one counseling session with a trained psychologist. At first.g001 Optimism was defined as an individual’s ability to channel an PLOS ONE | www. These studies contributed to the transactional under- (T2). obtained. According to the patients with stress response syndromes) based on cognitive- stress-model. The patients included in standing of stress by identifying the direct effects of resources on this study waited between one day and 8 weeks after the initial visit the perception of stress and the indirect effects on health-related for inpatient treatment.e. at Charite´ University Medicine Berlin. emotional distress. This instrument is considered valid and reliable (Cronbach’s a = . doi:10. in order to study these complex Clinical Setting reciprocal stress relationships in the current study (Figure 1).70) [20]. including stress perception and emotional disorders but lower than in patients with somatic disorders. and c) the Ethics Statement inhibition of cognitive processing. women scoring lower than men [7. The The psychosomatic inpatient treatment included an extensive total effects of resources (T1) on mental health (T3) are postulated clinical interview by an experienced clinician. All patients completed all population as an accurate operationalization of the stress construct questionnaires during an outpatient evaluation session (either at a with cross-sectional empirical data to be used for further analysis visit to the outpatient department or via a psychosomatic liaison service) at baseline (T1).pone.14]. The authors created a model assumption on the basis of the aforementioned previous results.’’ and ‘‘true. swimming.

respectively [30].’’ ‘‘more than overview on the concept). The BSF is one of the six mood scales of high reliability and validity among primary care patients [32–34]. Longitudinal Study on Adjustment Disorders Figure 2. operationalized as the level of anxiety and depressive symptoms bodily pain. In addition to the perception of stress.’’ ‘‘more than half the time. and C for latent variable resources [23]. The SF-8 is a generic questionnaire concerning perceived health-related quality of life. The GAD-7. 2 = sometimes. worries.. Participants reported how often each depressive well as interactions between age and gender with regard to mental symptom bothered them over the last two weeks. and (c) perceived stress should be cultures. stress percep- PHQ-9 scores range from 0 to 27. Mental health (SF-8). role physical. it assesses the Emotional Distress overall subjective state of health of adults with different diseases in Emotional distress is one aspect of stress among people with relation to physical. These items are answered using a four-point rating scale (1 = almost never. The PSQ-20 scoring methods [35. scores of $5. and severe levels of depressive independent variables and mental health (SF-8) as the dependent symptoms. and social aspects. relationships among resources (BRCS and SWOP).36]. This scale was added to account for generalized anxiety disorder [29]. By adding a constant (regression was administered to measure perceived stress during the previous intercept).pone. vitality. respectively.plosone. and $15 represent mild. and severe Mertensdorf. and the multidimensional mood questionnaire of Hecheltjen and scores of $5. physical functioning. Depressive symptoms were performed with regard to mental and physical health.1371/journal. and 4 = always) with regard to the last 4 weeks. the aggregate PCS-8 and MCS-8 scores are standard- 4 weeks [27]. Earlier studies of indicate how often they have been bothered by each of the 7 core emotional adaptation and health-behavior change have identified symptoms of generalized anxiety disorder over the last 2 weeks. The SF-36 was as follows: (a) stress was recorded as subjective perceived stress. 1.’’ and ‘‘nearly every day’’ and scored as 0. Therefore. 3 = often. the Berlin Mood Questionnaire. see [31]). respectively. but it is also used for clinically The PSQ-20 includes 20 items that are assigned to four scales relevant subgroups. and emo- PHQ-9 are well documented (for an overview. options are ‘‘not at all. has Motivation (BSF).g. moderate.’’ Multiple linear regressions were performed to examine the and ‘‘nearly every day’’ and scored as 0. The 8-item version was specifically developed for recorded independently of the current stage in the coping process. The SF-8 ADs. 1. and emotional distress (PHQ-9 and GAD-7) as represent mild. see [18]). (rANOVAs) with least significant difference (LSD) post-hoc tests Depressive symptoms (PHQ-9). 2. which was used for stress The items of the GAD-7 describe the most prominent diagnostic modeling only to represent one of the indicator variables for the features of the DSM-IV diagnostic criteria A. stress perception.g002 attitude in such a way that it will have an advantageous effect in Anxiety (GAD-7). Flow-chart of the study participants. and 3. list of Nowlis [25. joy. depression and anxiety (PHQ-9) [28]. this construct was one-item scales (general health.nihpromis. tional distress at T1 were used to assess associations with mental PLOS ONE | www. psychological.0097303. mental health. or emotional 3 May 2014 | Volume 9 | Issue 5 | e97303 .’’ ‘‘several days. moderate. (PCS-8 and MCS-8. and tension). ‘‘You feel under quality of life of patients with various diseases across different pressure from deadlines’’).g. GAD-7 scores range from 0 to 21. (demands. $10. stress perception. Specifically. social functioning. doi:10. The response health. 2. (a) resources. The SF-36 has been used to compare the health-related but apply to a variety of real-life situations (e. B. The psychometric properties of the variable.’’ ‘‘several The Data Analyses psychometric properties of the PSQ are well documented (for an A series of repeated measures one-way analyses of variance overview. stress were assessed using the nine-item PHQ depression module perception. and role according to the Patient Reported Outcomes Measurement emotional) as well as physical and mental summary measures Information System of the NIH in the US (www. which is itself a translation of the mood adjective anxiety symptom levels. and emotional distress (e.. motivation as a resource for goal achievement (see [24] for an The response options are ‘‘not at all. Participants use the GAD-7 to the amount of motivation for treatment. generalized anxiety disorder and assesses symptom severity. which identifies likely cases of dealing with change across various levels [22]. (b) constructed to survey health status in the Medical Outcomes Study stress factors and subjective perceived stress should be unspecific [38]. This validated questionnaire is a shortened and rescaled form of respectively. respectively) are scored using norm-based Perceived stress questionnaire (PSQ-20). Each of the nine items corresponds to one of the symptoms) to assess changes for each variable separately over time. $10. and 3. population-based questionnaires. The criteria used to construct the questionnaire were ized to have the same mean as the SF-36 [37]. and $15 tion (PSQ). half the time.26]. DSM-IV diagnostic criterion A symptoms for major depressive This approach was used to test for possible within-group effects as disorder [29].

001) and anxiety regression analysis because it deals with a system of regression symptoms (b = 20. and the SF-8 had an a of 0.5.97) and the normed-fit index (NFI.’’ Stress perception was operationalized as T1 to T3. $0. resulting in a 29% reduction from ience. 1.0% ‘‘stressor’’ (demands) and ‘‘stress reactions’’ (tension and worries). p. discussed.0% were taking a barbiturate. $0. Thus. explained 29% of the total variance (R2 = 0.95.plosone. stress perception. The question- at T3 and resources and stress perception at T1 using a structural naires were presented via PDAs to all consecutive patients at T1. stress scale was the strongest predictor of mental health.18] among people with ADs. we investigated the relationship between mental health Sample characteristics are described in Table 1. p.001). emotional distress.87.907). present study did not reveal significant time*gender or time*age PLOS ONE | www.’’ ‘‘joy.0. inpatients with ADs [44].53.48. [17. among patients diagnosed with ADs to clarify the role of stress within this disorder. Long-term and depressive symptoms (b = 20. stress perception.0. equation model of stress (Figure 1). $0.e. Forty-four using the constructs ‘‘self-efficacy. The between the critical values of 1.6%.001) (Durbin-Watson d = 1.5% were taking neuroleptics.97) following Tanaka [40]. Furthermore. Results Proposed Stress Model of ADs Sample Characteristics Finally. Durbin-Watson acceptable. was operationalized whereas 108 patients responded at all three time points.0.’’ ‘‘optimism. We used the comparative fit index (CFI.78. the examined the longitudinal associations of stress perception. the fit indices did not allow 4 May 2014 | Volume 9 | Issue 5 | e97303 . were taking multiple types of the aforementioned medications. and With a CFI of 0. The Durbin-Watson statistic was such as fatigue and high perceived stress in general [41]. anxiety group of patients with ADs significantly improved with regard to symptoms.’’ and ‘‘motivation. 3-month and 2-year follow-up evaluations [42.0. in which ADs are categorized under the We observed significant within-subjects changes from T1 heading of ‘‘Disorders Specifically Associated with Stress’’ [2]. whereas 14. good.001) effects are not valid for depressive syndromes [45].0. stress perception.86. associated with the anxiety level at T1 (b = 20. Collinearity statistics (tolerance and variance inflation All data analyses were conducted using AMOS 20 and SPSS factor) indicated that multicollinearity was not an issue in these with an a level of 5%. and emotional distress at correlation among the residuals).001) and significantly associated perception. equations. and anxiety correspond to other studies in which the primary aim was assessing symptoms) decreased.23. LSD post-hoc tests revealed that the score the treatment effectiveness among people with ADs. depressive symptoms.73 for.86 and an NFI of 0. The 3rd stepwise multiple linear regression analysis (i. resources. three stepwise multiple linear regressions. number of ‘‘structural’’ parameters defined by the hypothesized The mental health summary score at T3 was only significantly underlying model [39]. Readmission rates among people with The 1st stepwise multiple linear regression analysis (cross. and stable effects were observed at from T1 to T3 were significant for all scale scores (Figure 3).902). (b) resources.41].001) but not for stress perception.95.e.001).5 (d = 2. 76.254). and (c) resources. T3 were used to predict mental health at T3. Emotional Distress. This model was constructed in T2.2% of the patients.5% of the patients for acceptance of the stress-model (Cmin/df = 15. in which the of a stress model [17. Longitudinal Study on Adjustment Disorders health at T1.43]. it also represents hypotheses regarding the means. as it explained 44% of the years [46]. At T1.27. Structural equation modeling exceeds multiple with depressive symptoms (b = 20. and Mental Our selection of variables under investigation was derived from Health the ICD-11 Beta Draft. RMSEA = 0. This age range is typical for stress-related syndromes total variance (R2 = 0.44). good. and emotional distress (in perception. sectional analysis at T1) indicated that the mental health summary which might be due to the recovery effects of chronic stress.21).28. These findings terms of perceived stress. and subjective mental health state 0. The work absences due to ADs are best predicted by comorbidity.18. therefore. and T3. Internal Consistency Discussion The internal consistency (Cronbach’s a) statistics for the scales The role of stress among people diagnosed with ADs is often were as follows: (a) The BRCS had an a of 0. The medication data were missing for 5. p. see Table 2) yielded Model 3. and a total of 124 light of our previous cross-sectional population-based studies patients were enrolled at T1. Structural equation The 2nd stepwise multiple linear regression analysis (cross- modeling was applied to test an earlier empirical conceptualization sectional analysis at T3) produced Model 2. this model was association between mental health and perceived stress was again based on previous cross-sectional population-based studies of stress the strongest (b = 20.0.. Changes in Resources. The through T3 with regard to mental health.4% were taking antidepressants. stress perception. these score was significantly associated with stress (b = 20. Another Significant time*gender or time*age interaction effects were not follow-up study found that chronicity and behavioral symptoms observed with regard to mental health.35. yet it remains under-researched [8].81.0. d . 1. see Table 2).3% of the patients were not taking a latent variable based on a combination of the constructs medications. The latent variable. ADs are significantly lower than those with other mental disorders. GAD-7 anxiety scale had an a of 0. each independent variable uniquely predicted the dependent variable.001. The mean of mental health rose changes from T1 through T3 with regard to mental health. and emotional distress (p. d = 1. the PSQ had an a of 0. the PHQ-9 had an a of resources. and results of the present study revealed significant within-participant emotional distress (p. Differences from T1 to T2 and symptoms and life satisfaction. p. p. p. the SWOP self. stress significantly over the three time points.2. no serial T3. and covariances of observed data in terms of a smaller longitudinal analysis from T1 to T3. $0. Compared differences from T2 to T3 were significant for depressive with untreated control groups. 1. or were the strongest predictors of poor outcomes among psychiatric emotional distress..’’ ‘‘resil- patients were lost to follow-up. when followed by under employment with an age between 35 and 44 taken into account only in a first model. Our study efficacy scale had an a of 0. and emotional we can assume that first-order linear auto-correlations were not distress at T3 were used to assess associations with mental health at present in our multiple linear regression data (i.29. 152 patients were approached.0. the variances.0.80.001) and acceptable. were taking a tranquilizer.79. The response rate at T2 was 81.26. an intervention psychotherapy symptoms (p. or mental health.

Results of the within-subjects effects..2% No 36.g003 PLOS ONE | www. unpublished data). The longitudinal effects of stress and resources on [18.3% High School 52. settings investigating gender differences in stress processing can be We found that stress was strongly correlated with mental health divided into those which have shown that women tend to report and explained nearly half of the variance in this variable at T1. However.0097303. P-values are reported for significant changes from T1 through T3. thereby accounting for the more on age than on gender (Kocalevent et al..59].2% Education None 1. Sample characteristics n 108 Sex (men) 35% Age.8% Visited a physician before admission 84.9% College 45.8% Cohabitation or married Yes 63. Data from a recent representative population study assumption that role differences have decreased over the past suggested that the relationship between health and stress depends decades (at least in industrial countries). or 1980s [50] reported clearer gender differences and support the depression. fading gender effects with regard to stress. who are more likely to have less favorable this period of life [47].plosone. Longitudinal Study on Adjustment Disorders Table 1. Recent studies of different health care socioeconomic statuses [35. Characteristics of the sample under investigation. early adulthood) self-rated health status and quality of life remain disadvantageous might be due to the work.2 (range: 22–71) Job status Employed 74.5% doi:10.pone. overall stress.0097303.e. The population-based samples between the 1960s and mental health among patients with ADs could not be established. Figure 3.and family-related challenges during for women.54–58].1371/journal.1371/journal.t001 interaction effects with regard to mental health. differences in The peak in the range between 16–40 years (i. more psychological stressors than men [48–53] and those that Stress was also the strongest cross-sectional predictor of mental have reported no differences (or differences with small effect sizes) health at 5 May 2014 | Volume 9 | Issue 5 | e97303 . years 45.pone. doi:10. 6 May 2014 | Volume 9 | Issue 5 | e97303 . Second stepwise multiple linear regression T3 (discharge) T3 (discharge) Model 2 PHQ-9 (Depressive Symptoms) SF-8 (Mental Health) 20. The insufficiently elaborated our results were in the right direction and need additional analysis assessment of ADs with regard to structured and standardized with larger sample sizes. practice sample showed that clients’ mean pretreatment-posttreat- Emotional distress (i.18 n. This change of duration (in the range of 0 to 20 sessions) [64].0. the development of a CIDI for patients with cancer (i.18 BRCS (Resource) 20. Yet. which to the longitudinal data.1371/journal. Our stress model hypothesis based on previous cross-sectional The recognition of ADs by primary care remains low [7]. SWOP (Resource) 20.. which missing. and increased levels of harm model. BRCS (Resource) 20. variability in patient treatment experience iology of this disorder is the same as that of major depressive would likely be highly influential. the CIDI) has recently been described and led to sample size to the number of free parameters should be 20:1. anxiety symptoms) at T1 best predicted ment change was approximately constant regardless of treatment the mental health of patients with ADs at T3. A recent study protocol aimed to investigate the evaluated the temporal precedence and causality of the observed pharmacological interventions among people with ADs under.s.07 n. doi:10. SWOP (Resource) 20. however. this limitation. mental disorders [63]. it was only moderately associated with the present sample passes. dysregulation. results of a large routine disorder and generalized anxiety disorder [60].g.plosone.s.53 0. our theoretical conceptualization of ADs using a In general. PSQ (Perceived Stress) 20.g. However. O) by adding the items for the diagnostic group of stress-related plished within the current study timeline. colleagues [14. the variation in length hospital stay reduced tonic activity of the HPA axis. yet 37% had at least one psychotropic prescription. Measures of association Independent Variables Dependent Variable b Coefficient* Adjusted R2 First stepwise multiple linear regression T1 (baseline) T1 (baseline) Model 1 PSQ (Perceived Stress) SF-8 (Mental Health) 20.12 n. this longitudinal study represents avoidance.06 n.e.48 PHQ-9 (Depressive Symptoms) 20.s. they decrease as time studies.s.e. a typical behavior of anxiety-related symptoms and a PLOS ONE | www. which might be related to from T1 to T3 remains under-investigated in the proposed stress chronicity. Longitudinal Study on Adjustment Disorders Table 2. the CIDI- our required sample size was N = 600.29 PHQ-9 (Depressive Symptoms) 20.23 0. the ratio of the procedures (e.. Considering the pinned by biological parameters by assuming that the pathophys. Nevertheless.s.48 0. stress associations among people with ADs. but would reports without objective markers (e.35 GAD-7 (Anxiety Level) 20.56 PSQ (Perceived Stress) 20. Furthermore. the fit indices suggested that indicates the need for treatment [7].pone. Although hormonal and neurotransmitter (e. or One limitation of this study was that all measures relied on self- both of the HPA axis with regard to emotional distress. distress can also be characterized by the given its size.27 BRCS (Resource) – SWOP (Resource) – Third stepwise multiple linear regression T1 (baseline) T3 (discharge) Model 3 GAD-7 (Anxiety Level) SF-8 (Mental Health) 20. biomarkers). symptoms might be due to the level of activation. The results of stepwise multiple linear regressions with mental health as the dependent variable. which was not accom. timing is an especially critical element because dysfunctional transactional stress model is relatively new.62]. *Multiple linear regressions were performed (p.001). According to Tanaka [40].s. longitudinal design. dopamine) activity are the model itself has been validated in several cross-sectional elevated at the onset of a stressor. Aside from lead to an over-interpretation of the data in the current study [61]. general practitioner identified only 2 of 110 cases using the SCID- nalization of the stress process among people with ADs according I.09 n.t002 Resources did not significantly predict mental health among postulated central process of AD according to Maercker and people with ADs..07 n.28 GAD-7 (Anxiety Level) 20. Sufficient neurobiolog.. Despite these limitations.. ical models of prolonged (dis)stress syndromes/ADs are currently The major strength of the study is its longitudinal design. exposure to a stressor. thus.0097303. A studies of the general population was not an accurate operatio.

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