The Psychophysiology of Stress and Coping

The psychophysiology of stress and coping:
Is the discrepancy between autonomous

reactivity and self-reported negative affect of
health psychological relevance?
Dissertation
zur Erlangung des akademischen Grades Doktor der
Naturwissenschaften (Dr.rer.nat.) an der Naturwissenschaftlichen
Fakultät der Karl-Franzens-Universität Graz
vorgelegt von
Eva-Maria Messner
aus Oberdischingen
2020
Verfasst von:
Mag.a Eva- Maria Messner (geb. Rathner)
Institut für Psychologie
Abteilung Klinische Psychologie und Psychotherapie
Universität Ulm, Deutschland
Betreuung/Erstbegutachtung von:
Univ.-Prof. Dr. Andreas Schwerdtfeger
Institut für Psychologie
Arbeitsbereich Gesundheitspsychologie
Karl-Franzens-Universität Graz, Österreich
Zweitbegutachtung durch:
Univ.-Prof. Dr. Thomas Kubiak
Psychologisches Institut
Abteilung Gesundheitspsychologie
Johannes Gutenberg Universität Mainz, Deutschland
Eingereicht am: 31.7.2020

Acknowledgments
As a psychotherapist, trained in systemic therapy, I do not believe in isolated
individuals. I am sure humans are first and foremost social beings. Therefore, this
dissertation would have never been achieved without the support of my environment.
So a massive thank you to everyone who took part in my life so far. To those who
taught me gently and with love, those who guided me through example and to those
whom I perceived negatively at the time but who helped me develop abilities I have
never dreamed of achieving.
At first, a thank you to my parents Manuela and Albert, who were brave enough to let
me develop as a free spirit. Warm gratitude to my families, it means the world to me to
feel connected and integrated. A thank you to my siblings, who taught me, real
unconditional love. I have no idea what I would be without you.
A thank you to all the teachers who saw talent in me, even when I was doubting myself
or struggling with the demands of my early life. Many thanks to the inspiring Professors,
such as Andreas Schwerdtfeger, Thomas Kubiak, Harald Baumeister, Christian
Montag, Rüdiger Pryß, Thomas Probst, Tamlin Conner, David Kavanagh, Nicholas
Cummins, and Björn Schuller, who stimulated my research. My gratitude to my student
assistants Alexandra, Linda, and Thomas, who support my work on a day-to-day basis.
Moreover, the highest appreciation to all my friends who patiently loved me and
nourished the positive aspects of mine through all those years. Lots of love for our child
Felix, who gave me the patience and spirit to ultimately finish my thesis. Special thanks
to my sister Hannah, who supported me with babysitting for the last 20 pages. Finally,
yet importantly, thanks to my husband Matthias, who is my anchor and gives me wings
at the same time. With all that support, I am looking forward to many occupational and
private adventures in this new chapter in my life.

Abstract - English
Introduction: Although stress is a part of daily life, prolonged and repetitive exposure
to stressors contributes to adverse health outcomes. When dealing with stressors,
diverse coping strategies are linked to health outcomes. This thesis aims to broaden
the knowledge about novel approaches to assess stress and coping in the field.
Furthermore, the association between coping and cardiovascular health will be
discussed.
Methods: In the first study, the possibility of using smartphones to estimate levels of
experienced stress was investigated by tracking 157 individuals for eight weeks. In the
second study (n = 111), the association between cardiovascular reactivity (CVR)
assessed in the lab and field was examined. In the third study, the ecological validity
of the autonomic-subjective response dissociation (ASRD) in repressive coping was
tested on a sample of 114 individuals. Data were analyzed with multilevel models. In
the fourth study, markers of cardiovascular disease were associated with cognitive
avoidant coping (CAV) to investigate the clinical relevance of the habitual use of coping
strategies in healthy individuals (n = 124).
Results: Smartphones could be used in the future to unobtrusively assess mental
states such as stress in humans, especially when including sensor variables into the
models. When assessing coping and CVR, the generalizability of CVR retrieved in the
lab is limited. When inferring from CVR obtained in the lab to daily life CVR, the
baseline heart rate should be taken into account. In repressive coping, which is
accompanied by increased CVR, an interaction of CAV with markers of atherosclerosis
increasing with age was found. Furthermore, it could be shown that the ASRD in
repressive coping can be retrieved validly in the field, thus making it possible to study
the long-term effect of heightened CVR on health.
Discussion: This thesis adds knowledge regarding the methodology of the
assessment of stress and coping in the field. Taken together, these findings point out
that a.) valid and reliable unobtrusive assessment of stress and coping in the field will
be possible in the future; b.) this opportunity poses major legal and ethical challenges
as sensitive data (e.g., heart rate) could be collected on a large scale; c.) future studies
will be able to study the long-term health outcomes of habitual coping styles in the field.
Keywords: stress, coping, ambulatory assessment, passive sensing, smartphone
tracking
Abstract - Deutsch
Einleitung: Obwohl Stress ein essentieller Bestandteil des täglichen Lebens ist, kann
wiederholte und lang andauernde Exposition zu adversen gesundheitlichen Folgen
führen. Der habituelle Gebrauch spezifischer Bewältigungsstrategien ist mit
gesundheitlichen Folgen verbunden. Diese Dissertation diskutiert neuartige Ansätze
zur Erhebung von Stress und Bewältigungsstrategien im täglichen Leben. Darüber
hinaus wird der Zusammenhang zwischen habituellen Bewältigungsstrategien und
kardiovaskulärer Gesundheit diskutiert.
Methoden: In der 1. Studie wurde der Einsatz von Smartphones zur passiven
Erhebung von subjektivem Stresserleben untersucht, indem das
Smartphonenutzungsverhalten von 157 Personen acht Wochen lang erfasst wurde. In
der 2. Studie (n = 111) wurde der Zusammenhang zwischen der im Labor und im Alltag
gemessenen kardiovaskulären Reaktivität (CVR) erfasst. In der 3. Studie wurde die
ökologische Validität der autonom-subjektiven Reaktionsdissoziation (ASRD) bei
repressivem Coping an 114 Individuen getestet. In der 4. Studie wurden Marker von
Herz-Kreislauf-Erkrankungen mit kognitiv-vermeidendem Coping (CAV) assoziiert, um
die klinische Relevanz der habituellen Anwendung von Coping-Strategien bei
gesunden Personen zu untersuchen (n = 124).
Ergebnisse: Smartphones könnten in Zukunft verwendet werden, um psychische
Zustände wie Stress beim Menschen passiv, valide und reliabel zu erfassen. Die
Generalisierbarkeit von im Labor gewonnener CVR ist limitiert. Bei der spezifischen
Betrachtung der repressiven Bewältigung wurde eine Interaktion von CAV mit Markern
einer Atherosklerose und dem Lebensalter gefunden. Es konnte gezeigt werden, dass
die ASRD bei repressivem Coping im Alltag valide ermittelt werden kann.
Diskussion: Die Ergebnisse weisen darauf hin, dass a.) in Zukunft eine valide und
reliable, passive Erfassung von Stress und Bewältigung im Alltag durch Smartphones
möglich sein wird; b.) diese Möglichkeit große rechtliche und ethische
Herausforderungen mit sich bringt, da sensible Daten in großem Umfang erhoben
werden können; und c.) künftige Studien in der Lage sein werden, die langfristigen
gesundheitlichen Folgen von habituellen Bewältigungsstilen im Alltag zu untersuchen.
Schlüsselwörter: Stress, Coping, Ambulantes Assessment, Passive Datenerhebung,
Smartphonetracking
Table of Contents
1 Introduction .............................................................................................................. 1
1.1 Stress ................................................................................................................ 2
1.1.1 Stress in the meaning of episodic events or acute stress ........................... 3
1.1.2 Stress defined as significant life events ...................................................... 4
1.1.3 Chronic stress ............................................................................................. 5
1.1.4 Daily stressors............................................................................................. 5
1.2 Stress and Age .................................................................................................. 6
1.3 Stress and Mental Health .................................................................................. 7
1.4 Stress and Physical Health................................................................................ 8
1.5 Focus on Stress and Cardiovascular Health ................................................... 10
1.6 Treatment and Prevention of Stress ................................................................ 11
1.7 Theories of Coping .......................................................................................... 13
1.7.1 Krohne´s Model of Coping Modes ............................................................. 14
1.7.2 Coping and Personality ............................................................................. 18
1.7.3 Coping and Age ........................................................................................ 19
1.7.4 Coping and Mental Health ......................................................................... 20
1.7.5 Coping and Physical Health ...................................................................... 22
1.8 Focus on Repressive Coping and its Association with Cardiovascular Health 23
1.9 Cardiovascular Variables in Stress and Coping Research .............................. 25
1.10 The Assessment of Stress and Coping ......................................................... 26
1.10.1 The Autonomic-Subjective Response Dissociation ................................. 30
1.10.2 The Association of Laboratory and Field Studies .................................... 32
2 Research Questions .............................................................................................. 35

3 Study 1: Insights- Future implications of passive smartphone sensing in the
therapeutic context ................................................................................................... 37
4 Study 2: Does cardiac reactivity in the laboratory predict ambulatory heart rate? . 73
5 Study 3: The ecological validity of ASRD in responsive coping. .......................... 103
6 Study 4: Cognitive avoidant coping is associated with higher IMT in middle aged
adults. ..................................................................................................................... 137
7 General Discussion ............................................................................................. 165
7.1 Embedding of Relevant Findings into Current Literature ............................... 166
7.1.1 The Use of Smartphones to Assess Mental States ................................. 166
7.1.2 The Association of Cardiovascular Parameters Assessed in the Field and
under Laboratory Conditions ............................................................................ 170
7.1.3 The Ecological Validity of the ASRD in Repressive Coping .................... 173
7.1.4 The Association of Repressive Coping and Cardiovascular Health ........ 176
7.1.5 Summary of the Contribution of Own Research to the State of Art ......... 178
7.2 The Association of Laboratory and Field Studies .......................................... 179
7.3 The Association of Coping and Cardiovascular Health: Implications and Future
Directions ............................................................................................................ 181
7.4 Smartphones as a Way of Assessing Stress and Coping ............................. 183
7.5 Future Directions of Field Assessments: Potential, Limitations and Ethical
Considerations .................................................................................................... 187
8 Synopsis and a General Conclusion .................................................................... 192
9 References .......................................................................................................... 195
10 Curriculum Vitae ................................................................................................ 215
11 List of Publications ............................................................................................. 219
12 Author Disclosure .............................................................................................. 223

Figures
Figure 1: The stage model of stress and disease of Cohen, Gianaros, and Manuck
(2016). SAM= sympathoadrenal-medullary mediators, HPA= hypothalamic-pituitary-
adrenal system…………………………………………………………………………..…..8
Figure 2: Model of coping modes Krohne (1989) ……………………….………16

Abbreviations
AA Ambulatory Assessment
AIDS Acquired Immunodeficiency Syndrome
ANS Autonomous Nervous System
ASRD Autonomic-subjective Response Dissociation
BNS Body Sensor Networks
BP Blood Pressure
CAV Cognitive Avoidant Coping
CVD Cardiovascular Diseases
CVR Cardiovascular Reactivity
EMA Ecological Momentary Assessment
GPS Global Positioning System
HIV Human Immunodeficiency Virus
HR Heart Rate
HRV Heart Rate Variability
HPA-axis Hypothalamus-Pituitary-Adrenal Axis
IMI Internet- and Mobile Based Intervention
IMT Intima-Media Thickness
MCI Mainz Coping Inventory

PANAS Positive and Negative Affect Scale
SMS Short Message Service
VARD Verbal Autonomic Response Dissociation
VIG Vigilance
WHO World Health Organization

Psychophysiology of Stress and Coping 1
1 Introduction
Modern life is characterized by an elevated amount of self-reported stress (American
Psychological Association, 2017; Milczarek et al., 2009). In Germany, 60% of adults report
a substantial increase in experienced stress in their daily lives (Wohlers & Hombrecher,
2016). With minor exceptions (e.g., natural disasters, accidents) stressful life experiences
do not occur at random, they are influenced by environmental circumstances (e.g.,
socioeconomic status) and psychological characteristics of individuals (e.g., neuroticism)
(Cohen et al., 2019). Life stress has been associated with the development, maintenance
and acceleration of mental and physical diseases including asthma, rheumatoid arthritis,
anxiety disorders, depression, cardiovascular disease, chronic pain, HIV/AIDS and certain
types of cancer (e.g., ovarian cancer, breast cancer) (Slavich, 2016). Moreover, life stress
is linked to premature aging and higher mortality risk (Slavich, 2016).
Although stress is continuously found to be related to increased risk of disease in general,
most individuals who experience stressful events do not get sick (Cohen et al., 2019). It
is known that the response to a given stressor varies enormously between individuals.
While some individuals like giving oral presentations, others show signs of severe distress
when confronted with the same task. Therefore, psychological stress can be seen as the
endpoint of an appraisal process in which the threat is believed to exceed our resources
and coping abilities (Gianaros & Wager, 2015). In line with that, coping can be described
as a process of permanent effort to reduce stress. Therefore, the understanding of the
biological, psychological, and social determinants of stress experience and an individual's
capability of coping with stressors might lead to the development of interventions that
reduce the individual and societal burden of stress in the future.

This dissertation will give insight into the theory behind stress and coping, the relation
between the experience of stress and health, the impact of coping onto this relationship,
and novel ways to assess stress and coping in the field. It will end with conclusions on
how to best assess stress and coping in daily life and propose future developments in the
field.
1.1 Stress
There is an ongoing debate about what the term stress means and which definition can
be used in science (Cohen et al., 2019). One reason why there is inconsistency in findings
along stress is that the term is used inconsistently across disciplines, and diverse
methodological approaches are used to assess stress (Cohen et al., 2016). While the
specification of the term will be discussed in this chapter, the methodological aspects will
be discussed later in chapter 1.3.1.
The term stress is used differently in the scientific literature either by the description of a
stressful situation per se in the meaning of a contextual variable, such as 1.) episodic
events/ acute stress such as changes at work, job interviews, sporting events, etc. 2.)
major life events such as natural or human-made disasters, severe disease, etc.; 3.)
chronic stressors such as chronic disease, marital problems, work-related demands; 4.)
daily hassles such as traffic jam, unfinished tasks, etc. (Kivimäki & Steptoe, 2018; Steptoe
& Kivimäki, 2013). Or the term stress is used to describe the response to a stressful
situation, the actual stress experience.

1.1.1 Stress in the meaning of episodic events or acute stress
While the physiological changes following acute stress are well established, little is known
about how exactly stress responses convert over time to pathological changes resulting
in mental and physical disease. In a nutshell, under acute stress, the autonomous nervous
system is activated within seconds. The nervous system innervates nearly all organs of
the body over the sympathetic and parasympathetic nervous systems. Catecholamines
and norepinephrine heighten the heart rate, decrease heart rate variability (HRV),
optimize muscular blood flow, and elevate core body temperature (Brotman et al., 2007).
Heart rate variability is the measure of time intervals between the r-peaks of heartbeats.
For example, decreased heart rate variability was linked to overall health problems, stress
response, depression, and anxiety disorders (Chalmers et al., 2014; Koch et al., 2019;
Thayer et al., 2012).
In the second wave of the stress response, the hypothalamus-pituitary-adrenal axis (HPA-
axis) is activated within minutes. A sequence of hormones is released, resulting in
elevated levels of the adrenocorticotropic hormones, glucocorticoid cortisol, and blood
glucose (Brotman et al., 2007). While the experience of acute stress followed by a period
of rest and regeneration might not impair mental and physical health, the prolonged
exposure to stress is likely affecting an individual’s risk for the development and
occurrence of disease (Lagraauw et al., 2015). The before mentioned changes in the
sympathetic-parasympathetic balance in combination with an altered tone of the HPA-
axis are likely influencing the atherosclerotic process and lead to cardiovascular disease
in the long run (McEwen, 1998).

1.1.2 Stress defined as significant life events
The theory behind significant life events is that there are objective stressors, which affect
all individuals, such as trauma, death, natural disasters, violence, and so forth (Williams
et al., 1981). Two reviews studied the epidemiology of stressful and traumatic events, one
focusing on the developed countries (Hatch & Dohrenwend, 2007) and one worldwide
(Benjet et al., 2016). In developed countries, men and women seem to experience similar
total amounts of critical life events but differ in the type of events. While men reported
more injuries, accidents, and physical assault, women reported more sexual assault. In
general, a low socioeconomic or minority status was linked to elevated levels of
experienced life events.
Moreover, young adulthood was associated with a peak in the experience of life events
(Hatch & Dohrenwend, 2007). Worldwide the occurrence of significant life events is
prevalent in two-thirds of the population. Five major life events, namely witnessing death
or severe injury, unexpected death of a loved one, being mugged, having a life-threatening
car accident, experiencing a life-threatening illness or injury account for over half of all
instances worldwide. The rate and type of significant life events vary concerning the
country of residence, sociodemographic status, education status, and the number of prior
life events (Benjet et al., 2016). Of note, experienced significant life events do not cause
disease directly. Most people stay healthy despite experiencing adverse life events
(Cohen et al., 2019). Mainly if stress exposure persists over time (e.g., chronic stress) with
too little resources to cope, thus it increases the chance for adverse health outcomes.
1.1.3 Chronic stress
When looking at the construct of stress from a time perspective, stress can be
distinguished into acute stress and chronic stress. Both forms of stress have been
extensively examined for decades, but the complexity of the term stress and the biological
systems which are involved still leave many questions open (Nater, 2018). As mentioned
above, stress seems to increase the risk of mental and physical disease more if the stress
is experienced chronically. Persisting life events such as physical limitations are
associated with deterioration in mental health over time (Williams et al., 1981). One form
of chronic stress is low socioeconomic status. Low socioeconomic status has been
associated with the total number of life events and specific types of stressors (Benjet et
al., 2016; Hatch & Dohrenwend, 2007; Lantz et al., 2005). Moreover, specific stressors
related to a poor socioeconomic status like financial and parenting stress are related to
poor self-rated physical health (Lantz et al., 2005). Accumulated life stress is associated
with the development, maintenance, and acceleration of several physical and mental
diseases (Slavich, 2016).
1.1.4 Daily stressors
Daily stressors are more and more recognized as risk factors for adverse mental health
outcomes. Earlier research focused on the impact of significant life events on mental
health and well-being than on the effect of daily life stressors. There is evidence that daily
life stress is a better predictor of mental health and well-being than significant life events
(Newnham et al., 2015). Daily hassles appear to be more strongly associated with physical
health than life events (DeLongis et al., 1982). Charles and colleagues (2013) could show
that both, the average level of negative affect and the affective reactivity to daily stressors
are related to long term mental health outcomes (e.g., affective disorders) (Charles et al.,
2013). The negative impact of daily hassles has also been shown for physical health, both
short term via elevated inflammatory levels (Sin et al., 2015) and on long term health
outcomes (Leger et al., 2018). In both studies, the prolonged experience of negative
emotions caused the effect, thus leading to the conclusion that quick affective recovery
alias successful coping has a buffering effect on the association between daily stressors
and adverse health outcomes.
1.2 Stress and Age
There are sensitive periods in life when stressful events are more likely to have an impact
on ones´ health and well-being (Cohen et al., 2019). It was shown that prolonged
childhood stress exposure leads to increased risk for chronic illness and higher overall
mortality (Norman et al., 2012). This higher risk for the development of a disease in later
life may be rooted in altered biological processes as well as behavioral proclivities. In
general, the association between stress and mortality is higher in younger individuals
when compared to older individuals (Cohen et al., 2019). There is an association between
the number of adverse life events and the total number of daily hassles with depression
in the elderly, pointing towards a cumulative effect of stressors over the lifespan (Kraaij et
al., 2002).
Moreover, older age is associated with a lower overall stressor diversity. While network
stressors and health stressors increase with age, work-related, overload-related, financial,
and interpersonal stressors diminish (Koffer et al., 2016). Moreover, older individuals are
more prone to chronic unavoidable stressors (such as disease, loss of a significant other,
or pain), which are characterized by high stressor exposure and low stressor diversity
(Koffer et al., 2016). From a biological perspective, older people show an increased
cortisol response in stressful situations. This effect is three-fold stronger in females (Bale
& Epperson, 2015).
1.3 Stress and Mental Health
Overall prolonged stress exposure has been associated with mental health problems,
such as depression, anxiety, aggression (Richter-Levin & Xu, 2018; van Praag, 2004;
Wang, 2005) and increased suicide risk (Phillips et al., 2002). One biological pathway for
the association between stress exposure and mental health are altered cortisol levels.
Depending on the kind of mental illness, hair cortisol levels are increased (e.g.,
depression, late-onset bipolar disorder) or decreased (e.g., anxiety, posttraumatic stress
disorder) (Staufenbiel et al., 2013).
There are factors like forgiveness or self-efficacy, which moderate the association
between lifetime stress and decreased mental health (Schönfeld et al., 2016; Toussaint
et al., 2016). Forgiveness and self-efficacy buffer the effect of stress on mental health
(Toussaint et al., 2016).

1.4 Stress and Physical Health
To sum up the evidence on the association
between stress and disease, Cohen and
colleagues (2016) introduced the stage model of
stress and disease. They argue that a broad view
of the term stress helps to subsume the
epidemiological, psychological, and biological
tradition of stress research. While the
epidemiological tradition aims to investigate the
objective levels a given stressor poses on an
individual life, the psychological tradition sheds
light on the interindividual differences in stress
appraisal and coping with stressors. The biological
tradition defines stress as the perturbation of the
physiological homeostasis. These different
approaches can be integrated into various stages
of a process linking environmental demands to
disease development (see figure 1). While Cohen
and colleagues (2016) illustrate a unidirectional
process, they recognize that some processes
might be organized bidirectional or in loops (Cohen
et al., 2016).
Figure 1: The stage model of stress and disease of Cohen, Gianaros, and Manuck (2016). SAM=
sympathoadrenal-medullary mediators, HPA= hypothalamic-pituitary-adrenal system.
In the stage model of stress and disease, an individual is confronted with environmental
demands. The individual can interpret these demands as stressful or harmless. In the
case of a stressful appraisal, the person perceives stress and experiences negative
emotional responses. These negative emotional responses lead to physiological reactions
such as an activation of the sympathoadrenal-medullary and the hypothalamic-pituitary-
adrenal system. Furthermore, these negative emotional responses - when activated
frequently - result in poor health decisions and behaviors. In the long run, these result in
disease-related physiological changes and, subsequently, an increased risk for the onset
or progression of the disease.
It was shown that prolonged stress experience could increase the risk of mortality and
morbidity (McLaughlin & Hatzenbuehler, 2009). In line with that, prolonged exposure to
stress could result in significant health impairments (Slavich, 2016). These include
physiological issues like gastrointestinal problems, metabolic syndrome, coronary heart
disease, cancer, allergies and neurodegenerative diseases (Adam & Epel, 2007;
Chandola et al., 2006; Dallman et al., 2005; Dalton et al., 2016; Diop et al., 2008; Hollifield
et al., 2018; Kane, 2009; Montoro et al., 2009; Padgett & Glaser, 2003; Richards &
Richardson, 2012; Rosengren et al., 2004; Segerstrom & Miller, 2004; Steptoe & Kivimäki,
2013).
Moreover, the impact of prolonged stress exposure on brain structure was shown in
several studies. Gianaros and colleagues (2007) could show that self-reported chronic
stress was a predictor of the diminished volume of the right orbitofrontal cortex and the
right hippocampus 20 years later. Furthermore, Papagni and colleagues (2011) could
show that the number of stressful life events in three months was associated with a volume
reduction in the right hippocampus, the parahippocampi, and the anterior cingular cortex.
These regions are associated with learning, memory, and neuroendocrinological activity.
1.5 Focus on Stress and Cardiovascular Health
Cardiovascular diseases cause nearly 30% of deaths globally (WHO, 2007). In Europe,
cardiovascular diseases are the most common cause of death and the leading cause of
disease burden (Kivimäki & Steptoe, 2018; Townsend et al., 2015). Next to known risk
factors like genetics, obesity, smoking, diabetes mellitus, and hypercholesterolemia, self-
reported stress gained attention in the scientific community as a risk factor for
cardiovascular disease (Chida & Steptoe, 2010). Stress in childhood, like physical abuse,
sexual abuse, domestic violence, parental mental illness, neglect, and parental substance
abuse, can increase the risk of multiple chronic conditions in adulthood, including
cardiovascular disease (Hughes et al., 2017; Kivimäki & Steptoe, 2018). The association
between chronic stress and cardiovascular disease in adulthood is weaker when
compared to chronic childhood stress. Nevertheless, psychological factors like social
isolation, loneliness, and work-related stress are associated with cardiovascular risk on a
meta-analytic evidence level (Dragano et al., 2017; Kivimäki et al., 2012).
Kivimäki and Kawachi (2015) conducted a meta-analysis on the association between
work-related stress and cardiovascular disease, including 600,000 individuals from cohort
studies from Europe, the United States, and Japan. They conclude that work stressors
(e.g., job strain, long working hours, etc.) are associated with a moderately elevated risk
for a coronary incident. The increase in risk is ranging from 10-40% in affected individuals.
Furthermore, they point out that differences between men and women, as well as between
younger and older employees, are small and socioeconomic status also has no significant
effect on the association between work-related stress and cardiovascular disease.
Moreover, they could show that work-related stress is also associated with other adverse
health outcomes such as type 2 diabetes but not to common forms of cancer. Overall, the
evidence is consistent but mainly based on correlational studies. They are thus leaving a
lack of knowledge concerning cause and effect.
A meta-analysis on the prospective evidence on the influence of mental stress on the
cardiovascular risk status showed that higher responsivity and weaker recovery from
acute stress are longitudinally associated with an elevated cardiovascular risk status.
Therefore, the management of stress responsivity alias coping could be used in the
preventive and curative treatment of stress-related disease (Chida & Steptoe, 2010).
Another meta-analysis of Richardson and colleagues (2012) indicates an elevated risk for
incident coronary heart disease in individuals with high perceived stress levels.
One plausible biological mechanism to explain the association between stress and
cardiovascular disease is the phenomenon of atherosclerosis. Atherosclerosis describes
the development of plaques and the progressive thickening of arterial walls, which then
results in cardiovascular events like stroke or cardiac infarction (Hintsanen et al., 2005).
There is, moreover, some evidence linking stress with metabolic syndrome (Chandola et
al., 2008), which could be moderated by fitness (Gerber et al., 2016). One cross-sectional
study found differences between men and women concerning increased cardiovascular
risk associated with self-reported stress (Hintsanen et al., 2005).
1.6 Treatment and Prevention of Stress
Although there is substantial evidence that stress increases the risk of a variety of
diseases, individuals have significant power to reduce these effects and improve their
well-being (Slavich, 2016). Psychotherapy, self-help, and the internet- and mobile-based
interventions (IMIs) aim to strengthen an individual's capability of coping with stress.
Lately, third-wave interventions became extensively studied in the prevention and
treatment of stress-related diseases (Hayes et al., 1999; Hayes, 2004; Hayes et al., 2011).
These include mindfulness, meditation, acceptance, and commitment training. These
approaches focus on altering the way individuals perceive situations and how they handle
their thoughts, feelings, and behavior (O’Connor et al., 2018). Regarding their
effectiveness, a meta-analysis about meditation showed moderate effects on anxiety,
depression, and pain. There were little to no effects of meditation on perceived
stress/distress and mental-health-related quality of life (Goyal et al., 2014). A meta-
analysis about the efficacy of mindfulness for healthy individuals showed significant
effects on stress but only moderate effects on stress-related diseases like depression,
burn-out, anxiety, and quality of life (Khoury et al., 2015). The effect of third-wave
interventions on perceived stress levels are also moderate (Messner et al., n.d.).
Next to these classical face to face approaches, the efficacy of IMIs concerning stress
reduction have been studied. IMIs offer one possibility to distribute psychological
interventions on a broad scale with acceptable costs, thus making them ideal for targeting
such a widespread phenomenon like stress. Heber and colleagues (2017) showed that
IMIs are moderately effective in reducing self-perceived stress. Moreover, the effect size
was larger in guided interventions, medium-long interventions, and interventions that were
based on cognitive behavioral therapy or third wave therapy. There is also evidence that
IMIs are effective in addressing work-related stress (Ebert et al., 2016) as well as stress
in college students (Harrer et al., 2018).

1.7 Theories of Coping
Although, as previously described, stress is related to increased risk of mental and
physical disease, the majority of individuals who experience stressful events stay healthy
(Cohen et al., 2019). It is known that the response to a given stressor varies enormously
between individuals. In line with that, coping can be described as a process of permanent
effort to reduce stress. Folkman and Lazarus (1980) defined coping as „…the cognitive
and behavioral efforts made to master, tolerate, or reduce external and internal demands
and conflicts among them“. Therefore, vulnerability to stress is likely mediated by the use
of coping strategies. Most coping theories are based on the individuals´ focus of attention
in a stressful situation. Two meta-analyses were looking at the relative efficacy of coping
strategies (Mullen & Suls, 1982; Suls & Fletcher, 1985). Both concluded that the short
term outcome of subtracting attention from the stressor is superior, while in the long run
focusing attention on the stressor is advantageous.
Up to date, several theories on coping were postulated. An extensive overview is given
by Krohne (2001). Krohne (2001) outlines a classification of coping theories on the
dimensions a) trait (e.g., repression-sensitization (Byrne, 1964)) vs. state (e.g., Freud´s
defense mechanisms (1926)) and b.) micro-analytic vs. macro-analytic approaches. While
micro-analytic approaches focus on direct coping behavior, macro-analytic approaches
try to explain coping from a meta-perspective. In the following, macro-analytic trait-
orientated theories of coping will be described:
The repression-sensitization model was first introduced by the psychologist Byrne (1964).
The construct repression-sensitization is a unidimensional model. While repressers react
to stress with denial, inability to verbalize their experience, and suppression of negative
thoughts and emotions, sensitizers try to gain more information about the stressor and
exhibit a tendency for rumination.
The monitoring and blunting theory of coping was introduced by Miller (1980) and is also
based on the assumption that individuals who are experiencing a threat can shift their
attention towards or away from the stressor. Blunting is a strategy in which individuals use
cognitive strategies such as distraction, denial, or reinterpretation to reduce the impact of
the stressor. These strategies are highly effective in uncontrollable situations such as
exams or surgeries (Miller & Mangan, 1983). In contrast, successful coping in controllable
situations is related to monitoring, which includes strategies like seeking information and
attaining control. Furthermore, the use of blunting or monitoring strategies relies not only
on the controllability of the stressful situation itself but also on the individuals´ personality
(Miller, 1987). The model of coping modes, which is the groundwork for this dissertation,
will be described in detail in the following chapter.
1.7.1 Krohne´s Model of Coping Modes
To classify different types of coping, Krohne developed the “Model of Coping Modes".
Krohne (1993) suggests that individuals widely differ in their ability to tolerate either
uncertainty inherent in ambiguous situations or emotional arousal triggered by danger
cues. Krohne postulates a two-stage process of attention orientation. At first, the
threatening stimulus is identified, and subsequently, the attention is turned towards or
away from the threatening stimulus (Krohne, 1993). The “Model of Coping Modes” aims
to describe and explain differences in individual behavior regulation in stressful situations
on the two independent dimensions vigilance (VIG) and cognitive avoidance (CAV). The
first, vigilance is a person's focus on the threatening attributes of a stressor, the second
one cognitive avoidance relates to responses in which awareness is turned away from the
stressor (Krohne & Hock, 2011). The tendency to predominantly use vigilance or cognitive
avoidance is motivated by the characteristics of the individual and the situation (Krohne,
1993).
According to this theory, individuals who are more intolerant of uncertainty are prone to
vigilance as a strategy to cope with stress. Vigilant strategies comprise a multitude of
factors, for instance: the search for information, planning for the future, the anticipation of
adverse events, situation control, and control, among others. Due to their heightened
attention to potentially threat-related cues, vigilant individuals tend to interpret ambiguous
stimuli more likely as threatening (Hock et al., 1996). Hence, the aim of vigilant coping is
to minimize the probability of unexpected aversive events and to regain control over the
situation.
Conversely, individuals who are intolerant of emotional arousal triggered by danger cues
are hypothesized to be more prone to the use of cognitive avoidant strategies. In order to
decrease arousal in such situations, the individual may engage in attentional diversion,
self-enhancement, minimization, denial, or trust in positive outcomes, among others.
Thus, cognitive avoidant coping aims to shield the organism from aversive emotional
arousal. Of note, it has been shown that the habitual use of these coping strategies varies
between individuals and is stable over time (Derakshan et al., 2007; Egloff & Krohne,
1998; Hock & Krohne, 2004; Krohne, 1993; Krohne et al., 2000; Krohne & Hock, 2011).
Importantly, both vigilant and cognitive avoidant super-strategies are supposed to be
enacted independent of one another, thereby constituting orthogonal dimensions. That is,
individuals can engage in either vigilance or cognitive avoidance, in both vigilance and
cognitive avoidance within the same situation or use neither vigilance nor cognitive
avoidance to cope with stress. Hence, by contrasting both super-strategies (vigilance and
cognitive avoidance) in a coordinate system, four distinct coping modes were
distinguished: sensitization (high vigilance, low cognitive avoidance), repression (high
cognitive avoidance, low vigilance), non-defensiveness (low on both dimensions) and
high-anxiousness (high on both dimensions) (illustration in figure 2).
Figure 2: Model of coping modes Krohne (1989)
High intolerance of uncertainty characterizes sensitizers. To reduce the uncertainty, they
shift attention towards the stressor. Furthermore, they show an interpretation and memory
bias in favor of threat-related cues. This strategy might prolong emotional arousal (Hock
et al., 1996; Hock & Krohne, 2004). Sensitization aims to minimize the probability of
unexpected aversive events as well as to regain control.

People who mainly use cognitive avoidant coping and rarely vigilance are designated
repressers. They are hypothesized to recognize the ambiguity of stimuli instantly and to
show a retrieval bias towards a non-threatening interpretation. Concisely, ambiguous
stimuli end up as a non-threat memory (Hock et al., 1996). Repressers tend to show
diminished retrieval of emotional stimuli, especially for anxiety and threat-related cues
(Baumeister & Cairns, 1992; Cutler et al., 1996; Derakshan et al., 2007; Fajkowska et al.,
2011; Hock & Egloff, 1998; Hock & Krohne, 2004; Holtgraves & Hall, 1995; Mendolia et
al., 1996; Orbach & Mikulincer, 1996; Schimmack & Hartmann, 1997; Vendemia &
Rodriguez, 2010). Moreover, they show specific memory deficits for threat-related cues
as a strategy to reduce the experience of arousal and rumination. Correspondingly,
repressive copers have been found to exhibit reduced learning caused by retrieval deficits
and therefore are hesitant to flexibly change health behavior (Hock & Krohne, 2004). Of
note, on an organismic level, repressers have been found to show elevated physiological
stress reactivity while reporting little negative affect and anxiety, thus possibly putting them
at risk for bodily diseases (Schwerdtfeger & Kohlmann, 2004; Schwerdtfeger & Rathner,
2016). Accordingly, avoidant or repressive coping has also been associated with an
elevated risk for cancer and infectious diseases (Baltrusch et al., 1991; Mund & Mitte,
2012; Zozulya et al., 2008). The association with cancer might be a reaction to a life-
threatening stressor. In contrast, the association with infectious diseases might stem from
lower hygienic behavior due to the suppression of threatening information.
Individuals using both vigilant as well as cognitive avoidant coping strategies are termed
high-anxious. Their coping is assumed to shift between both these strategies, and they
are thought to be unable to tolerate both: heightened uncertainty and elevated arousal.
Their inconsistent use of coping strategies is likely maladaptive (Krohne, 1989, 1993).
Finally, people who use neither vigilant nor cognitive avoidant coping strategies are
labeled as non-defensive. They are supposed to show reduced arousal and uncertainty
when confronted with threat-related cues. Those individuals might use different strategies
like cognitive suppression, reappraisal, acceptance, problem-solving, or exhibit more
flexible, situation-specific coping than the other three groups (Egloff & Krohne, 1998;
Krohne, 1993; Krohne & Hock, 2011).
General associations between a broader definition of coping and the variables personality,
age, mental and physical health will be discussed within the next chapters to paint a full
picture of the current state of research.
1.7.2 Coping and Personality
Coping has also been defined as “personality in action under stress," indicating that
personality and coping are intertwined (Bolger, 1990). A meta-analysis focussing on the
relationship between coping and personality studied possible moderators (Connor-Smith
& Flachsbart, 2007). It was found that personality was weakly correlated to coping in the
sense of engagement or disengagement from the stressor. Neuroticism, extraversion, and
conscientiousness were each associated with different coping actions. For example,
extraversion and conscientiousness were positively related to problem-solving and
cognitive restructuring, while neuroticism was related to dysfunctional strategies such as
wishful thinking, withdrawal, and emotion-focused coping (Connor-Smith & Flachsbart,
2007).
Furthermore, the strength of the association between coping and personality seems to be
moderated by age, stressor severity, and the mode of coping assessment. Younger age
is associated with a stronger relationship between personality and coping. With increasing
stressor severity, the association increases, and dispositional coping assessment is
stronger related to personality measures (Carver & Connor-Smith, 2010). In line with that,
another study postulates that the association between coping and the five facets of
personality is strongest in neuroticism and conscientiousness. While neuroticism is
characterized by the use of passive and ineffective coping mechanisms,
conscientiousness is related to active more problem-focused coping actions (Watson &
Hubbard, 1996). The relationship between coping actions and extraversion is less clear
but points toward the direction that extraverted individuals use coping actions like seeking
social support, positive reappraisal, and problem-focused coping. Openness and
agreeableness are not consistently related to coping (Watson & Hubbard, 1996).
1.7.3 Coping and Age
As mentioned above, the relationship between coping and age appears to be stronger in
younger individuals (Carver & Connor-Smith, 2010). In childhood and adolescence,
adaptive forms of coping are associated with lower levels of psychopathology (e.g.,
internalizing and externalizing psychopathology) and maladaptive coping strategies such
as suppression, avoidance, and denial to higher levels of psychopathology (Compas et
al., 2017). Furthermore, Diehl and colleagues (1996) state that younger individuals are
more characterized by a weak impulse control as well as lower self-awareness resulting
in the use of more outwardly aggressive and undifferentiated coping actions. Older adults,
on the other hand, are characterized by a greater impulse control and the tendency to
approach stressful situations positively. In line with that, research shows that problem-
focused coping increases with age, while emotion-focused coping is not related to age
(Trouillet et al., 2011), thus indicating a stronger form of cognitive impulse control and self-
awareness. In concordance with this, McCrae (1982) found that middle-aged and older
individuals are characterized by less frequent use of internal emotion-focused
maladaptive coping strategies such as hostility and escape fantasies regardless of the
type of stress. This less frequent use of escape strategies was also found by Aldwin (1991)
in a sample of community-residing middle-aged adults. Moreover, he found no other
differences between younger and older individuals. He explains this finding with the
assumption that not the coping ability is changing over the lifespan but rather the types of
stressors (Aldwin et al., 1996). Folkman and colleagues (1987) state that although there
are age-related differences in daily stressor and coping efforts, the primary source for
different use of coping strategies is rooted in development.
1.7.4 Coping and Mental Health
There is a relationship between coping and mental health. Especially in children and
youth, a meta-analysis showed that maladaptive forms of coping are related to both
internalizing and externalizing psychopathology (Compas et al., 2017). The same was
found in young adults, while adaptive coping strategies such as searching for social
support, problem-solving, and help-seeking contribute to better mental health,
maladaptive coping strategies like blame, wishful thinking, and withdrawal are associated
with psychopathology (Wang et al., 2018). These independent contributions of adaptive
and maladaptive forms of coping to mental health outcomes were also found in a study
on the association between coping and depression. In healthy and depressed adults,
maladaptive coping was only associated with depressive symptoms when there were low
levels of adaptive coping present (Thompson et al., 2010). Moreover, in adults coping
moderated the relationship between occupational stress and mental health outcomes in
nurses (Mark & Smith, 2012). When looking at the association between burnout and
coping, it was found that problem-focused coping is negatively correlated to burnout
severity and emotion-focused coping positively (Shin et al., 2014).
The psychological mechanisms between coping and mental disease are still unclear. It
might be that the altered memory of repressers results in adverse health outcomes
through an inability to learn from a negative experience. Furthermore, defense
mechanisms like suppression, which is present in repressers, might prevent health-related
behavior such as visiting the psychotherapist, practicing mental first aid, and so forth
(Ollonen et al., 2005). The reduced memory retrieval of repressers was explained
differently by diverse research groups (Baumeister & Cairns, 1992; Cutler et al., 1996;
Derakshan et al., 2007; Fajkowska et al., 2011; Hock & Egloff, 1998; Holtgraves & Hall,
1995; Krohne & Hock, 2008; Mendolia et al., 1996; Orbach & Mikulincer, 1996;
Schimmack & Hartmann, 1997; Vendemia & Rodriguez, 2010). There are four main
theories to describe that phenomenon: Firstly, the superficial encoding hypothesis by
Davis (1990) states that repressers’ poor emotional memory is caused by reduced
emotional processing. Secondly, the frequency hypothesis by Schimmack and Hartmann
(1997) proposes that repressers have difficulties to feel the emotional response and,
therefore, do not establish associations between affect and event representations. Thirdly,
the emotional discreetness hypothesis by Hansen and Hansen (1988) suggests that
repressers encode anxiety-related cues into less complex cognitive-emotional structures.
Therefore, the links between representations of threatening events and insignificant
emotions are weak. Those representations are difficult to access due to their isolation.
Fourthly the repressive discontinuity hypothesis by Hock and colleagues (1996) is

characterized by a consecutive sequence of stress-related information processing.
Initially, repressers react unconsciously highly sensitive to threat-related cues, which is
followed by counteraction of suppression. Those inhibitory processes may lead to a poor
memory of threat.
1.7.5 Coping and Physical Health
The relation between coping and health is not only present for mental disorders. The use
of positive coping is intertwined with perceived psychological and physical health (Chraif
& Anitei, 2012). Concerning physical diseases, repressers are of peculiar interest. As
mentioned in the previous section, repressers tend to show a memory bias in the way that
they have a diminished ability to recollect adverse events (Baumeister & Cairns, 1992;
Cutler et al., 1996; Derakshan et al., 2007; Fajkowska et al., 2011; Hock & Egloff, 1998;
Hock & Krohne, 2004; Holtgraves & Hall, 1995; Mendolia et al., 1996; Orbach
& Mikulincer, 1996; Schimmack & Hartmann, 1997; Vendemia & Rodriguez, 2010). Myers
and Brewin (1996) could show that repressive individuals rate themselves as less likely to
experience adverse events and that they rated negative words less descriptive of
themselves.
Thus, they conclude that repressers create an illusion of well-being. This illusion of
prosperity might lead to impaired health and prevention behavior resulting in a higher rate
of morbidity and mortality (Myers, 2010).
Furthermore, a meta-analysis of the relation between repressive coping and somatic
diseases concludes that individuals with a repressive coping style have a 31% higher risk
to suffer from a physical illness (Mund & Mitte, 2012). In specific, the risk of suffering from
cancer is increased by 51% and hypertension by 80% in repressers. Of note, the authors
state that the included studies cannot be interpreted causal. So far, only two studies
assessed coping styles before the cancer diagnosis, and both conclude that repressive
coping is instead a consequence rather than a cause of a cancer diagnosis (Kreitler et al.,
1993; Zachariae et al., 2004). When children suffering either from a severe but non-
malignant disease or cancer were compared to healthy children, the same pattern was
found. Children with a chronic disease showed higher levels of repression for one year,
thus indicating that repression is instead a consequence and less a cause of a severe
diagnosis (Phipps et al., 2001).
In individuals suffering from chronic physical disease, coping is the strongest predictor for
psychological distress. Primarily avoidant coping was found to increase illness-related
mental distress (Dempster et al., 2015). The associations between coping strategies and
health outcomes for individuals who have HIV yield similar results. While active forms of
coping such as direct action and reappraisal have been associated with better health
outcomes, avoidant coping strategies like behavioral disengagement or substance abuse
were associated with poorer health outcomes (Moskowitz et al., 2009).
1.8 Focus on Repressive Coping and its Association with Cardiovascular Health
To date, there is only one meta-analysis focusing on the relationship between repressive
coping and somatic diseases. The meta-analysis included 22 studies (n = 6775) and found
an increased risk for repressive copers for cancer, coronary heart disease, and
hypertension. The association between repressive coping and hypertension is medium to
high. Mund and Mitte (2012) conclude that repressive coping might be a consequence of
a cancer diagnosis. Furthermore, they point out that repressive coping plays a vital role in
the development of hypertension, possibly leading to cardiovascular diseases (CVD) in
the long term (Mund & Mitte, 2012).
One large-scale prospective study on Japanese individuals found a negative correlation
between comorbid use of approach-oriented coping strategies with overall cardiovascular
disease-related mortality and stroke incidence (Svensson et al., 2016). A positive
relationship was found between the premorbid use of avoidant coping strategies, like
repression, and mortality from ischaemic heart disease only in hypertensive individuals,
thus indicating that the resulting increased mortality likely reflects an interplay between
psychological and physiological variables. This finding is in line with theories, suggesting
that repressive coping might not be adverse to mental health in general, but when
combined with the frequent experience of stressful events that lead to CVD in the long run
(Treiber et al., 2003). The vigilance avoidance theory states that repressive coping is a
two-stepped process with early vigilance accompanied by elevated cardiovascular
reactivity (CVR) and subsequent suppression of the arousal (Derakshan et al., 2007).
Repressive copers could, therefore, not be able to avoid stressful situations as they
suppress their response leading to a reduced ability to learn other ways of coping or to
prevent specific stressful situations.
When looking into the metabolic and immune function of repressive copers, it was found
that repressers showed changes in immune parameters (e.g., lower t-helper cells, higher
natural killer cells) as well as altered blood lipid parameters (e.g., lower high-density
lipoproteins, higher cholesterol ratio, and higher fasting insulin levels) when compared to
non-repressers. Moreover, under acute stress, repressers manifested an attenuated
increase in circulating natural killer cells. All these findings were unrelated to cofounding
variables like age, physical activity, and such (Barger et al., 2000). Another study on blood
lipids and repression showed that male repressers had elevated cholesterol levels (Niaura
et al., 1992). Taken together, these findings indicate that there might be biological baseline
differences between repressers and non-repressers, which appear to be accelerated
under acute stress. Especially repressive men might be at higher risk for atherosclerotic
diseases (Niaura et al., 1992).
1.9 Cardiovascular Variables in Stress and Coping Research
There is a belief in psychological research about psychophysiology and health, that the
stronger the response to a laboratory stressor, the higher the risk for the development of
cardiovascular diseases (Lovallo, 2005; Treiber et al., 2003). Meta-analytic evidence from
prospective studies points to moderating and confounding variables for this association
such as 1.) duration of follow-up measures (more extended follow-ups lead to more
consistent associations), 2.) age (the association is more robust in younger individuals),
3.) exposure to psychological stress (the relation is more robust in individuals that
experience stress more frequently), 4.) methods of measurement of CVR (e.g., blood
pressure, heart rate, etc.), and 5.) baseline level of disease risk (elevated in individuals
that have a pre-existing medical condition) (Treiber et al., 2003).
So far, most research on CVR focused on high reactivity, but current studies imply that
also reduced CVR might be detrimental to health (Lovallo, 2011; Lovallo et al., 2012).
Therefore, healthy CVR might be in the medium range. Lovallo (2005) introduces a three
leveled model of the central nervous system control over peripheral response systems.
These three sources of elevated CVR might vary between individuals. The top-level
includes the limbic system and prefrontal cortex. These regions form a psychological
stress response. They translate experiential and affective cues into bodily responses. The
middle level consists of the hypothalamus and the brain stem, which function as
translators in descending signals into physical outputs. The base-level consists of
peripheral tissues that build the response itself. To assess all sources of elevated CVR,
Lovallo (2005) proposed that studies should include physical and psychological stressors
and physiological and self-reported (psychological) outcomes as well. Therefore, groups
with different risks for cardiovascular outcomes could be figured out. Thus, the next
chapter introduces ways to assess the amount of stress and individual experiences as
well as methods for evaluating habitual coping modes.
1.10 The Assessment of Stress and Coping
There are several ways to assess stress and coping, including 1.) self-report 2.)
observation, and 3.) biomarkers. To date, self-report is the most common method to
determine stress levels or coping efforts (Kivimäki & Steptoe, 2018). Self-report
measurements are prone to several sources of bias including the poor capacity of
individuals to objectively assess their current stress and (emotional) states, individuals are
subject to recall biases, and show a tendency to answer in a socially desirable way
(Paulhus, 2017; Sariyska et al., 2018; Stone & Shiffman, 2002; Yannakakis et al., 2018).
Therefore, other ways to assess coping will later be discussed in this chapter.
Examples for widely used self-reported stress assessment are the Perceived Stress Scale
(PSS (Cohen et al., 1983)), the Depression Anxiety Stress Scales (DASS (Lovibond &
Lovibond, 1995)), the Perceived Stress Questionnaire (PSQ (Levenstein et al., 1993));
the Dundee Stress State Questionnaire (DSSQ (Matthews et al., 1999; Matthews et al.,
2002)), and the Everyday Stressors Index (EDI (Hall, 1990)). Furthermore, numerous self-
report stress assessments are focussing on specific target groups like children and
adolescents (Adolescent Stress Questionnaire; ASQ (Byrne et al., 2007)), and specific
stressors such as parental stress (PSS (Berry & Jones, 1995)).
An overview of self-reported coping assessments is reported in Schwarzer and
Schwarzers' book chapter (1996). The most widely used coping inventories are the
Repression-Sensitization Scale (RSS (Byrne, 1961)), the Mainz Coping Inventory (MCI
(Krohne et al., 2000)), the Miller Behavioral Style Scale (MBSS (Miller, 1987)), the Ways
of Coping Questionnaire (WOC (Folkman & Lazarus, 1988)), the Coping Strategy
Indicator (CSI (Amirkhan, 1990)), the Life Events and Coping Inventory (LECI (Dise-
Lewis, 1988)), the Coping Inventory for Stressful Situations (CISS (Endler & Parker,
1990)), the COPE-Scale (SC (Carver et al., 1989)) and for adolescents the Adolescent
Coping Orientation for Problem Experiences Inventory (A-COPE (Patterson & McCubbin,
1987)). Furthermore, the three ways of stress and coping assessment will be discussed
in detail to introduce into the currently used methods and prepare for the suggestions to
collect data in the future, as discussed in chapter 7.5.
Self-reports can be obtained either at one or more defined time points, for example,
through the questionnaires, as mentioned earlier. Questionnaires can assess stress and
coping as a trait or state. A trait is a personality characteristic of an individual, consistent
over time, which is partly moderated by a given situation (Fleeson & Jayawickreme, 2015).
1.) Stress and coping can also be assessed in a situation of interest (e.g., a laboratory
stress task) in the sense of a state. The assumption behind a state assessment is
that there is also variance within a person concerning the level of stress or coping
in a given situation. State assessments are usually obtained several times. Lately,
multiple self-report measurements gained popularity. These multiple self-report
measures are called ecological momentary assessment (EMA) or ambulatory
assessment (AA) (Beltrán-Velasco et al., 2018; Conner & Mehl, 2015). There are
basically two reasons: On the one hand, self-reports show higher correlations with
biological markers, and on the other hand, there is technological progress. For
example, self-reported stress measured at the end of the day is associated with
long-term health and well-being. Of note, daily measurements might not capture
negative affective responses to a given stressor adequately, as negative affect is
best assessed in the stressful situation (Koffer et al., 2016).
EMA and AA studies aim to increase ecological validity, try to avoid memory biases,
increase sensitivity to measure temporal dynamics, and to capture within- and
between-person patterns over time. Such studies cannot only assess self-reported
data, but they can also provide observational and physiological data via sensors
(e.g., accelerometer, GPS, heart rate, smartphone usage, online social activity,
etc.).
2.) The collection of observational data is the second way to assess stress and coping.
Observation is believed to be less biased than self-report but has been proven not
to be objective either (Jorgensen, 2015). Nowadays, there is a variety of
possibilities to track an individual's behavior, and methods of handling such big
data are developing rapidly (Miller, 2012). Primarily, smartphones are used to
collect data about location, movement patterns, voice, surrounding sounds, and
closeness to other smartphones as a measure of social activity (Mehrotra et al.,
2014; Mehrotra & Musolesi, 2017). Smartphone usage and smartphones sensor
data have been associated with mental states, disease, and well-being (Alvarez-
Lozano et al., 2014; Canzian & Musolesi, 2015; LiKamWa et al., 2013; Mehrotra et
al., 2014; Messner et al., 2019; Saeb et al., 2015; Servia-Rodríguez et al., 2017;
Suhara et al., 2017). These direct and indirect data assessment possibilities are
used to estimate person characteristics and environmental conditions (Servia-
Rodríguez et al., 2017). To handle such large data, (deep) machine learning
approaches have emerged. They provide data-driven insights into human behavior,
leading to new hypotheses about the development, maintenance, and cure of
disease. These new hypotheses can subsequently be tested in experimental
studies.
3.) Conventional biomarkers to assess stress and coping are heart rate (HR), heart
rate variability (HRV), blood pressure (BP), cortisol, and proinflammatory markers.
They can be used to assess both acute stress responses (e.g., cortisol levels in
saliva, blood pressure) and chronic stress levels (e.g., hair cortisol) (Kivimäki
& Steptoe, 2018). Such markers are now non-invasively accessible through
wearable electrochemical and biosensor devices.
In a nutshell, studies assessing stress and coping so far used self-report in the form of
questionnaires and multiple self-reports assessed in the field. Both types of self-report can
measure stress and coping with stress in general (trait-like) or in a given situation of
interest (state-like). Moreover, stress and coping with stress can be captured trough
observation and biomarkers such as HR, HRV, BP, Cortisol, and proinflammatory
markers. Through technological advances, possibilities for the collection of observational
and biological data have evolved rapidly within the last decade. Therefore, possible
developments in the near future will be discussed in chapter 7.5.

1.10.1 The Autonomic-Subjective Response Dissociation
Interestingly, there is often a discrepancy between self-reported levels of stress and
coping and biological markers (Conner & Mehl, 2015). When looking at coping, the so-
called autonomic-subjective response dissociation (ASRD) (earlier called verbal-
autonomic response dissociation; VARD) has been extensively studied. In repressers,
self-reported stress and anxiety levels appear to be contrary to physiological
measurements (e.g., heart rate, skin conductance, etc.) (Schwerdtfeger & Kohlmann,
2004). Repressers have been found to exhibit elevated autonomous stress reactions while
reporting diminished negative affect (see Asendorpf & Scherer, 1983; Barger et al., 1997;
Brosschot & Janssen, 1998; Derakshan & Eysenck, 2001; Gudjonsson, 1981; Kohlmann
et al., 1996; Krohne & Fuchs, 1991; Newton & Contrada, 1992; Rohrmann et al., 2003;
Weinberger et al., 1979; Weinstein et al., 1968). The ASRD/VARD is a timely stable, and
cross-situational personality characteristic (Schwerdtfeger et al., 2006b), which could be
assessed continuously during stressful situations (Brosschot & Janssen, 1998). As
outlined lately, the VARD has been renamed to ASRD, thus putting more emphasis on
the autonomic-subjective dissociation (Schwerdtfeger & Rathner, 2016). The ASRD is not
only accessible in laboratory situations; the discrepancy between self-reported negative
affect and autonomic response can also be observed in daily life. This trans-situational
stability is of interest because most stressors in everyday life are moderate to mild and
still evoke similar coping mechanisms (Schwerdtfeger & Rathner, 2016).
The ASRD is amplified in public social-evaluative situations in repressers (Newton
& Contrada, 1992). Repressive women exhibited higher ASRD in a public speech
condition than in a private speech condition. Contrary, high-anxious women showed
elevated ASRD in a way that their self-reported stress exceeded their autonomous stress
reaction (Newton & Contrada, 1992). Bonanno and colleagues (1999) studied how ASRD
affected grief and health outcomes after the loss of a close person. Surprisingly, they
found that reduced experience of self-reported negative emotion when coupled with high
levels of autonomic responsivity was associated with a mild grief course after 6, 14, and
25 months.
Moreover, there was no effect of ASRD on short, middle, or long-term health outcomes
(Bonanno et al., 1999). It is thus showing that repressive coping might be helpful in
uncontrollable situations. These findings are in line with the results of the efficacy of
repressive coping in dealing with a chronic or life-threatening disease (Kreitler et al., 1993;
Phipps et al., 2001; Zachariae et al., 2004). Coifman and colleagues (2007) confirmed
these findings. They found that ASRD is beneficial in dealing with extremely adverse, non-
controllable life situations. They argue that ASRD is a mainly automatic process of
emotion regulation that is outside of conscious awareness. Thus, the contradictory
findings of the association between ASRD/ repressive coping and health might be
explained by the level of consciousness involved in the process. While automated emotion
regulation might be adaptive, conscious, and active emotion suppression might be
maladaptive (Coifman et al., 2007).
Furthermore, there is not only a discrepancy between self-report and autonomous
reactions to stressors but also a difference between the assessment of stress and coping
in the field and under controlled conditions in the lab. The next chapter will introduce the
association between laboratory and field studies.

1.10.2 The Association of Laboratory and Field Studies
To date, there is disagreement on the external validity of research conducted in
psychological laboratories. One large-scale meta-analysis summarising 82 prior meta-
analyses on the association of laboratory and field studies concludes that external validity
depends on the psychological subfield, research topic, and effect sizes (Mitchell, 2012).
Therefore, this chapter will focus on research associating field and lab assessments of
coping and stress, in particular, CVR.
Most studies on CVR have been conducted in the laboratory (Zanstra & Johnston, 2011).
While there are advantages of laboratory stress studies such as a controlled environment,
practicality and the possibility to imply a standardized stressor, there are several severe
limitations of laboratory stress studies including 1.) Ethical constraints on the intensity of
stress induction (e.g., prolonged harm to the participant must be avoided); 2.) Ethical
considerations about the nature of the stressor (e.g., mainly cognitive and social-
evaluative stressors); and 3.) Ethical limitations on the duration of the stress induction.
These limitations reduce the generalizability of findings from laboratory stress studies to
the field.
Furthermore, it is likely that CVR in a laboratory setting differs from everyday CVR
regarding size, duration, and underlying mechanisms (Zanstra & Johnston, 2011). CVR
measured in real life is often more extensive than that captured in the laboratory setting.
This might stem from differences in the subjective relevance of the stressor to the
individual. Real-life stressors are relevant to people while coping with laboratory stressors
could involve strategies such as altering the perceived impact of the event. Nevertheless,
it is assumed that the underlying mechanisms are similar between situations. Zanstra and
Johnston (2011) found that averaging CVR over multiple stressors leads to a better
correlation between laboratory and real-life cardiovascular responses to stressful
situations.
A study by Johnston and colleagues (2008) tested whether the CVR to five laboratory
stress-inducing tasks is related to heart rate reactivity captured in the field. They found no
consistent relationship between laboratory and real-life heart rate reactivity in general, but
a better association under stressful conditions in real life. Therefore, they conclude that
elevated heart rate reactivity in real life may be a risk factor for the development of
cardiovascular disease if an individual experiences stressful events regularly. The
research presented points towards the limited generalizability of CVR induced through a
standardized laboratory stress task into everyday CVR (Schwerdtfeger et al., 2014). Only
baseline laboratory heart rate predicted ambulatory heart rate, whereas heart rate
reactivity was not associated. To conclude, further studies are necessary to understand
the biological and behavioral factors that contribute to the different CVR in the laboratory
and field setting (Kamarck et al., 2003).

2 Research Questions
Taken together, stress and coping are complex, semi-conscious psychophysiological
phenomena that occur regularly in a human’s lifespan. So far, there is neither agreement
on the definition of both terms, nor on the best way to assess stress or coping. Moreover,
there is little knowledge about the long-term effects of stress exposure and coping with
stress on health, especially CVD. Therefore, further research is needed to address these
gaps in scientific knowledge. This accumulative dissertation studied how the reaction to
standardized laboratory stressors and daily life stressors are affecting well-being and
physical health and how to assess them validly in the field with the following research
questions:
The first study addresses the association between self-reported and behavioral measures
of stress, thrive, and mood assessed via a smartphone. The smartphone offers unique
possibilities to track an individual's behavior and well-being in the field. Moreover, it might
be possible to passively collect data leading to good long-term adherence while reducing
intrusion. Therefore, the research question is:
1.) Can smartphones be used to assess stress and other parameters of mood in the
field passively?
With the second study, the question of how physiological stress response can be captured
in the laboratory and field setting was addressed as there is an ongoing debate about the
generalizibility of laboratory studies on the daily life. It was tested whether there is an
association between CVR assessed in the laboratory and the field.
2.) Does cardiac reactivity in the laboratory predict heart rate in daily life?
In line with the idea of addressing the gap between laboratory and daily life research, it
was tested whether the autonomic-subjective response dissociation can be found in the
field. Therefore, the third research question is:
3.) Can the autonomic-subjective response dissociation in repressive coping be
assessed ecologically and valid in the field?
To shed further light on the association between repressive coping and cardiovascular
disease and coping, it was tested whether middle-aged individuals show physiological
alterations (intima-media thikness) depending on their dominant coping style with the
following final research question:
4.) Is cognitive-avoidant coping associated with cardiovascular changes?

3 Study 1: Insights- Future implications of passive

smartphone sensing in the therapeutic context
Title: Insights- Future implications of passive
smartphone sensing in the therapeutic context
Brief title: Insights- Passive smartphone sensing in
psychotherapy
Eva-Maria Messner1*, Rayna Sariyska2, Benjamin Mayer3, Christian Montag2, Christopher
Kannen4, Andreas Schwerdtfeger5 und Harald Baumeister1
1 Ulm University, Clinical Psychology and Psychotherapy, Institute of Psychology and Education, Ulm,
Germany;
2 Ulm University, Molecular Psychology, Institute of Psychology and Education, Ulm, Germany;
3 Ulm University, Institute of Epidemiology and Medical Biometry, Ulm, Germany;
4 ckannen Software Development, Cologne, Germany;
5 Karl- Franzens University Graz, Health Psychology, Institute of Psychology, Graz, Austria.
* Corresponding Author:
Eva-Maria Messner
Ulm University
Clinical Psychology and Psychotherapy
Albert Einstein Allee 47
89081 Ulm
Germany
eva-maria.messner@uni-ulm.de
Abstract
Background: Due to the ubiquitous use of smartphones in daily life, they offer unique
opportunities to study human behavior. This study sheds light on associations between
self-reported stress, drive, and mood levels and smartphone usage behavior.
Methods: A total of 157 students installed the Insights app on their personal smartphone
and tracked smartphone usage behavior. Furthermore, students assessed self-reported
levels of stress, drive, and mood for 8 weeks.
Results: Three multilevel models were used to associate smartphone usage behavior
and self-reported mood, drive, and stress levels. Results indicate a negative association
of self-reported stress and number of SMS (–3.539, SE = 0.937) as well as a positive
relation of stress and call duration (0.018, SE = 0.937). Mood was linked negatively with
total usage time (–0.019, SE = 0.004) and call duration (–0.016, SE = 0.007). Moreover,
drive was negatively associated with Facebook usage time (–0.127, SE = 0.041).
Discussion: Overall smartphone usage behavior is negatively associated with
measurements of well-being.
Conclusions: Passive smartphone tracking could assist in the standardized assessment
of behavioral data in real life in the future. Due to the risk of data misuse, ethical, legal,
and clinical guidelines have to be developed.
Key words: thrive; mood; smartphone-tracking; psychotherapy; stress.

Theoretical Background
Digital interventions lead to behavior changes in individuals as well as societal
adjustments [Montag and Diefenbach, 2018]. For the first time in history, it is economically
possible to collect and analyze longitudinal data on a big scale [Montag et al., 2016, 2019].
The rise of technology is increasingly affecting mental health care through technology-
assisted diagnostic, prevention, treatment, and big data-based guidance in treatment
decisions [Ebert et al., 2017, 2018; Rathner and Probst, 2018].
The majority of the collected data is sensitive in nature (e.g., biographical data, GPS
location, social contacts, activity patterns, etc.) and requires a high standard of data
protection and further ethical consideration regarding patient safety [Harari et al., 2016;
Rubeis and Steger, 2019]. If these requirements are met, the collection and analysis of
big data on specific mental conditions could enhance diagnostic possibilities in the future
[Onnela and Rauch, 2016; Ben-Zeev et al., 2015]. This form of direct unobtrusive behavior
observation (e.g., movement patterns, number of social interactions, etc.) could provide
deeper insight into the development and preservation of mental disease. Moreover, data-
driven knowledge could in turn enhance established psychotherapeutic processes (e.g.,
passive monitoring of therapeutic processes) and lead to the development of novel
internet- and mobile-based interventions [Baumeister et al., 2018; Domhardt et al., 2018].
The distribution of tailored interventions could furthermore reduce health care costs
through shortened referral and decreased treatment duration [Insel, 2017; Markowetz et
al., 2014; Mohr et al., 2017; Onnela and Rauch, 2016; Raballo, 2018; Rathner et al.,
2018a, 2018b; Torous et al., 2017].

The smartphone is one possibility to collect behavioral data in everyday life [Alvarez-
Lozano et al., 2014; Canzian and Musolesi, 2015; LiKamWa et al., 2013; Mehrotra et al.,
2014; Saeb et al., 2015; Suhara et al., 2017]. Currently, around 36% of individuals all over
the world and 81% of Germans own at least one smartphone, which is used by youths
and young adults for an average of 162 min a day [Montag et al., 2015].
The analysis of smartphone usage like daily usage time, size of the social network,
number of daily short messages and texts, number and duration of calls, or application
use is not only providing insights into an individual’s online life but also into their routine
behavior [Harari et al., 2016, 2017; Servia-Rodríguez et al., 2017a].
In addition to the smartphone usage, smartphone sensors can be used to observe
everyday behavior [Miller, 2012]. By using smartphone sensors (e.g., GPS, microphone,
accelerometer, camera, light sensors, Bluetooth, etc.) the assessment and analysis of
position, movement patterns, voice, environmental sounds, and distance to other
smartphones is attainable [Cummins et al., 2013, 2017; Mehrotra et al., 2014; Mehrotra
and Musolesi, 2017; Stasak et al., 2016]. This allows inferring to environmental conditions
(such as noise, surrounding, etc.), characteristics of the person itself (e.g., well-being,
mood, etc.), or an individual’s behavior (e.g., movement, social interaction, etc.) [Harari et
al., 2017; Saeb et al., 2015; Servia-Rodríguez et al., 2017a].
To date, mainly self-reports (e.g., questionnaires) have been used to assess such
characteristics. Passive sensing of behavior offers unique advantages when compared to
self-report. First, individuals have a limited capability of insight and are rather poor at
objectively assessing their own mood [Sariyska et al., 2018]. Secondly, humans are prone
to recall biases [Montag et al., 2015; Stone and Shiffman, 2002]. Thirdly, a tendency to
socially desired answer behavior is present [Paulhus, 2017]. Fourthly, adherence to

repetitive data input is low and diminishing with progressing time [Donkin and Glozier,
2012; Markowetz et al., 2014].
One app that combines the advantages of mobile assessment and passive sensing is the
Insights app [Montag et al., 2019; Sariyska et al., 2018]. Prior studies using the Insights
app showed a correlation of the size of the social network with genetic polymorphisms
that are related to attachment [Sariyska et al., 2018] and the usefulness of the Insights
app to assess personality traits [Montag et al., 2019]. A detailed description of possible
applications of the Insights app can be found in the article by Montag and colleagues
[2019].
The use of passive sensing in the health care sector could lead to reduced burden in
health care providers and patients. Passive sensing software could assist in (a) early
detection of disease, (b) diagnostics, (c) evaluation of treatment course, (d) evaluation of
treatment outcome, (e) giving feedback on a patient’s behavior, (f) delivering tailored
interventions, and finally, developing new internet-, mobile-, or face-to-face-based
therapeutic interventions.
As a first step to achieve these far-reaching visions, proof-of-concept studies are needed
which test whether mental well-being or disease is linked to variables that can be tracked
via smartphone. This feasibility study provides first insights into the use of smartphone
usage behavior to predict mental states such as self-reported mood, drive, and stress.
These variables mirror core symptoms of affective disorders [Kessler et al., 2003].
Currently between 9.3 and 23% of the population worldwide are affected by depression
[Moussavi et al., 2007]. Thereby, depression is the most common mental disease [Kessler
et al., 2003; Richards, 2011; Richards and Salamanca-Sanabria, 2014]. Major depression
is characterized by diminished affect and drive over a period exceeding 2 weeks.

Furthermore, changes in appetite, sleep, concentration, psychomotor speed, and
exhaustion are symptoms associated with depression [ICD-10; WHO, 2001]. Besides
depression, a variety of mental diseases are defined by the trans-diagnostic variables
mood, drive, and stress.
Moreover, there is an association of self-reported stress and the development of physical
and mental disease [de Boer et al., 2017; Cohen et al., 2007; Mund and Mitte, 2012;
Slavich, 2016; van Praag, 2004; Wang, 2005]. Thus, the assessment of self-reported
stress as a general risk factor for the development of disease is expedient, especially
when self-reported stress is elevated over an extended period of time [de Boer et al.,
2017]. Vice versa, individuals affected by mental disease report higher levels of stress
when compared to healthy individuals, pointing towards a bidirectional association
[Kampling et al., 2014; Milczarek et al., 2009].
Previous studies differ in their findings [Alvarez-Lozano et al., 2014; Canzian and
Musolesi, 2015; Elhai et al., 2017; Ferdous et al., 2015; Rozgonjuk et al., 2018; Saeb et
al., 2015; Seabrook et al., 2016; Servia-Rodríguez et al., 2017; Suhara et al., 2017].
According to Saeb and colleagues [2015], an association between depression severity
and smartphone usage behavior was found. Other research groups could not find any
associations between daily usage time and depression [Elhai et al., 2017; Rozgonjuk et
al., 2018].
The largest study using smartphone tracking to predict mood in daily life was conducted
by Servia-Rodriguez and colleagues [2017]. They used smartphone sensors (such as
accelerometer, microphone, and location) as well as smartphone usage data (number of
text messages and calls) and collected self-reported mood twice a day between 8 a.m.
and 10 p.m. To assess self-reported mood, the core affect model by Russell [1999; 2003],
which quantifies mood on the subscales valence and arousal, was used. The self-reported
valence and arousal scores could be predicted through the models with an accuracy of
64 and 60%. In a rather limited subset of the original data (1,600 participants), it was
shown that the percentage of significant correlation was higher when using smartphone
sensor variables compared to smartphone usage variables. A major limitation is the high
amount of missing values in this study and the so far insufficient prediction models.
Another comparably small study (n = 18) provides first insights into a relationship between
daily usage time as well as the usage of social applications (e.g., Facebook, WhatsApp)
and negative mood [Alvarez-Lozano et al., 2014].
In this study, the following three research questions are addressed: Is it possible to predict
self-reported mood (model 1), self-reported drive (model 2), and self-reported stress
(model 3) via smartphone usage variables?

Method
Participants
Participants were recruited via the online platform SONA of the Ulm University as well as
via flyers and posters. Data were obtained in two waves from April to September 2017
and November 2017 to February 2018 at Ulm University. The local ethics committee
approved the study. From a total of 253 participants, 157 (62.1%) were included in the
study. People were excluded for the following reasons: technical failure (n = 85; 33.5%)
or noncompliance with the study protocol (n = 11; 4.3%). Technical failures were for
example a server breakdown, insufficient battery status of the smartphone, or
compatibility problems of specific smartphones with the Insights app. The Insights app is
continuously refined and the occurrence of malfunction was less prone in the second wave
of data collection. Noncompliance with the study protocol was defined as missing data
above 25% [Enders, 2003].
Inclusion criteria were age above 18, ownership of a private smartphone running on
Android ≥4.1 Jelly Bean, and agreement with informed consent. The sample consisted
mainly of young (mean = 22.4; SD = 6.1) females (n = 115; 72.3%) with higher education
(n = 113; 85.5%). Details can be obtained from Table 1.
Study Design
At first, the Insights app was installed on the participants’ private smartphone. A detailed
description of the Insights app and its applicability can be found in the article by Montag
and colleagues [2019]. Subsequently, demographic variables and personality
characteristics were obtained. Results regarding these variables have been published
elsewhere [Sariyska et al., 2018]. During the following 8 weeks, participants were asked
to report their mood, drive, and stress three times a day. Due to the extensive study
duration, a sample rate of three times a day was deemed sufficient. The largest
comparable study in the field only obtained mood twice a day [Servia-Rodríguez et al.,
2017a]. In addition to these self-reports, the Insights app collected smartphone usage data
passively. After completion of the 8 weeks, participants were either reimbursed with EUR
10 or 5.5 credits in the SONA system. Finally, the Insights app was uninstalled.
Variables
Smartphone Usage Behavior
The Insights app recorded smartphone usage behavior as anonymized data tuples and
automatically generated participant codes. The raw data was encrypted via a SHA-2
algorithm (version SHA-512) by the National Institute of Standards and Technology and
transferred to an encrypted server of Ulm University. For the current study, the total daily
smartphone usage time, the total time of incoming and outgoing calls per day in minutes,
the daily total number of sent and received text messages (SMS), and the usage of the
Facebook app were extracted from the database. A detailed description of the variable
characteristics can be obtained from Table 2.
Mood, Drive, Stress
The self-reported mood was assessed via the question “How are you feeling right now?”
on a visual analogue scale ranging from 0 to 100 with the endpoints “very bad” and “very
good.” The default mode of the cursor was set at 50. All three variables were collected
three times a day (8 a.m., 12 a.m., 8 p.m.). Correspondingly, drive was captured via the
question “How active do you feel right now?” with an endpoint caption of “very passive” to
“very aroused.” Those two items were developed to assess the core affect according to
Russel [2003] as well as Russell and Barrett [1999], which consists of the dimensions
valence (mood) and arousal (drive). The item to assess self-reported stress was as
follows: “How stressed do you feel right now?” with the endpoints “extremely relaxed” to
“extremely stressed”. For the association of self-reported mood, stress, and drive, these
values have been averaged on a daily basis. A correlation matrix of the variables at
baseline is depicted in Table 3.
Statistical Analysis
To account for the nested structure of the data, we used multivariate multilevel models
(MLM) [Goldstein, 2008; Laurenceau and Bolger, 2012; MacCallum et al., 1997; Nezlek,
2012]. MLM take into account that answers are nested within persons and the resulting
dependence between variables [Nezlek, 2001; Nezlek et al., 2006]. In this study, the
repeated measurements (level 1) are nested within a person (level 2).
To test the association between smartphone usage behavior and mood (model 1), drive
(model 2), and stress (model 3), three MLM with a random intercept and a random slope
were modelled. Therefore, the random intercept mirrors the variance between individuals.
Mood, drive, and stress were predicted via smartphone usage variables (total usage time,
total calls, total texts, and total Facebook app usage). For an easier interpretation the
variables were z-standardized. The intercept represents the average mood, drive, or
stress across the study and the slope pictures the association between mood, drive, or
stress and smartphone usage behavior.

For all computations, a two-sided alpha error likelihood of p < 0.05 was used. The software
SPSS (version 24; IBM, 2016) and SAS (version 9.4 M4, www.sas.com) were used for
statistical analysis. Due to the explorative nature of the research questions no a priori
power analysis was conducted. Not alpha error adjusted significance indications which
were reported but should not be interpreted as in confirmatory studies [Bender and Lange,
2001].
Results
Table 3 presents a Spearman correlation matrix of the variables at baseline. There is a
correlation (p < 0.01) between mood and drive (r = 0.635) as well as between total usage
time and Facebook app usage time (r = 0.427). Furthermore, there is a negative
correlation between mood and stress (r = –0.427) and a negative correlation (p < 0.05)
between mood and number of SMS (r = –0.638). There are no gender differences between
the variables.
Mood
In model 1, self-reported mood was predicted through smartphone usage variables. With
every additional minute of calls, mood decreased 0.0166 (SE = 0.007). Furthermore,
mood attenuated by 0.019 (SE = 0.003) with every minute of total usage time. The number
of daily SMS and Facebook app usage were not associated with self-reported mood.
Parameters can be seen in Table 4. The model shows the association between self-
reported mood and call duration varies between individuals (var = 0.001, SE = 0.000).
Drive
Analogous to model 1, in model 2, the self-reported drive was predicted via smartphone
usage behavior. Drive decreased by 0.127 points (SE = 0.041) with every additional
minute spent using the Facebook app. The number of SMS, call duration, and total usage
time were not associated with self-reported drive. There was no variance between
individuals regarding the association between smartphone usage and drive. Detailed
parameters of the MLM are depicted in Table 5.
Stress
In model 3, self-reported stress was predicted over smartphone usage variables. With
every additional minute of call duration, the self-reported stress level was increased by
0.018 points (SE = 0.006). Every additional SMS was associated with a 3.539 (SE = 0.937)
reduction in self-reported stress. Facebook app usage time and total usage time were not
associated with self-reported stress. In regard to the association between smartphone
usage and self-reported stress, differences between individuals (var = 0.002, SD = 0.001)
were found. Parameters are shown in Table 6.

Discussion
This feasibility study shows that passively sensed smartphone usage is associated with
self-reported mood, drive, and stress. In general, current mental states emerge in reaction
to various internal and external demands. One of these external demands is smartphone
usage. The magnitude of these associations is minor and can be rooted in the fact that
not only usage duration but also content or intention of use contribute to well-being [Harari
et al., 2016]. There are associations between smartphone usage variables and the
dependent variables as well as variance between individuals. These interpersonal
variances should be addressed in further studies. In regard to the dependent variable,
different smartphone usage variables were useful predictors. Therefore, it is
recommended to shed light on different smartphone usage patterns in relation to specific
psychopathological states.
In regard to mood, there was a negative association between call duration and total usage
time. This negative correlation between total usage time and mood was already reported
in a smaller sample [Alvarez-Lozano et al., 2014]. The elevated smartphone usage when
experiencing negative mood could be explained via the mood management theory by
Zillmann [1988a; 1988b]. The central assumption is that media consumption is used to
enhance one’s own mood. In line with that, individuals suffering from foul mood would try
to improve their mood by using their smartphone. Correspondingly, the increased call
duration could be interpreted as a form of mood manipulation through social contacts. On
the other hand, there are findings which show a direct influence of media consumption on
mood [David et al., 2018]. Due to the correlative study design, there is no way to make
causal assumptions about the association between smartphone usage and negative
mood. Furthermore, some studies could not show a correlation between mood and
smartphone usage or found a positive association between mood and total usage time
[Elhai et al., 2017; Rozgonjuk et al., 2018; Saeb et al., 2015]. This could be a hint that
associations between smartphone usage and mood are nonlinear [Scherr, 2018].
Moreover, mood and drive represent two core symptoms of depression. Their different
expression in diverse clinically relevant subtypes could play a moderating role
[Baumeister and Parker, 2012; Saeb et al., 2015]. Moreover, variance in measurement
methods could account for the inconsistent findings [Stone und Shiffman, 2002].
Drive was best predicted via Facebook app usage time. This finding was confirmed by
Alvarez-Lozano and colleagues [2014], who also found a negative correlation between
mood and the usage of social networks. Again, the usage of social networks could be
seen as an attempt to manipulate one’s own mood through social contacts. Or on the
other hand, smartphone usage could be the cause of negative emotions [Lachmann et al.,
2018]. In line with this, Rotondi and colleagues [2017] could show that technological
interruptions reduce the quality of face-to-face interactions. Distinct smartphone usage
patterns (e.g., active versus passive usage) are associated with diverse outcomes [Burke
et al., 2010; McCord et al., 2014; Primack et al., 2017; Verduyn et al., 2017]. Tando and
colleagues [2015] could show that the correlation between depression and Facebook app
usage was moderated by envy.
In the current study, stress was associated negatively with number of SMS and positively
with call duration. Likewise, Sano and Picard [2013] could show that with elevated self-
reported stress levels, the number of SMS diminished. Overall, the literature regarding the
association between stress and smartphone usage is contradicting [Vildjiounaite et al.,
2018]. One reason could be that the used variables are not suitable to capture the
difference between relaxed and stressed behavior. The use of smartphone sensors (e.g.,
accelerometer) could in future improve the stress prediction models. Furthermore, the
content of SMS or calls could contribute more to changes in mental states than the
frequency of the latter [David et al., 2018; Przybylski and Weinstein, 2017]. Due to the
significance of the association between mental states and smartphone usage, further
studies could test the clinical relevance of manipulating smartphone usage.
Due to the complexity of the original data set, further explorative analysis using deep
machine learning approaches could be fruitful. Deep machine learning is a method which
can handle big data very well and results in data-driven theories and hypotheses, which
can be subsequently tested in confirmatory studies [Oquendo et al., 2012]. In deep
machine learning approaches, the computer iteratively tries to find patterns in big data in
a bidirectional manner, so that additional data input leads to better models [Bengio et al.,
2013; Längkvist et al., 2014; Miotto et al., 2018; Mohr et al., 2017].
The results of the current study should be interpreted with caution because 85 (33.5%)
participants have been excluded due to technical failure. In future, the Insights app should
be expanded to the iOS operating system to broaden its application. Due to the closed
functionality of iOS products, this is hardly realizable. According to Götz and colleagues
[2017], there are no differences in personality characteristics like well-being, self-efficacy,
or big five personality dimensions between iOS and android users.
Due to the high homogeneity of the sample in regard to age, gender, and educational
status, the generalizability is questionable. Therefore, a replication study including
participants of diverse gender, educational status, and age is needed [Thomee, 2018].
With regard to psychotherapy research, this requires the use of passive sensing in
patients who are validly diagnosed.

Overall, the knowledge about being observed could have led to an alteration of
smartphone usage behavior in participants. With the concept of habituation in mind, an
explorative analysis between the first and the other weeks of smartphone usage was
conducted. No differences were found. These first results point in the direction that an
alteration of smartphone usage through the observation itself is unlikely, given the
assumption that individuals would not show altered usage behavior over the span of 8
weeks.
On the other hand, there is evidence that repetitive assessment of mental states is itself
a minimal intervention [Runyan et al., 2013]. According to this, the iterated focus on one’s
own mental state leads to an altered perception of the same [Shiffman, 2009]. In future,
an automated detection of mental states could avoid those natural processes of attention
control.
Future studies should also take human rhythmicality into account (e.g., differences
between weekdays and weekends or variance within a day). A study by Servia-Rodriguez
and colleagues [2017] showed differences in prediction accuracy between weekends and
weekdays.
Moreover, there are first hints that the association between mental states and smartphone
usage are nonlinear [Scherr, 2018; Przybylski and Weinstein, 2017]. Future studies
should test whether cubic or quadratic models have a better fit.
Due to the fact that the observed associations between smartphone usage and mental
states were of small nature, the analysis of content could be promising [Harari et al., 2016].
In future, the content of apps (e.g., data mining of messages or on social networks) could
be used to develop better mental state prediction models. Despite this, potential ethical
considerations have to be taken into account [Schwartz et al., 2014].

Moreover, the combination of smartphone usage variables with smartphone sensor
variables could lead to more precise results, due to the fact that smartphone usage
provides more insight into the online life of a person, whereas sensor variables provide
deeper insight into everyday life [Servia-Rodríguez et al., 2017a].
Future Developments
If these preliminary results can be replicated in a confirmatory study, the future
implications could be as following: self-report tools like questionnaires could be
complemented through automatized smartphone usage and sensor analysis. Therapists
and patients could therefore have more time to work on interpersonal or disease-specific
topics, and errors in questionnaire analysis or other diagnostic methods (such as
structured interviews) could be avoided. By using passive sensing, the issue of poor long-
term adherence could be circumvented because there will be no need for active user input.
Moreover, clinical judgements could be augmented through comparably objective
automated analyses. The extension of diagnostic possibilities through technology-based
assistance (e.g., voice or video analyses) could, in the long term, result in more accurate
international standards in diagnostics.
Given the assumption that enough primary data is available, therapy courses could be
captured in an automatized way and therapists could get feedback if the therapy course
deviates from the predicted one.
Overall, automatized behavior observations of any kind are highly prone to misuse for
individuals or vulnerable person groups. Up to date, there are no international standards
on how privacy and sensitive data can be protected sufficiently [Mohr et al., 2017; Shilton
and Sayles, 2016]. In respect of the novel general data protection regulation (GDPR) of
the European Union, the current solution is to give the rights to use data to the individual
who produced it. Individuals can therefore maximize their control over who is collecting,
using, and sharing their data. To increase the acceptance, comprehensible informed
consent and data safety-friendly default modes are inevitable [Shilton, 2009]. There is
hope that data handling will be improved through the GDPR because it improved an
individual’s right on his data by allowing him to obtain all collected data from a given data
collection, a right that all collected data will be erased, a right to know which data is
collected, where this data is stored, and with whom it is shared (see https://dsgvo-
gesetz.de/). All organizations which collect, or process data can be fined by the European
Union with 4% of their revenue or 20 million. Furthermore, software which is used for the
administration, maintenance, or improvement of health of individuals is affected by the
IEC82304 of the Medical Devices Act since May 2017. Tracking apps which are used in
the medical or psychotherapeutic context are affected by the IEC82304 and are tested for
their functionality and data safety.
Taking into account the previous arguments, it becomes obvious that digitalization in
health care carries enormous social, legal, and ethical challenges. Psychotherapists
should contribute to the developments with their expert knowledge.

Acknowledgements
We thank Angela Serian, Annalena Schröder, Lisa-Marie Hank, Marcel Peitgen, Julia
Thümmler, Maximilian Buyer, Sarah Schneider, and Lisa Hummel for their help in data
collection. Furthermore, we want to thank Selma Catic and Yannik Terhorst for their help
in data preparation. A sincere thank you to my student assistants Linda Armbruster, Elmas
Can, Milena Engelke, and Alexandra Portenhauser for their help in formatting.
Statement of Ethics
The local ethics committee approved the study.
Disclosure Statement
The authors declare no conflict of interest.
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Beste aus zwei Welten? PiD. 2018;19(4):33–8.
Baumeister H, Parker G. Meta-review of depressive subtyping models. J Affect Disord. 2012

Jul;139(2):126–40.
Bengio Y, Courville A, Vincent P. Representation learning: a review and new perspectives. IEEE Trans
Pattern Anal Mach Intell. 2013 Aug;35(8):1798–828.
Bender R, Lange S. Adjusting for multiple testing – when and how? J Clin Epidemiol. 2001 Apr;54(4):343–
9.
Ben-Zeev D, Scherer EA, Wang R, Xie H, Campbell AT. Next-generation psychiatric assessment: using
smartphone sensors to monitor behavior and mental health. Psychiatr Rehabil J. 2015
Sep;38(3):218–26.
Burke M, Marlow C, Lento T. Social network activity and social well-being. In: CHI '10: Proceedings of the
SIGCHI Conference on Human Factors in Computing Systems. New York: ACM Press; 2010. p.
1909–1912.
Canzian L, Musolesi M. Trajectories of depression: unobtrusive monitoring of depressive states by means

of smartphone mobility traces analysis. In: UbiComp '15: Proceedings of the 2015 ACM International
Joint Conference on Pervasive and Ubiquitous Computing. New York: ACM Press; 2015. p. 1293–
1304.
Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007 Oct;298(14):1685–
7.
Cummins N, Joshi J, Dhall A, Sethu V, Goecke R, Epps J. Diagnosis of depression by behavioral signals:
a multimodal approach. In: AVEC '13: Proceedings of the 3rd ACM international workshop on
audio/visual emotion challenge. New York: ACM Press; 2013. p. 11–20.
Cummins N, Vlasenko B, Sagha H, Schuller B. Enhancing speech-based depression detection through

gender dependent vowel-level formant features. In: ten Teije A, Popow C, Holmes JH, Sacchi L,
editors. Artificial Intelligence in Medicine. Cham: Springer International Publishing; 2017. p. 209–
14.
David ME, Roberts JA, Christenson B. Too much of a good thing: investigating the association between
actual smartphone use and individual well-being. Int J Hum Comput Interact. 2017 Jul;265–275.
de Boer SF, Buwalda B, Koolhaas JM. Untangling the neurobiology of coping styles in rodents: towards
neural mechanisms underlying individual differences in disease susceptibility. Neurosci Biobehav
Rev. 2017 Mar;74 Pt B:401–22.
Domhardt M, Steubl L, Baumeister H. Internet- and mobile-based interventions for mental and somatic
conditions in children and adolescents. Z Kinder Jugendpsychiatr Psychother. 2018 Nov:1–14.
Donkin L, Glozier N. Motivators and motivations to persist with online psychological interventions: a
qualitative study of treatment completers. J Med Internet Res. 2012 Jun;14(3):e91.
Ebert DD, Cuijpers P, Muñoz RF, Baumeister H. Prevention of Mental Health Disorders using Internet and
mobile-based Interventions: a narrative review and recommendations for future research. Front
Psychiatry. 2017 Aug;8:116.
Ebert D, Daele T, Nordgreen T, Karekla M, Compare TA, Zarbo C, et al. Internet and mobile-based
psychological interventions: applications, efficacy and potential for improving mental health. A report
of the EFPA e-health taskforce. Eur Psychol. 2018;23(2):167–87.
Elhai JD, Tiamiyu MF, Weeks JW, Levine JC, Picard KJ, Hall BJ. Depression and emotion regulation predict
objective smartphone use measured over one week. Pers Individ Dif. 2018 Oct;133:21–28.
Enders CK. Using the expectation maximization algorithm to estimate coefficient alpha for scales with item-
level missing data. Psychol Methods. 2003 Sep;8(3):322–37.
Ferdous R, Osmani V, Mayora O. Smartphone app usage as a predictor of perceived stress levels at
workplace. Int Conf Pervasive Comput Technol Healthc. 2015.
Goldstein H. Hierarchical data modeling in the social sciences. J Educ Behav Stat. 1995;20(2):201–204.
Götz FM, Stieger S, Reips UD. Users of the main smartphone operating systems (iOS, Android) differ only
little in personality. PLoS One. 2017 May;12(5):e0176921.
Harari GM, Lane ND, Wang R, Crosier BS, Campbell AT, Gosling SD. Using Smartphones to Collect
Behavioral Data in Psychological Science: Opportunities, Practical Considerations, and Challenges.
Perspect Psychol Sci. 2016 Nov;11(6):838–54.
Harari GM, Müller SR, Aung MS, Rentfrow PJ. Smartphone sensing methods for studying behavior in
everyday life. Curr Opin Behav Sci. 2017;18:83–90.
ICD-11 for Mortality and Morbidity Statistics [cited 2019 Mar 13]. Available from:
https://icd.who.int/browse11/l-m/en.
Insel TR. Digital phenotyping: technology for a new science of behavior. JAMA. 2017 Oct;318(13):1215–6.
Kampling H, Baumeister H, Jäckel WH, Mittag O. Prevention of depression in chronically physically ill adults.
Cochrane Database Syst Rev. 2014; https://doi.org/10.1002/14651858.CD011246.
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al.; National Comorbidity Survey
Replication. The epidemiology of major depressive disorder: results from the National Comorbidity
Survey Replication (NCS-R). JAMA. 2003 Jun;289(23):3095–105.
Lachmann B, Sindermann C, Sariyska RY, Luo R, Melchers MC, Becker B, et al. The role of empathy and
life satisfaction in internet and smartphone use disorder. Front Psychol. 2018 Mar;9:398.
Längkvist M, Karlsson L, Loutfi A. A review of unsupervised feature learning and deep learning for time-
series modeling. Pattern Recognit Lett. 2014;42:11–24.
Laurenceau J-P, Bolger N. Analyzing diary and intensive longitudinal data from dyads. In: Mehl M, Conner
TS, editors. Handbook of Research Methods for Studying Daily Life. New York: Guilford; 2011.
LiKamWa R, Liu Y, Lane ND, Zhong L. MoodScope: building a mood sensor from smartphone usage
patterns. In: MobiSys 2013 – Proceedings of the 11th Annual International Conference on Mobile
Systems, Applications, and Services. New York: ACM Press; 2013. p. 389–401.
MacCallum RC, Kim C, Malarkey WB, Kiecolt-Glaser JK. Studying multivariate change using multilevel
models and latent curve models. Multivariate Behav Res. 1997 Jul;32(3):215–53.
Markowetz A, Błaszkiewicz K, Montag C, Switala C, Schlaepfer TE. Psycho-informatics: Big Data shaping
modern psychometics. Med Hypotheses. 2014 Apr;82(4):405–11.
McCord B, Rodebaugh TL, Levinson CA. Facebook: social uses and anxiety. Comput Human Behav.
2014;34:23–7.
Mehrotra A, Musolesi M. Designing effective movement digital biomarkers for unobtrusive emotional state
mobile monitoring. In: DigitalBiomarkers ’17 – Proceedings of the 1st Workshop on Digital
Biomarkers. New York: ACM Press; 2017.
Mehrotra A, Pejovic V, Musolesi M. SenSocial: a middleware for integrating online social networks and
mobile sensing data streams. In: Middleware '14 – Proceedings of the 15th International Middleware
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Miller G. The Smartphone Psychology Manifesto. Perspect Psychol Sci. 2012 May;7(3):221–37.
Miotto R, Wang F, Wang S, Jiang X, Dudley JT. Deep learning for healthcare: review, opportunities and
challenges. Brief Bioinform. 2018 Nov;19(6):1236–46.
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Montag C, Błaszkiewicz K, Sariyska R, Lachmann B, Andone I, Trendafilov B, et al. Smartphone usage in

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Baumeister H, Parker G. Meta-review of depressive subtyping models. J Affect Disord. 2012

Jul;139(2):126–40.
Bengio Y, Courville A, Vincent P. Representation learning: a review and new perspectives. IEEE Trans
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Bender R, Lange S. Adjusting for multiple testing – when and how? J Clin Epidemiol. 2001 Apr;54(4):343–
9.
Ben-Zeev D, Scherer EA, Wang R, Xie H, Campbell AT. Next-generation psychiatric assessment: using
smartphone sensors to monitor behavior and mental health. Psychiatr Rehabil J. 2015
Sep;38(3):218–26.
Burke M, Marlow C, Lento T. Social network activity and social well-being. In: CHI '10: Proceedings of the
SIGCHI Conference on Human Factors in Computing Systems. New York: ACM Press; 2010. p.
1909–1912.
Canzian L, Musolesi M. Trajectories of depression: unobtrusive monitoring of depressive states by means

of smartphone mobility traces analysis. In: UbiComp '15: Proceedings of the 2015 ACM International
Joint Conference on Pervasive and Ubiquitous Computing. New York: ACM Press; 2015. p. 1293–
1304.
Cohen S, Janicki-Deverts D, Miller GE. Psychological stress and disease. JAMA. 2007 Oct;298(14):1685–
7.
Cummins N, Joshi J, Dhall A, Sethu V, Goecke R, Epps J. Diagnosis of depression by behavioral signals:
a multimodal approach. In: AVEC '13: Proceedings of the 3rd ACM international workshop on
audio/visual emotion challenge. New York: ACM Press; 2013. p. 11–20.
Cummins N, Vlasenko B, Sagha H, Schuller B. Enhancing speech-based depression detection through

gender dependent vowel-level formant features. In: ten Teije A, Popow C, Holmes JH, Sacchi L,
editors. Artificial Intelligence in Medicine. Cham: Springer International Publishing; 2017. p. 209–
14.
David ME, Roberts JA, Christenson B. Too much of a good thing: investigating the association between
actual smartphone use and individual well-being. Int J Hum Comput Interact. 2017 Jul;265–275.
de Boer SF, Buwalda B, Koolhaas JM. Untangling the neurobiology of coping styles in rodents: towards
neural mechanisms underlying individual differences in disease susceptibility. Neurosci Biobehav
Rev. 2017 Mar;74 Pt B:401–22.
Domhardt M, Steubl L, Baumeister H. Internet- and mobile-based interventions for mental and somatic
conditions in children and adolescents. Z Kinder Jugendpsychiatr Psychother. 2018 Nov:1–14.
Donkin L, Glozier N. Motivators and motivations to persist with online psychological interventions: a
qualitative study of treatment completers. J Med Internet Res. 2012 Jun;14(3):e91.
Ebert DD, Cuijpers P, Muñoz RF, Baumeister H. Prevention of Mental Health Disorders using Internet and
mobile-based Interventions: a narrative review and recommendations for future research. Front
Psychiatry. 2017 Aug;8:116.
Ebert D, Daele T, Nordgreen T, Karekla M, Compare TA, Zarbo C, et al. Internet and mobile-based
psychological interventions: applications, efficacy and potential for improving mental health. A report
of the EFPA e-health taskforce. Eur Psychol. 2018;23(2):167–87.
Elhai JD, Tiamiyu MF, Weeks JW, Levine JC, Picard KJ, Hall BJ. Depression and emotion regulation predict
objective smartphone use measured over one week. Pers Individ Dif. 2018 Oct;133:21–28.
Enders CK. Using the expectation maximization algorithm to estimate coefficient alpha for scales with item-
level missing data. Psychol Methods. 2003 Sep;8(3):322–37.
Ferdous R, Osmani V, Mayora O. Smartphone app usage as a predictor of perceived stress levels at
workplace. Int Conf Pervasive Comput Technol Healthc. 2015.
Goldstein H. Hierarchical data modeling in the social sciences. J Educ Behav Stat. 1995;20(2):201–204.
Götz FM, Stieger S, Reips UD. Users of the main smartphone operating systems (iOS, Android) differ only
little in personality. PLoS One. 2017 May;12(5):e0176921.
Harari GM, Lane ND, Wang R, Crosier BS, Campbell AT, Gosling SD. Using Smartphones to Collect
Behavioral Data in Psychological Science: Opportunities, Practical Considerations, and Challenges.
Perspect Psychol Sci. 2016 Nov;11(6):838–54.
Harari GM, Müller SR, Aung MS, Rentfrow PJ. Smartphone sensing methods for studying behavior in
everyday life. Curr Opin Behav Sci. 2017;18:83–90.
ICD-11 for Mortality and Morbidity Statistics [cited 2019 Mar 13]. Available from:
https://icd.who.int/browse11/l-m/en.
Insel TR. Digital phenotyping: technology for a new science of behavior. JAMA. 2017 Oct;318(13):1215–6.
Kampling H, Baumeister H, Jäckel WH, Mittag O. Prevention of depression in chronically physically ill adults.
Cochrane Database Syst Rev. 2014; https://doi.org/10.1002/14651858.CD011246.
Kessler RC, Berglund P, Demler O, Jin R, Koretz D, Merikangas KR, et al.; National Comorbidity Survey
Replication. The epidemiology of major depressive disorder: results from the National Comorbidity
Survey Replication (NCS-R). JAMA. 2003 Jun;289(23):3095–105.
Lachmann B, Sindermann C, Sariyska RY, Luo R, Melchers MC, Becker B, et al. The role of empathy and
life satisfaction in internet and smartphone use disorder. Front Psychol. 2018 Mar;9:398.
Längkvist M, Karlsson L, Loutfi A. A review of unsupervised feature learning and deep learning for time-
series modeling. Pattern Recognit Lett. 2014;42:11–24.
Laurenceau J-P, Bolger N. Analyzing diary and intensive longitudinal data from dyads. In: Mehl M, Conner
TS, editors. Handbook of Research Methods for Studying Daily Life. New York: Guilford; 2011.
LiKamWa R, Liu Y, Lane ND, Zhong L. MoodScope: building a mood sensor from smartphone usage
patterns. In: MobiSys 2013 – Proceedings of the 11th Annual International Conference on Mobile
Systems, Applications, and Services. New York: ACM Press; 2013. p. 389–401.
MacCallum RC, Kim C, Malarkey WB, Kiecolt-Glaser JK. Studying multivariate change using multilevel
models and latent curve models. Multivariate Behav Res. 1997 Jul;32(3):215–53.
Markowetz A, Błaszkiewicz K, Montag C, Switala C, Schlaepfer TE. Psycho-informatics: Big Data shaping
modern psychometics. Med Hypotheses. 2014 Apr;82(4):405–11.
McCord B, Rodebaugh TL, Levinson CA. Facebook: social uses and anxiety. Comput Human Behav.
2014;34:23–7.
Mehrotra A, Musolesi M. Designing effective movement digital biomarkers for unobtrusive emotional state
mobile monitoring. In: DigitalBiomarkers ’17 – Proceedings of the 1st Workshop on Digital
Biomarkers. New York: ACM Press; 2017.
Mehrotra A, Pejovic V, Musolesi M. SenSocial: a middleware for integrating online social networks and
mobile sensing data streams. In: Middleware '14 – Proceedings of the 15th International Middleware
Conference. New York: ACM Press; 2014. p. 205–216.
Milczarek M, Schneider E, Gonzalez ER. OSH in figures: stress at work – facts and figures. Luxembourg:
Office for Official Publications of the European Communities; 2009.
Miller G. The Smartphone Psychology Manifesto. Perspect Psychol Sci. 2012 May;7(3):221–37.
Miotto R, Wang F, Wang S, Jiang X, Dudley JT. Deep learning for healthcare: review, opportunities and
challenges. Brief Bioinform. 2018 Nov;19(6):1236–46.
Mohr DC, Tomasino KN, Lattie EG, Palac HL, Kwasny MJ, Weingardt K, et al. Intellicare: an eclectic, skills-
based app suite for the treatment of depression and anxiety. J Med Internet Res. 2017a
Jan;19(1):e10.
Mohr DC, Zhang M, Schueller SM. Personal sensing: understanding mental health using ubiquitous sensors
and machine learning. Annu Rev Clin Psychol. 2017b;13:23–47.
Montag C, Baumeister H, Kannen C, Sariyska R, Messner EM, Brand M. Concept, Possibilities and Pilot-
Testing of a New Smartphone Application for the Social and Life Sciences to Study Human Behavior
Including Validation Data from Personality Psychology. J Multidisciplinary Scientific Journal.
2019;2(2):102–15.
Montag C, Błaszkiewicz K, Sariyska R, Lachmann B, Andone I, Trendafilov B, et al. Smartphone usage in

the 21st century: who is active on WhatsApp? BMC Res Notes. 2015 Aug;8(1):331.
Montag C, Diefenbach S. Towards homo digitalis: important research issues for psychology and the
neurosciences at the dawn of the internet of things and the digital society. Sustainability.
2018;10(2):415.
Montag C, Duke É, Markowetz A. Toward Psychoinformatics: Computer Science Meets Psychology.

Comput Math Methods Med. 2016;2016:2983685.
Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and
decrements in health: results from the World Health Surveys. Lancet. 2007 Sep;370(9590):851–8.
Mund M, Mitte K. The costs of repression: a meta-analysis on the relation between repressive coping and
somatic diseases. Health Psychol. 2012 Sep;31(5):640–9.
Nezlek JB, Schröder-Abé M, Schütz A. Mehrebenenanalysen in der psychologischen Forschung. Psychol

Rundsch. 2006;57(4):213–23.
Nezlek JB. Multilevel modeling for psychologists. In: Cooper H, Camic PM, Long DL, Panter AT, Rindskopf
D, Sher KJ, editors. APA handbook of research methods in psychology, vol 3: Data analysis and
research publication. Washington: American Psychological Association; 2012.
Nezlek JB. Multilevel random coefficient analyses of event- and interval-contingent data in social and
personality psychology research. Pers Soc Psychol Bull. 2001;27(7):771–85.
Onnela JP, Rauch SL. Harnessing Smartphone-Based Digital Phenotyping to Enhance Behavioral and
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Tables
Tab. 1. Characteristics of the sample

Variable Parameter
Age m=22.53 sd=6.12 Streuung=18-63
Education A-levels N=136 85.53%
University degree N=23 14.47%
Gender male N=44 27.67%
female N=115 72.33%
m= mean; sd= standard deviation; N= number of participants
Tab. 2. Characteristics of the variables

Variable Kennwerte
Call duration a m=2.11 sd= 2.14 range=0.07-16.27
Number of messagesb m=0.64 sd= 1.04 range=0-8.81
Daily usage time c m=168.77 sd= 98.52 range=0.25-692.83
Facebook usage timed m=8.73 sd= 12.98 range=0-63.47
Mood m=63.83 sd= 11.78 range=28-92
Thrive m=50.94 sd= 10.31 range=24-81
Stress m=38.70 sd= 14.18 range=28-81
a
m= mean; sd= standard deviation; Total time of incoming and outgoing calls per
day, bTotal number of received and sent text messages per day, cTotal daily usage
time, dTotal daily usage time of the Facebook app in minutes
Tab. 3. Correlation matrix at baseline
Mood Thrive Stress Telea SMSb TDUc FBUd
Mood 1**
Thrive 0.653** 1**
Stress -0.427** -0.157 1**
Telea -0.266 -0.198 0.081 1**
SMSb -0.638* -0.416 0.495 -0.072 1**
TDUc 0.095 -0.116 -0.018 0.104 -0.036 1**
FBUd -0.063 -0.005 -0.06 0.009 0.049 0.454** 1**

a
*Significant correlation p<0.05, **Highly significant correlation p<0.01, Daily
incoming and outgoing calls, bDaily received and sent messages, cTotal daily
usage time, dTotal daily usage time of the facebook app in minutes
Tab. 4. Model 1: Multivariate multi-level model to predict self-reported mood

Parameter SE
Model fit
Restricted -2LLa 26744.1
AICb 26766.1
BICc 26799.2
Fixed effects*
Level 1 intercept 68.803* 1.490*
Call durationd* -0.016* 0.007*
Number of SMSe 0.657 0.655
Daily usage timef* -0.019* 0.004*
Daily facebook usageg -0.065 0.037
Random effects*
Call durationd* 0.001* 0.000*
Daily usage timef* 0.000 0.000
Daily facebook usageg 0.005 0.006
*Significant result p<0.05, aLog likelihood, bAkaike criterion, cBayesan criterion, dTotal
daily time of incoming and outgoing calls in minutes, eNumber of receives and sent text
messages per day, fTotal daily usage time, gTotal daily facebook usage time in minutes.
Tab. 5. Model 2: Multivariate multi-level model to predict self-reported thrive

Parameter SE
Model fit
AICb 27921.1
BICc 27954.3
Fixed effects*
Call durationd* -0.007 0.006
Daily usage timef* -0.009 0.005
Daily facebook usageg -0.127* 0.041*
Random effects*
Call durationd* 0.000 0.000
daily time of incoming and outgoing calls in minutes, eNumber of receives and sent
text messages per day, fTotal daily usage time, gTotal daily facebook usage time in
minutes.
Tab. 6. Model 3: Multivariate multi-level model to predict self-reported stress

Parameter SE
Model fit
AICb 28093.3
BICc 28126.4
Fixed effects*
Call durationd* 0.018* 0.006*
Number of SMSe -3.539* 0.937*
Daily facebook usageg -0.016 0.052
Random effects*
Call durationd* 0.000 0.000
Daily usage timef* 0.002* 0.001*
daily time of incoming and outgoing calls in minutes, eNumber of receives and sent text
messages per day, fTotal daily usage time, gTotal daily facebook usage time in minutes.
4 Study 2: Does cardiac reactivity in the laboratory predict

ambulatory heart rate?
Does Cardiac Reactivity in the Laboratory Predict Ambulatory

Heart Rate? Baseline Counts.
Andreas R. Schwerdtfeger*1, Anne Schienle1, Verena Leutgeb1 & Eva-Maria

Rathner1, 2
1 Department of Psychology, University of Graz, Austria
2 Department of Applied Psychology: Health, Development, Enhancement and
Intervention, University of Vienna, Austria
Dr. Andreas R. Schwerdtfeger
Department of Psychology
Karl-Franzens-University Graz
A-8010 Graz, Austria
Email: andreas.schwerdtfeger@uni-graz.at
Tel.: +43 316 380-4953
Fax: +43 316 380-9807
Abstract
Background: Cardiovascular reactivity to laboratory stress might predict cardiovascular
load in everyday-life. However, previous research throws doubt on this hypothesis.
Methods: This study examined associations between heart rate (HR) to a public speaking
task and ambulatory HR throughout a day. ECG, bodily movement, and psychosocial
variables (affect, context) were recorded in 111 individuals.
Results: Ambulatory HR was positively associated with both positive and negative affect.
Baseline HR in the laboratory significantly predicted ambulatory HR, but HR reactivity did
not. The interaction of momentary negative affect and cardiac reactivity in the laboratory
was also not significant. However, a significant interaction of baseline HR and reactivity
indicated that when baseline was high, there was a positive relation between HR reactivity
and ambulatory HR.
Conclusions: Findings suggest that baseline has to be considered when aiming to predict
cardiovascular load in everyday-life.
Key words: Ambulatory monitoring, cardiovascular reactivity, heart rate, laboratory stress
Introduction
The hypothesis that comparably strong cardiovascular responses to a standardized
laboratory stress protocol (so-called cardiovascular reactivity; CVR) might impose risk for
cardiovascular diseases has a long tradition in psychophysiology and health psychology
(for an overview, e.g., Treiber et al., 2003; Zanstra & Johnston, 2011). An elevated CVR
is thought to index the individual’s disposition to respond strongly to a variety of different
challenging situations outside the laboratory, ultimately indicating elevated risk for
cardiovascular diseases. Of note, although the reactivity hypothesis has put strong
emphasis on the health-related consequences of exaggerated cardiovascular stress
responses (e.g., Lovallo, 2010; Schwartz et al., 2003), recent research suggests that also
blunted physiological stress reactivity could be maladaptive implying a loss of homeostatic
regulation (e.g., Lovallo, 2011; Lovallo, Farag, Sorocco, Cohoon, & Vincent, 2012). Thus,
it should be kept in mind that both exaggerated and attenuated cardiac reactivity in the
laboratory should generalize to everyday-life if they are thought to have health-related
consequences.
However, the generalizability of the laboratory-based CVR has been challenged by
several studies. Usually, such studies measure the CVR in the laboratory and relate it to
the cardiovascular variability (i.e., standard deviation or other measures of variability) in
everyday-life (e.g., Fredrickson, Tuomisto, Lundberg, & Melin, 1990; Johnston,
Anastasiades, & Wood, 1990; Kamarck, Schwartz, Janicki, Shiffman, & Raynor, 2003) or
to an ecologically valid field stressor (e.g., giving a presentation or taking part in an exam;
e.g., Davig, Larkin, & Goodie, 2000; Johnston, Tuomisto, & Patching, 2008; Matthews,
Manuck, & Saab, 1986; van Doornen, & van Blokland, 1992). Although quite reasonable,
both approaches have their pitfalls. First, the use of cardiovascular variability as an
indicator of stress reactivity poses the challenge that other various influences on
cardiovascular function in everyday-life that are unrelated to stress could severely bias
the data and, hence, need to be controlled (e.g., metabolic changes, situational and
affective characteristics, orthostatic challenges, circadian rhythms). Second, the use of a
standardized field stressor is grounded on the idea that this encounter represents a typical
and frequently occurring challenge for this individual. However, stressors remarkably differ
both between and within individuals, thus precluding generalizability (e.g., Schwartz et al.,
2003; Treiber et al., 2003). Consequently, a comparably strong CVR to a specific
laboratory challenge could be a rather poor indicator of cardiovascular disease risk.
Indeed, literature reviews suggest that lab – field associations appear to be moderate at
best with approximately only 20-25% of the predicted relationships to be significant (e.g.,
Kamarck & Lovallo, 2003; Turner, 1994). It should be emphasized, though, that
correlations tend to increase when responses are aggregated across different laboratory
challenges, thus increasing reliability of the measure (e.g., Gerin et al., 1998; Kamarck,
Debski, & Manuck, 2000; Manuck, Kamarck, Kasprowicz, &Waldstein, 1993).
Notably, studies comparing the relative predictive power of CVR with absolute values of
cardiovascular function suggest that absolute (i.e., tonic) values are far better predictors
of the cardiovascular load exhibited in daily life (e.g., Davig et al., 2000; Fredrickson et al.,
1990), thus challenging the incremental validity of laboratory-based stress protocols.
Moreover, it is striking to note that most studies examining the generalizability of
laboratory-based CVR did not analyze the moderating role of baseline activity. In general,
delta scores (stress activity minus baseline activity) or residualized change scores (i.e.,
regressing cardiovascular activity during a stress task on the baseline value and
subtracting the predicted value from the observed value) are used to quantify CVR.
Whereas delta scores ignore the potential impact of different baseline values on CVR,
residualized change scores remove their influence. Either approach, however, might be
problematic when aiming to examine laboratory – field correspondence of CVR.
In particular, a comparably high baseline activity together with elevated CVR could
indicate enhanced load on the cardiovascular system. Such a response pattern may
characterize a hyperreactive response system that is associated with enhanced vigilance
and anxiety (e.g., Berntson, Sarter, & Cacioppo, 1998; Gianaros et al., 2008; Suinn, 2001).
We would expect this pattern of CVR to be associated with elevated cardiovascular activity
in everyday-life. Conversely, a comparably low baseline activity together with blunted CVR
seems to be more challenging to interpret. First, it could indicate a low-reactive
cardiovascular system with low cardiac load in daily life and rather favorable health-related
outcomes. Second, given recent evidence for health-compromising effects of blunted CVR
(e.g., Lovallo, 2011) it could be accompanied by rather maladaptive function. Hence, the
present study aimed to analyze interactive effects of cardiac baseline activity and reactivity
in the laboratory on ambulatory HR in everyday-life. Specifically, we hypothesized that
ambulatory HR could be predicted by the interaction of baseline HR and reactivity during
a laboratory challenge.
A second aim of this study was to examine the reactivity hypothesis more directly.
Therefore, we aimed to analyze interactive effects of the laboratory-based cardiac
reactivity and negative affect as exhibited throughout everyday-life on ambulatory HR. In
line with the reactivity hypothesis it was expected that ambulatory HR would be higher
when both laboratory-based HR reactivity and ambulatory negative affect, presumably
signaling increased levels of stress, are comparably high.

Methods
Participants
Overall, 131 individuals participated in the study. The data of 11 participants could not be
used due to ECG artefacts (poor signal quality, frequent ectopic beats), technical failure
(n = 2; problems with the positioning of the chest belt or data retrieval), or withdrawal from
the study (n = 7), leaving a total of 111 participants (54 women) for the analysis of
ambulatory HR. The remaining sample had a mean age of 37.34 years (SD = 7.90) and a
mean waist to hip-ratio (WHR) of 0.81 (SD = 0.09). Twenty-seven individuals (24.3%)
reported to be smokers. Participants were screened prior to the study for medication use
and cardiovascular diseases by means of an online questionnaire. Hence, only individuals
without cardiovascular diseases (hypertension, ischemic heart disease, cardiopulmonar
disease, cerebrovascular disease) and without cardiovascular and psychoactive
medication were eligible for study participation. Participants were paid up to 100 Euros for
participation.
Study Design
This study was part of a larger study on coping and health. A 22-hours
psychophysiological ambulatory monitoring was conducted following the completion of a
standardized laboratory stress task (public speaking). Participants were equipped with
ambulatory monitoring devices (Varioport-b, Becker Meditec, Karlsruhe, Germany) to
record the electrocardiogram (ECG) and bodily movement to control for metabolically
relevant changes in HR. In addition, participants were repeatedly asked to provide ratings
of their current location, smoking, negative affect (NA) and positive affect (PA) on that
particular day using iPODs (iPOD touch 4GB, Apple Inc.). The study was approved by the
institutional ethics review board and was therefore performed in accordance with the
ethical standards laid down in the 1964 Declaration of Helsinki.
Laboratory Stress Task
For examining CVR to laboratory stress a public speaking task was used. This task has
been shown to elicit reliable and relatively strong physiological responses (Al’Absi et al.,
1997). Participants were enrolled in a simulated job interview during which they should
introduce themselves unveiling their personal strengths and weaknesses in front of a
camera. To enhance social-evaluative cues the camera was adjusted prior the speech
and they were informed that the video would be evaluated by experts for authenticity and
eloquence. The task endured 3 minutes and was imbedded between a 3 minute baseline
period, a 3 minute preparation period and a recovery period (also 3 minutes). Prior to the
baseline recording, individuals were allowed to get adapted to the laboratory environment
for 5 minutes during which they were given the opportunity to read lifestyle-magazines.
During baseline and recovery tracks from an audiobook were presented (The Little Prince;
Antoine de Saint-Exupéry) to achieve a basal resting state (e.g., Piferi, Klein, Younger, &
Lawler, 2000).
Ambulatory Psychological Variables
We used iPODs programmed with the software iDialogPad App by G. Mutz (University of
Cologne, Germany) to assess PA, NA, and situational and behavioral characteristics.
Reports were given signal-contingent following a vibration signal, which was part of the
physiological monitoring equipment (see below). The signal was initialized about every 45
minutes (± 10 minutes). The interval between two alarms could therefore vary between 35
and 55 minutes. Participants were asked to rate various affective states that they
experienced during the five minutes prior to each alarm. Items were adopted from the
German version of the PANAS (Krohne, Egloff, Kohlmann, & Tausch, 1996). The
corresponding items were presented in pseudo-randomized order. NA was assessed
using six adjectives that were presented on the screen (unsafe, discouraged, anxious,
ashamed, worried, and dissatisfied). PA was assessed via the following 6 adjectives:
dynamic, relaxed, calm, brisk, delighted, awake. For each item a six-point response format
was chosen ranging from 1 (not at all) to 6 (very much so). PA and NA scores for each
entry were summed across items, resulting in a possible range of scores between 6 and
36. For NA the mean sum across all entries was 8.68 (SD = 3.77, MIN = 6.00, MAX =
36.00), indicating rather moderate levels of NA throughout the day. For PA the mean sum
was 24.53 (SD = 5.16, MIN = 7.00, MAX = 36.00), suggesting comparably high levels of
positive well-being. To assess reliability of ambulatory affect Generalizability Theory
Analysis (GTA; Brennan, 2001; for a comprehensive review, see, Shrout & Lane, 2012)
was applied. GTA is especially suited to assess reliability of repeated assessments in
daily life, because it allows partitioning between-person variance, within-person variance
and error variance. Hence, the observed variance is decomposed into components
attributable to person, item, measurement occasion (time), or their respective interactions.
-person variance) and the person by time variance
whereas the other variance components are considered as error variance. Furthermore,
the following reliability estimates were calculated: RKR as a measure of between-person
reliability (equivalent to traditional measures of reliability) and RC as a measure of within-
person reliability (see, Shrout & Lane, 2012).

The results of the GTA can be found in Table 1. The primary sources of variance in the
affect scales were between-person variance (P^2 > 11%) and change over time ((P*T)^2
> 30%; within-person variance). Variances resulting from measurement error or
methodological sources were ˂ 5%. Between-person reliability was very good for both
scales (RKF ≥ .87) and within-person reliability was adequate (RC ≥ .76), suggesting that
affect could be reliably assessed.
Additionally, participants were asked to report their location (work, home, outside, vehicle)
and whether they engaged in smoking during the last five minutes (no vs. yes) in case
they were smokers. We decided to contrast the location at home vs. all other locations,
because previous research has unveiled substantially lower cardiovascular activation and
NA when individuals were at home as compared to other settings (e.g., Gump et al., 2001;
Schwerdtfeger and Friedrich-Mai, 2009). Importantly, each assessment was supplied with
a time stamp to permit precise matching with the corresponding physiological signals (i.e.,
ECG traces, bodily movement).
Cardiac Reactivity and Ambulatory HR
The ECG in the laboratory was recorded by means of Ag/AgCl-electrodes attached with
adhesive collars at the right collar-bone and below left rib cage with Hellige electrode gel.
The signal passed a Coulbourn amplifier (V 75.04) with a low pass filter of 150 Hz. Time
constant was set to 0.16 seconds and the signal was sampled with 500 Hz. The
ambulatory ECG was recorded using disposable tap electrodes (Ambu® Blue Sensor VL).
The signal was scanned with 512 Hz and sampled with 256 Hz on a memory card. Both
laboratory and ambulatory data were analyzed offline by means of a semi-automatic peak
detection software written with LABVIEW® 6.0i (National Instruments). The ECG of each
participant was visually inspected on a 60-s basis and low-pass filtered with 30 Hz to
overcome gross movement artifacts. Interbeat intervals (IBIs) were calculated in ms for
each 60-s segment. Extraordinarily strong successive IBI variations were corrected if
necessary by a moving average procedure if they differed by more than a multiplier of 1.5
or 0.7 from the previous IBI. HR for each segment was calculated by dividing 60,000 by
the respective IBI.
For the laboratory stress task, HR was aggregated throughout baseline, anticipation,
speech, and recovery periods, respectively, for the ambulatory protocol it was aggregated
throughout the five minutes time interval prior to each iPOD assessment. That is,
segments were extracted out of the 22-hour recording according to the time stamps
identified on the iPOD. The ECG was then analyzed for five minutes prior to each iPOD
entry on a minute-by-minute basis as described previously. Cardiac reactivity to the
speech task was analyzed via change scores from baseline to the speech period.
Therefore, HR was analyzed during baseline and speech and the difference was
calculated (∆HR; task-related values minus baseline values).
Bodily movement was recorded during ambulatory monitoring by means of two
accelerosensors. A uni-dimensional accelerometer (Becker Meditec®, Karlsruhe,
Germany) was attached on the left thigh (above the knee) to measure leg movements with
a sensitivity of 0.2 milli Gs, and a three-dimensional accelerometer was located inside the
VARIOPORT-b. This sensor is sensitive in three dimensions and has a sensitivity of 0.2
milli Gs. Signals from each sensor were sampled at 16 Hz and stored on a memory card
for further offline processing. Bodily movement was also calculated across the five
minutes prior to each iPOD entry. The signal was quantified by integrating each of the
axes of the accelerosensors and calculating the mean across axes. Prior to integration,
the signal was detrended by subtracting the DC-component from the AC-component.
Integrals were subsequently square root transformed.
Procedure
Study participants were instructed to choose a typical day for participation. They took part
in the laboratory session, which was appointed during a weekday in a time window
between 10 am and 5.30 pm. Thereafter they followed the ambulatory assessment
protocol for 22 hours. Upon arrival, participants were made familiar with the study protocol
and the technical equipment and signed informed consent. Subsequently, the electrodes
were attached, and signal quality was checked. They were told that a period of 5 minutes
would be needed to check the integrity of the physiological signal. During this time frame
they were given the opportunity to read lifestyle-magazines. Thereafter, the laboratory
task was initialized, beginning with the 3-minutes baseline recording, preparation period,
speech delivery, and recovery period. After the laboratory task participants were made
familiar with the ambulatory monitoring equipment. The vibration signal was initialized,
and participants were instructed to provide ratings of PA, NA, and location on the iPOD
following each alarm. Special care was taken to familiarize participants with the procedure
(i.e., vibration signal, iPOD entries). Overall, 2786 valid entries in the natural environment
of the participants were obtained averaging to approximately 25 entries for each
participant. Participants were asked to detach the electrodes after the recording period of
22 hours and to return the equipment to the laboratory the next morning. On account of
the sensitive technical equipment, participants were not allowed to engage in intense
aerobic training, bathing, or showering during the recording time.

Data Analysis
Multilevel analyses were applied. Models were calculated to predict ambulatory HR by
various level 1 [bodily movement, current smoking (0 = yes, 1 = no), location (0 = home
vs. 1 = other), NA (mean centered), PA (mean centered)] and level 2 -variables [sex (0 =
men, 1 = women), age (grand mean centered), WHR (grand mean centered), baseline
HR (laboratory; grand mean centered), ∆HR (laboratory; grand mean centered)], as well
as by the level 2-interaction of baseline HR and ∆HR, and the cross-level interaction of
∆HR and NA.
A continuous autoregressive error structure (CAR1) was specified, which handles
unevenly spaced assessments and thus, has been recommended in ambulatory designs
with non-stationary data recording (Schwartz & Stone, 1998). The covariance parameter
estimate was significant (Phi = .59), suggesting that this assumption was consistent with
the data. Participants were treated as a random effects variable throughout. Moreover,
we allowed heteroscedasticity with respect to location for each participant (random
intercepts and random slopes for location). These models proved superior when
compared to more simple models according to Log-Likelihood tests. Moreover, a model
including random slopes for both PA and NA was not superior, thus it was decided to
focus on the simpler model. Multilevel models were calculated by using the statistics
program R (Version 2.13.0; R Development Core Team, 2011), package “nlme” (Version
3.1-101; Pinheiro et al., 2012). The level of significance was fixed to p < .05 (two-tailed).
Results
Preliminary data analysis aimed to evaluate the effectiveness of the laboratory stress task.
Table 2 depicts M and SD of HR throughout the phases of the task. Data were analyzed
by means of a repeated-measurement ANOVA with Greenhouse-Geisser corrected
degrees of freedom, which revealed a significant main effect of task period [F(1.85,
224.38) = 209.19, p < .001, ε = .62, η2p = .63]. HR significantly increased from baseline
to preparation to speech (all p’s < .001) and declined thereafter (p < .001). Of note,
baseline and recovery values did not differ significantly from each other (p = .66).
Moreover, the Pearson correlation between baseline HR and ∆HR was calculated. It was
r = -.024 (p = .79), suggesting the independence of baseline and reactivity scores.
Next, the multilevel model was analyzed to predict ambulatory HR. First, a null model was
calculated to estimate the proportion of variance in ambulatory HR that could be
accounted for by individual differences (ICC, type 1; Bliese, 2000). It was found that
approximately 39% of the variance was due to individual differences, suggesting that a
substantial proportion of the variance was dependent on intraindividual (i.e., psychosocial,
contextual) factors. In a next step, the model was extended as reported in the Methods
section. The results of the random and fixed effects are shown in Table 3. The variance
of the random effect of location (random slope) was 15.52, thus corresponding to 20.26%
of the total variance. Moreover, there was a negative association between the intercept
and the slope of location (r = -.37), suggesting that with higher ambulatory HR the
difference between home versus other locations was attenuated. With respect to the fixed
effects several significant predictor variables could be identified. Bodily movement was
associated with elevated ambulatory HR. Moreover, men showed lower HR than women
and current smoking was accompanied by elevated HR. Being at home as compared to
other locations was related with lower ambulatory HR. Of note, both NA and PA were
positively associated with HR.
With respect to the laboratory variables it was found that baseline HR significantly
predicted ambulatory HR such that higher values were associated with elevated HR in the
field setting. Of note, ∆HR was not significantly related to ambulatory HR and there was
also no significant interaction effect of ∆HR and ambulatory NA. However, the interaction
of baseline HR and ∆HR on ambulatory HR was highly significant, suggesting that the
effect of cardiac stress reactivity was moderated by baseline HR. This interaction is
depicted in Figure 1.
In order to analyze this interaction in more detail, additional multilevel models were
calculated by centering either of the two interacting variables at the standard deviation
(resulting in high and low baseline HR or high and low ∆HR, respectively) and
recalculating the interaction with the other mean-centered variable. Hence, single slope
analyses for both baseline HR and ∆HR were conducted, thereby taking full advantage of
the whole sample size. For individuals showing attenuated baseline HR (1 SD below the
mean) there was a significant negative association between ∆HR and ambulatory HR (b
= -0.28, t = -2.89, p < .01), documenting that elevated ∆HR to laboratory stress was
accompanied by lower HR in the field. Conversely, for individuals with elevated baseline
HR (1 SD above the mean) a significant positive main effect for ∆HR was found (b = 0.42,
t = 4.48, p < .001), indicating higher ambulatory HR with elevated ∆HR in the laboratory.
After centering ∆HR at the standard deviation and mean-centering baseline HR the
following results were found: Participants with elevated ∆HR to the speech task (1 SD
above the mean) showed a significant positive relationship between baseline HR in the
laboratory and ambulatory HR (b = 0.76, t = 7.60, p < .001). There was also a significant
positive association for individuals with blunted ∆HR to the speech task (1 SD below the
mean), although this association was somewhat smaller in magnitude (b = 0.26, t = 5.38,
p < .001). Together, these findings suggest that ambulatory cardiac activation was highest
in individuals with both elevated baseline HR and elevated ∆HR during the laboratory
stress protocol and lowest for individuals with lower baseline HR and elevated ∆HR.
Discussion
The aim of this study was to analyse the relationship between cardiac responses to a
standardized laboratory challenge and ambulatory HR and to examine the reactivity
hypothesis in detail by applying a 22-hours ambulatory monitoring. It was found that ∆HR
in the laboratory was unrelated to ambulatory HR, thus suggesting that CVR might not be
a good indicator of everyday-life cardiovascular activity. Moreover, the interaction of ∆HR
and NA as exhibited in everyday-life was not significant in predicting ambulatory HR. Thus,
there was no support for the assumption that a strong cardiac response to the public
speaking task would be predictive of a comparably high ambulatory HR in situations that
are characterized by eliciting comparably high levels of NA (i.e., potentially indicating
stress).
Importantly, although ∆HR was not significantly associated with cardiac activation in
everyday-life per se, the relationship was moderated by baseline HR. In line with the
hypothesis of this study, elevated baseline HR and elevated cardiac reactivity to the
speech task were accompanied by elevated ambulatory HR. Conversely, when baseline
HR was low the relationship between HR reactivity and ambulatory HR was negative,
suggesting lower cardiac activity in the field with elevated ∆HR to laboratory stress.
Hence, these findings are in accordance with the hypothesis that both elevated baseline
HR and elevated CVR to stress might characterize hypervigilant and highly anxious
individuals (e.g., Berntson et al., 1998; Gianaros et al., 2008; Suinn, 2001), who tend to
exhibit elevated cardiovascular load in everyday-life. In particular, it might be assumed
that a hyperactive sympathetic nervous system activity underlies this phenomenon.

Importantly, elevated ∆HR and low baseline HR in the laboratory were related with the
lowest HR in the field. This finding is quite remarkable and documents that elevated
cardiac reactivity together with low baseline HR was accompanied by even lower
ambulatory cardiac activation than the combination of low baseline HR and blunted CVR
to stress. The findings seem to support theories proposing that elevated ∆HR might not
be problematic per se as long as it is accompanied by lower baseline activity (e.g.,
Dienstbier, 1989; McEwen, 1998). Dienstbier (1989) cited evidence suggesting that a fast
and strong physiological response to challenges assures energy allocation for active
coping at minimal psychological and physiological costs. Similarly, the theory of allostatic
load (McEwen, 1998) proposes that allostasis (i.e., the stress-related response of the
organism to regain homeostasis) is an adaptive response that aims to adjust the individual
to changing environmental demands. Correspondingly, when an individual exhibits low
basal cardiovascular activation and elevated CVR to a laboratory stressor one would
expect her/him to show comparably good adaptation to changing environmental demands,
leading to overall lower – and not higher – cardiovascular load in everyday-life.
Interestingly, the combination of low baseline HR and low cardiac reactivity was
associated with somewhat higher ambulatory HR. Although the clinical implication of this
finding warrants further research, it is somewhat in line with recent evidence suggesting
that blunted physiological reactivity might not always be beneficial for health (e.g., Phillips,
Ginty, & Hughes, 2013). Specifically, there is cumulating evidence suggesting that blunted
CVR to laboratory stress is related to depressive symptoms (e.g., Salomon, Clift,
Karlsdottir, & Rottenberg, 2009; Schwerdtfeger & Gerteis, 2013; Schwerdtfeger &
Rosenkaimer, 2011; York et al., 2007), early life adversity (e.g., Lovallo et al., 2012), poor
regulation of affect, obesity or abnormal motivational states in general (e.g., Carroll,

Phillips, & Lovallo, 2013; Lovallo, 2011). According to the findings of this study, it might
also be speculated that both blunted CVR and blunted baseline HR might not be
necessarily accompanied by beneficial cardiac functioning in daily life. Thus, grounded on
recent evidence for health-compromising effects of blunted CVR, the response pattern of
low cardiac baseline and low reactivity should be studied in more detail in future research.
Importantly, this study found no direct support for the reactivity hypothesis. In particular,
in accordance with this hypothesis it was expected that elevated cardiac reactivity to a
laboratory challenge should be related with elevated ambulatory HR in situations in which
NA is high, thus presumably indicating stressful events. However, the interaction was not
significant. It is interesting to note that this study is not the only one that failed to find
evidence for the generalizability of the reactivity hypothesis by applying an ecological
momentary assessment design. For example, Kamarck et al. (2003) could also not
demonstrate significant interactive effects of laboratory-based HR reactivity and
psychosocial variables related to stress in everyday-life on ambulatory HR.
The failure to find the hypothesized relationship in this study might be attributed to several
factors. First, it should be noted that this study sample exhibited a comparably low level
and variance of momentarily assessed NA, which might have resulted in restricted
statistical power to unveil meaningful interactions. Second, the NA measure might not
have captured stressful episodes with sufficient accuracy. Hence, alternative measures of
stress might be more adequate. Third, the validity of the laboratory stress task might be
questioned. Although we applied a well-validated laboratory challenge (Al’Absi et al.,
1997), which resulted in significant increases in HR, other research suggests that lab-field
generalizability might depend on very specific experimental conditions. For example,
Johnston et al. (2008) found that the cold pressor task was more closely related to a
standardized field stressor (giving a presentation) than to a public speaking task with
respect to CVR. Finally, it might be possible that lab-field generalizability is more prevalent
in other physiological measures, for example, blood pressure or cortisol, but to a lower
extend in HR.
Consequently, the results of this study warrant a closer examination of this interaction a)
in samples who have a comparably higher probability of experiencing NA and stressful
events in daily life (e.g., individuals undergoing stressful life events, individuals with high
job demands), b) with different laboratory stress tasks, and c) with different stress
measures and physiological variables (e.g., blood pressure, skin conductance, cortisol)
before definite conclusions about the generalizability of the reactivity hypothesis can be
drawn.
Although our findings suggest implications for health the clinical relevance of elevated or
blunted cardiac reactivity remains debatable. Whereas there is a large body of evidence
linking basal cardiac activation (i.e., resting heart rate) with CVD and mortality of various
causes (e.g., Benetos et al., 1999; Greenland et al., 1999; Hillis et al., 2012; Hsia et al.,
2009; Jensen, Suadicani, Hein, & Gyntelberg, 2013; Jouven, Zureik, Desnos, Guérot, &
Ducimetière, 2001; Okamura et al., 2004; Palatini, 2005; Woodward et al., 2012), other
research suggests that HR reactivity to a laboratory stress task is related with lower CVD
risk (Ahern et al., 1990) and lower prevalence of preclinical atherosclerosis as assessed
via intima media thickness (IMT; Heponiemi et al., 2007). Conversely, as already
mentioned recent research found evidence for adverse health effects of blunted
cardiovascular stress reactivity (e.g., Lovallo et al., 2012). Hence, considerably more
research is warranted on the health effects of both elevated and blunted laboratory-based
physiological reactivity measures.

The findings of our study could help explain the inconclusive findings for exaggerated
cardiac reactivity. Specifically, we would assume that when baseline HR is comparably
low, elevated cardiac responses to a stress task might not be related with elevated
disease risk, because this response pattern might not impose sustained effects on the
cardiovascular system. Hence, when studies aim to analyze cardiac reactivity without
taking baseline differences into account the clinical implications are likely to get blurred.
We are not aware of any study examining the interaction of baseline HR and CVR to
laboratory stress and to relate it to the development of clinical or preclinical disease states.
Such studies could help verify – or falsify – our hypothesis. Given the ambulatory findings
in our study and the robust evidence that basal cardiac activity is related to cardiovascular
morbidity and mortality, we would propose that both elevated baseline HR and ∆HR to a
laboratory challenge might have some clinical significance. With respect to the
consequences of blunted CVR our findings might suggest that low baseline cardiac
activation together with low cardiac reactivity might not necessarily indicate low
cardiovascular risk.
Of note, affect was positively associated with ambulatory cardiac activity, thus indicating
facilitating effects on HR. Whereas the finding for NA seems to be quite plausible, thereby
corroborating previous research (e.g., Brosschot, van Dijk, & Thayer, 2007; Pieper,
Brosschot, van der Leeden, & Thayer, 2007), the result for PA seems rather surprising.
Several studies suggest a soothing effect of PA on physiology as evidenced by higher
heart rate variability (e.g., Bacon et al., 2004), lower ambulatory heart rate (e.g., Steptoe,
Wardle, & Marmot, 2005) and lower cortisol levels (e.g., Polk, Cohen, Doyle, Skoner, &
Kirschbaum, 2005). However, it should be noted that the effects of PA on physiological
function may depend on different facets (Pressman & Cohen, 2005). In particular, whereas
activated PA might be associated with elevated psychobiological responses, indicating
metabolically relevant changes in activation, deactivated PA might be accompanied by
attenuated physiological responding. Importantly, the PA scale applied in this study
consisted of 4 activated adjectives (i.e., dynamic, brisk, delighted, awake) and 2
deactivated adjectives (calm, relaxed). Thus, the positive within-person association with
ambulatory HR could well be attributed to the activated connotation of the PA scale.
This study has some limitations that should be emphasized: First, the study was restricted
to HR only; hence, the findings may not generalize to other measures of autonomic
nervous system or endocrinological function (e.g., blood pressure, skin conductance,
cortisol). Thus, future studies are needed to explore the moderating role of baseline
activity to predict ambulatory psychophysiological activity from laboratory-derived
reactivity measures for other variables as well. Second, only one laboratory stress task
was applied, which precludes generalizability to other stress protocols. It would be
informative to analyze interactions between baseline HR and an aggregated score of CVR
to various stress tasks to predict ambulatory HR with higher accuracy (e.g., Kamarck et
al., 2000).
Conclusions
Although the present study could not find evidence that cardiac reactivity per se or in
combination with NA was predictive of cardiac activity in the field, it seems that elevated
baseline HR together with elevated stress reactivity could reliably index individuals who
are prone to elevated tonic cardiac activity in everyday-life, which is regarded a robust
indicator of morbidity and mortality (e.g., Palatini, 2005; Woodward et al., 2012). Hence,
our findings suggest that baseline has to be considered when aiming to generalize
laboratory-based CVR to cardiovascular activity as exhibited in the field. Both elevated
baseline HR and elevated cardiac reactivity to a public speaking task seem to be
accompanied by comparably high levels of cardiovascular load in everyday-life, thus
potentially increasing risk for CVD.

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Tables
Table 1: Variance Decomposition of Affect Scales Items and Summary Estimates of

Reliability
NA PA
Number of Items 6 6
Variance component
2Total 0.821 1.616
2P 0.112 13.6% 0.180 11.14%
2T 0.001 0.12% 0.005 0.31%
2I 0.038 4.63% 0.032 1.98%
2P*T 0.291 35.44% 0.488 30.50%
2P*I 0 0.00% 0 0.00%
2T*I 0 0.00% 0 0.00%
2Residual 0.379 46.46% 0.911 56.37%
GT reliability estimates
RKR .89 .87
RC .82 .76
Note. N=111. 2 = variance component, P = person, T = time, I = item; RKR =
between-person reliability; RC = within-person reliability.

Table 2: Descriptive statistics for heart rate (HR) during the laboratory stress protocol.
Values are beats per minute (BPM)
Baseline Preparation Speech Recovery

M 73.98 82.83 89.55 73.84
SD 10.84 12.88 15.02 11.21
Note: N = 122
Table 3: Multilevel Model Relating Heart Rate to Level 1 and Level 2 Predictors
Random Effects VAR Corr

Intercept 50.27 Intercept
Location 15.52 -.37
Residual 70.90
Fixed Effects
Parameter Estimatea (SE) Df t p
Intercept 76.24 (1.21) 2634 62.96 < .001
Bodily movement 1.04 (0.02) 2634 48.83 < .001
Sex (men vs. women) -5.93 (1.68) 104 -3.53 < .001
Age -0.10 (0.09) 104 -1.10 .275
WHR 12.33 (9.90) 104 1.25 .216
Smoking (yes vs. no) 3.09 (0.78) 2634 3.95 < .001
Location (at home vs. not at
-3.85 (0.57) 2634 -6.77 < .001
home)
NA 1.84 (0.41) 2634 4.50 < .001
PA 2.42 (0.30) 2634 8.20 < .001
HRBL 0.51 (0.06) 104 8.32 < .001
∆HR 0.07 (0.07) 104 1.06 .291
HRBL x ∆HR 0.02 (0.005) 104 5.11 < .001
∆HR x NA -0.02 (0.03) 2634 -0.45 .650
Note. N = 111 with 2,751 assessments. VAR = variance, a = estimates are
unstandardized partial regression coefficient, Df = degrees of freedom, SE = standard
error, WHR = waist to hip ratio, NA = negative affect, PA = positive affect, HRBL =
Heart rate during baseline, ∆HR = Heart rate reactivity during speech. The model
includes an autoregressive error term (Phi = .59), a random intercept (participant) and
a random slope for location (home vs. not at home).

Figure Captions
Figure 1. Two-way interaction between baseline heart rate (HR) and HR reactivity to a
public speaking task on ambulatory HR. When baseline was high, participants with
comparably strong responses showed significantly elevated HR in everyday-life.
Conversely, a low baseline together with elevated HR reactivity predicted a comparably
low ambulatory HR. Please note: Values are predicted values derived from the multilevel
model.
Acknowledgements
This research was funded by the German Research Foundation (DFG; Grant No. SCHW
1188/5-1).
5 Study 3: The ecological validity of ASRD in responsive

coping.
The Ecological Validity of the Autonomic-Subjective Response

Dissociation in Repressive Coping
Andreas R. Schwerdtfeger* & Eva-Maria Rathner
Department of Psychology, Health Psychology Unit, University of Graz, Austria
Acknowledgements: We are grateful to Michaela Hiebler, Sabine Heene, Bianca

Würger, Regina Pabst, Elisa Maier, and Bernadette Hofer for their help in data collection
and data parametrization.
This research was funded by the German Research Foundation (DFG; Grant No. SCHW
1188/5-1)
University of Graz
Tel.: +43 316 380-4953
Fax: +43 316 380-9807
Abstract
Background: Repressive coping has been associated with elevated cardiovascular
reactivity and diminished self-reported negative affect (so-called autonomic-subjective
response dissociation; ASRD) in response to laboratory stressors.
Objectives: However, there is a lack of knowledge regarding the ecological validity of this
response pattern.
Methods: An ambulatory assessment strategy was applied in order to analyze
associations between ASRD and repressive coping throughout a day. A sample of 114
individuals was recruited. Heart rate was recorded via ECG and subjective reports of
negative affect as well as the experience of demand and control (as indicators of stress)
and situational characteristics were assessed several times a day via mobile electronic
devices.
Results: Repressive coping relative to other coping dispositions was accompanied by
elevated ASRD during stressful episodes in daily life, thus supporting previous laboratory
research.
Conclusions: The findings suggest that repressive coping is associated with a
discrepancy between subjective reports of negative affect and autonomic responding to
stressful encounters in everyday-life, which might impact health.
Keywords: ambulatory assessment, demand-control model, repressive coping,
subjective-autonomic response dissociation

Introduction
Research throughout the last decades could convincingly demonstrate that individuals
seem to prefer certain coping strategies that they tend to use habitually throughout
different aversive encounters (e.g., Krohne, 2003; Weinberger, Schwartz, & Davidson,
1979). Whereas some individuals tend to avoid elaborating in detail on the threatening
aspects of a specific aversive situation, others seem to allocate their attention closely to
the impending aspects of the stressor. Indeed, both these strategies [i.e., cognitive
avoidance (CAV) and vigilance (VIG)] seem to play prominent roles in different theories
of coping with threat (e.g., Derakshan, Eysenck, & Myers, 2007; Krohne, 1993; Miller,
1980; Roth & Cohen, 1986; Skinner, Edge, Altman, & Sherwood, 2003).
According to the model of coping modes (Krohne, 1993), for example, CAV and VIG are
suggested to constitute conceptual independent coping dimensions that do not preclude
each other. That is, individuals might choose either more vigilant or more avoidant
strategies, both strategies in combination, or none of these. Thus, according to the model
of coping modes individuals can be designated along their preference of either of the two
strategies into repressive copers (high CAV, low VIG), sensitizers (low CAV, high VIG),
high-anxious copers (high on both dimensions), and non-defensive copers (low on both
dimensions) 1. The validity of this method has been demonstrated in several studies (e.g.,
Hock, & Krohne, 2004; Hock, Krohne, & Kaiser, 1996; Peters, Hock, & Krohne, 2012).
It has been suggested that some of these coping modes might be more adaptive than
others. Originating from psychodynamic theory (e.g., Erdelyi, 2006) the repressive coping
disposition has raised considerable interest among researchers for several decades now
(for a conceptual discussion of repressive coping, see Garssen, 2007 and Myers, 2010).
It refers to a group of strategies that aim to shield the organism from stimuli that could
threaten the self (e.g., Weinberger, 1990). Hence, individuals who consistently use
repressive coping strategies tend to minimize the relevance of the stressor, use self-
enhancing cognitive strategies, or negate the impact of threat-related cues on the self
(e.g., Krohne, 1989). Although repressive coping aims to shield the organism from threat,
it has been hypothesized to constitute a rather maladaptive strategy because the
consistent use of CAV could undermine more adaptive problem-focused approaches,
leading ultimately to deleterious effects on adjustment to stressful encounters.
Importantly, laboratory-based stress research converge to suggest that individuals who
predominately use repressive coping strategies exhibit elevated autonomic nervous
system (ANS) responses to stressful encounters [e.g., higher heart rate (HR)], while at
the same time they tend to report low subjective stress, anxiety and negative affect (NA;
for an overview, see, Schwerdtfeger & Kohlmann, 2004). Hence, the underreporting of
negative states and feelings is a characteristic of repressive copers. This response pattern
has been referred to as autonomic-verbal response dissociation or, more specifically, as
autonomic-subjective response dissociation (ASRD). For example, several studies found
comparably stronger behavioral (e.g., Asendorpf & Scherer, 1983; Weinberger et al.,
1979), cardiovascular (Asendorpf & Scherer, 1983; Kohlmann, Weidner, & Messina, 1996;
Newton & Contrada, 1992; Schwerdtfeger, Schmukle, & Egloff, 2006a), electrodermal
(e.g., Barger, Kircher, & Croyle, 1997; Brosschot & Janssen, 1998), and cortisol
responses (e.g., Rohrmann, Netter, Hennig, & Hodapp, 2003) than subjective reports of
discomfort to stressful aversive encounters in individuals with a repressive or cognitive
avoidant coping disposition, thus suggesting that elevated reactivity in repressers might
extend beyond the autonomic nervous system.

Of note, the vigilance-avoidance theory (Derakshan et al., 2007) aims to ascribe this
discrepancy in repressive copers to different, consecutively applied, information
processing strategies. In particular, whereas repressive copers are hypothesized to be
rather attentive at a very early stage of information processing, they seem to apply
cognitive avoidant strategies later on. This initial allocation of attention could be key to
detect threatening cues early and could trigger automatic behavioral and physiological
threat responses. In a later stage of information processing, avoidant cognitive biases
(e.g., attentional, interpretative, and memory) are thought to predominate that may result
in low self-reported NA, thus ultimately contributing to the ASRD. Other theorizing has
hypothesized that the discrepancy of self-reported NA and ANS reactivity could reflect an
impaired (i.e., dysregulated) self-regulatory system (e.g., Lambie & Marcel, 2002;
Schwartz, 1990). Hence, repressers might not adequately perceive and process
physiological signals, thus lacking feedback from the body, which might impair self-
regulation.
Of note, it has been shown that the ASRD constitutes a rather stable trait-like response
pattern (Levin & Linden, 2008; Schwerdtfeger, Schmukle, & Egloff, 2006b). Specifically,
Schwerdtfeger et al. (2006b) could show that the HR-based ASRD proved to be superior
to a skin conductance-based score with respect to consistency across different laboratory
stressors and long-term stability throughout a time interval of one year. Levin and Linden
(2008) could confirm the relative stability of the ASRD (based on different cardiovascular
measures) within a time period of 3 years. Given this evidence it might be assumed that
the cardiovascular-based ASRD constitutes a dispositional response style that pervades
various stressful situations in everyday-life. The ecological validity of this response
pattern, however, has not been demonstrated yet. Of note, identifying discrepant
responses of NA and ANS responses across diverse situations in everyday-life could
imply clinical relevance of this response pattern. Therefore, the present study aimed to
record HR and self-reported NA throughout 22 hours to examine the relative (im)balance
of both measures in real life as related to repressive coping. Drawing on previous research
it was of interest to examine whether repressers show elevated autonomic relative to
subjective responses in stressful situations outside the laboratory in everyday-life, thus
verifying the ecological validity of the ASRD.

Method
Participants
Overall, 131 individuals participated in this study. They were recruited via flyers and
announcements at the university campus and at the local city center. There were 66
women and 65 men and 31 (24%) were smokers. Participants were screened prior to the
study for medication use and cardiovascular diseases by means of an online
questionnaire. Hence, only individuals without self-reported cardiovascular diseases
(hypertension, ischemic heart disease, cardiopulmonar disease, cerebrovascular
disease) and without cardiovascular and psychoactive medication were eligible for study
participation. The data of 11 participants could not be used due to excessive artefacts in
the electrocardiogram (ECG; poor signal quality, frequent ectopic beats), technical failure
(n = 2), or withdrawal from the study (n = 4), leaving a total of 114 participants (60 women)
for analysis. Descriptive data of the final sample are reported in Table 1.
Research Design
The study was part of a larger research project on coping and health, comprising of a
laboratory stress protocol, a sonographic assessment of the carotid arteries, a blood
sample, and a 22-hours ambulatory assessment, which will be described in more detail.
Specifically, the individual’s mode of coping was assessed via questionnaire and
physiological and subjective variables were recorded throughout one weekday. Therefore,
participants were equipped with ambulatory monitoring devices to record the ECG and
bodily movement to control for metabolically relevant changes in HR. In addition,
participants were repeatedly asked to provide ratings of their current location, smoking,
affect, demand and control (to quantify stress) on that particular day by using electronic
devices (iPOD touch 4GB, Apple Inc.). The decision to use demand and control ratings to
measure stress was grounded on Karasek’s stress model (Karasek, 1989), which
postulates elevated vulnerability to disease in individuals who experience high demands
and comparably low control during work. Indeed, several studies found evidence for higher
risk for cardiovascular diseases in individuals who report more demands and less control
during work (so-called demand/control-ratio) (e.g., Alterman, Shekelle, Vernon, & Burau,
1994; Slopen, Glynn, Buring, Lewis & Williams, 2012). Of note, using an ambulatory
assessment strategy Kamarck et al., (2004) could show that the role of demand and
control experience in health and disease was not tied to the work context. They
demonstrated that both variables were reliably associated with physiological responding
on a momentary basis in everyday-life as well. Importantly, the advantage of using
demand and control ratings to quantify stress in the present research -- and not applying
a more ordinary stress measure -- was grounded on the common finding that individuals
with a repressive coping disposition tend to underreport both NA and stress during
aversive encounters (e.g., Schwerdtfeger & Kohlmann, 2004). Thus, a more indirect
approach deemed more appropriate for this study. Participants were also instructed to fill
out a questionnaire to assess coping modes and demographic and lifestyle variables (e.g.,
regular physical exercise, smoking status) prior to the ambulatory protocol.
Variables and Instruments
Coping. The German version of the Mainz Coping Inventory (MCI, Krohne, Egloff, Varner,
Burns, Weidner, & Ellis, 2000) was applied to assess coping modes. The MCI has been
developed to assess preferred coping strategies on a dispositional level and has been
well validated (e.g., Hock & Krohne, 2004; Krohne et al., 2000; Peters, Hock, & Krohne,
2012). The MCI measures CAV (e.g., attentional diversion, self-enhancement, denial) and
VIG (e.g., information search, anticipation of negative events) directly in four ego-(i.e.,
self-)threatening (public speaking, exam, job interview, mistake on the job) and four
physically threatening situations (dentist, inexperienced driver, group of people, turbulent
flight) of varying controllability. For each situation five CAV and five VIG response options
are given in a true-false format. Answers were summed for CAV and VIG items,
respectively, across all situations to yield a measure of dispositional cognitive avoidant
and vigilant coping. Cronbach’s alpha was .79 for CAV and .87 for VIG. CAV and VIG
were moderately negatively interrelated (r = -.38, p < .001), thus supporting recent
research with this instrument (e.g., Peters et al., 2012).
Of note, the model of coping modes posits that both CAV and VIG can vary independent
of each other, thereby determining an individual’s mode of coping (repressive copers,
sensitizers, non-defensive copers, and high-anxious copers; e.g., Krohne, 1993). It should
be noted that the negative interrelation of CAV and VIG in this sample leads to a slight
overrepresentation of repressers and sensitizers, whereas individuals scoring low or high
on both dimensions, respectively are underrepresented, thus diminishing statistical power.
Our main data analytic strategy was to calculate the interaction of the continuous variables
CAV and VIG to analyze coping modes.
Demographic and lifestyle variables. Demographic (age, sex, family status) and lifestyle
variables (smoking, physical exercise) were assessed by means of a self-constructed
questionnaire. Waist to hip-ratio (WHR) was assessed objectively via an elastic centimeter
belt. These variables were included because they could substantially effect HR and NA.
Psychophysiological monitoring. Physiological variables (ECG, bodily movement) were
recorded by means of a lightweight ambulatory monitoring device (Varioport-b, Becker
Meditec Karlsruhe, Germany). This device is capable of recording up to 16 physiological
channels with 16 bit resolution. It is lightweight (170 grams), and the dimensions are 12
(length) x 6.5 (width) x 2.2 cm (height). It is worn on the right side of the chest via a chest
belt. HR was recorded by means of an ECG by applying a chest lead, and participants
were grounded on the lower right rib cage. Disposable tap electrodes (Ambu® Blue
Sensor VL) were used for signal transduction. The ECG signal was scanned with 512 Hz
and sampled with 256 Hz on a memory card.
In addition, bodily movement was recorded by means of two accelerosensors. A uni-
dimensional accelerometer (Becker Meditec®, Karlsruhe, Germany) was attached on the
left thigh (above the knee) to measure leg movements, and a three-dimensional
accelerometer was located inside the VARIOPORT-b. The sensitivity of the
accelerometers is 0.2 milli Gs. Signals from each sensor were sampled at 16 Hz and
stored on a memory card for further offline processing. Importantly, bodily movement was
recorded to control for metabolically relevant changes in HR. Thus, increases in HR that
were not due to mental stress or affect but rather reflected metabolic adjustments to
increased muscle activity could be controlled for.
Ambulatory psychological variables. iPODs were programmed with the software
iDialogPad App by G. Mutz (University of Cologne, Germany) to assess demand, control,
NA, positive affect, and situational and behavioral characteristics in everyday-life. Reports
were given signal-contingent following an acoustic signal, which was initialized about
every 45 minutes (± 10 minutes). The interval between two alarms could therefore vary
between 35 and 55 minutes to prevent anticipatory behavioral adjustments. Participants

were asked about the perceived demand and control as well as affect during the five
minutes prior to each alarm. Items were presented in pseudo-randomized order. Demand
and control ratings were provided using 6-point Likert scales with the poles 1 (low) and 6
(high). The mean demand score in this sample was 3.21, indicating rather moderate levels
of demand (SD = 1.14, MIN = 1, MAX = 6). The mean control score was 5.16 (SD = 0.96,
MIN = 1, MAX = 6), documenting comparably high levels of control in everyday-life.
Demand/control ratio was calculated to quantify stress (e.g., Slopen et al., 2012). The
demand/control ratio was 0.67 (SD = 0.35, MIN = 0.33, MAX = 3), which indicated rather
moderate levels of perceived stress.
NA was assessed using six adjectives that were presented on the iPOD screen. Adjectives
were as follows: unsafe, discouraged, anxious, ashamed, worried, and dissatisfied. A six-
point response format was chosen ranging from 1 (not at all) to 6 (very much so). Scores
were summed across items, resulting in a possible range of scores between 6 and 36.
The mean sum across all entries was 8.68 (SD = 3.77, MIN = 6.00, MAX = 36.00),
indicating rather moderate levels of NA throughout the day. Of note, positive affect (i.e.,
dynamic, relaxed, calm, brisk, delighted, awake) was also recorded to ensure that
participants were not overly biased toward the reporting of negative affective states.
However, this measure was not further considered in this study because of the prominent
role of NA in research on repressive coping and the lack of a theoretical underpinning of
the relationship between repressive coping and positive affect. Reliabilities of the affect
scales are reported in detail elsewhere (Schwerdtfeger, Schienle, Leutgeb, & Rathner,
2014) and suggested that affect could be reliably assessed.
Additionally, participants were asked to report their location (work, home, outside, vehicle)
and whether they engaged in smoking during the last five minutes (no vs. yes). With
respect to location, being at home was contrasted with all other locations because
previous research has unveiled substantially lower cardiovascular activation and NA when
individuals were at home as compared to other settings (e.g., Gump et al., 2001;
Schwerdtfeger & Friedrich-Mai, 2009). Moreover, momentary smoking has been found to
impact ANS function (e.g., Karakaya et al., 2007; Schwerdtfeger & Gerteis, 2014).
Importantly, each EMA assessment was supplied with a time stamp to permit precise
matching with the corresponding physiological signals (i.e., ECG traces, bodily
movement). Overall, 2786 valid electronic momentary assessment (EMA) entries were
obtained, averaging to approximately 25 entries for each participant across the 22-hours
recording period.
Procedure
Study participants were instructed to choose a typical day for participation. Upon arrival,
participants were made familiar with the study protocol and the technical equipment and
signed informed consent. Subsequently, the electrodes were attached and signal quality
was checked. An acoustic signal was initialized, and participants were instructed to
provide ratings of demand, control, affect, and location on the iPOD following each alarm
(as referred to a time-interval of five minutes prior each alarm). Special care was taken to
familiarize participants with the procedure (i.e., acoustic signal, iPOD entries). Participants
were explicitly informed about the possibility of muting or ignoring a prompt if necessary
(e.g., while driving a car or attending a meeting), and to initialize an assessment manually
later on. However, it was emphasized that participants should make every effort to
respond to the acoustic prompts and that manual assessment initiation was meant to be
an exception. Participants were asked to detach the electrodes after 22 hours and to
return the equipment to the laboratory the next day. On account of the sensitive technical
equipment, they were not allowed to engage in intense aerobic training, bathing, or
showering during the recording time. Participants were compensated with up to 100 Euros
for participating in the research project. The study was approved by the institutional ethics
review board of the University of Graz and was therefore performed in accordance with
the ethical standards laid down in the 1964 Declaration of Helsinki.
Parameterization of the Physiological Signals and Calculation of the ASRD
The ECG was analyzed by means of a semi-automatic peak detection software (written
with LABVIEW® 6.0i; National Instruments). Segments were extracted out of the 22-hour
recording according to the time stamps identified on the iPOD. The ECG was analyzed
for five minutes prior to each EMA entry on a minute-by-minute basis. Previous to
parameterization, the ECG was low-pass filtered with 30 Hz to overcome gross movement
artifacts. Interbeat intervals (IBIs) were then calculated in milliseconds for each minute.
Extraordinarily strong successive IBI variations were corrected by a moving average
procedure if they differed by more than a multiplier of 1.5 or 0.7 from the previous IBI.
Minutes with more than 5 erroneous IBIs were discarded.
Bodily movement was also calculated across the five minutes prior to each iPOD entry.
The signal was quantified by integrating each of the axes of the accelerosensors and
calculating the mean across axes. Prior to integration, the signal was detrended by
subtracting the DC-component from the AC-component. Integrals were subsequently
square root transformed.
Ambulatory ASRD. Laboratory studies usually quantify ASRD by z-transforming both NA
and ANS reactivity (relative to a baseline period) and subtracting one value from the other.
Hence, individual autonomic and subjective reactivity is typically quantified relative to the
study sample (z-transformation). Obviously this approach is not feasible in ambulatory
designs with multiple assessments for multiple individuals, thus intermixing within- and
between-person variance. Specifically, z-standardization implies relating the individual
score to the sample. In ambulatory designs with multiple (and differentially spaced and
differentially numbered) repeated assessments per person a z-standardization would treat
intra- and interindividual assessments equally, which means that each data entry of each
person would be related to both within- and between-person variation. Even more,
because individuals differ in the number of data entries, the individual response in a given
situation would strongly depend on the number of assessments within the other
participants, which would severely distort the findings. Z-standardizing solely within-
person would also be problematic, because each data entry of each person would be
compared solely to the intraindividual variation. Obviously, such an approach would not
allow to detect stable between-person differences (i.e., trait differences in coping as
suggested by the model of coping modes), but merely context-dependent differences in
response discrepancies. Therefore, an alternative quantification was applied as outlined
below.
Ambulatory ASRD was quantified by referring HR and NA to the potential maximum and
then, calculating the difference between both relative values (HRrel minus NArel). The
potential maximum of HR was calculated for each individual separately with the formula
208 - (0.7 x age) (Tanaka, Monahan, & Seals, 2001). HRrel was then quantified by dividing
HR by the individual maximum HR and multiplying it by 100. We decided to use the
formula of Tanaka et al. (2001) instead of more simple formulas (e.g., 220 minus age),
because it has been developed for healthy participants based on meta-analytic evidence
with 18,712 participants. Of note, this quantification has been found to be independent of
sex and habitual physical activity status, thus suggesting a reasonable good
approximation to maximum HR. Maximum NA was set to the potential maximum of 36 (6
items with a maximum rating of 6) for each individual and each entry. Similar to HRrel,
NArel was calculated by dividing NA by the maximum and multiplying it by 100. Hence,
for each individual and each momentary assessment the percentage of actual NA relative
to the possible maximum score was subtracted from the percentage of actual HR relative
to the individual maximum HR. Across all entries this resulted in a mean ambulatory ASRD
of 20.59 (SD = 13.11, MIN = -51.74, MAX = 72.76), suggesting a preponderance of
autonomic relative to subjective responding. Importantly, it has been suggested that the
ASRD captures incremental information only when both variables entering the score are
somewhat interrelated. Otherwise, it would merely reflect the main effect of one of its
constituting variables (Walschburger, 1981). Therefore, a multilevel model accounting for
an autoregressive error structure was specified to predict HRrel from bodily movement
and NArel. Both variables were significantly positively correlated (b = 0.024, t = 1.98, p <
.05), suggesting that the ASRD captured unique variance.
Data Analysis
Multilevel modeling. Multilevel modeling was applied. This statistical approach is well
suited for ambulatory monitoring designs with extensive within-person assessments (e.g.,
Laurenceau & Bolger, 2012; Nezlek, 2012). Several models were calculated to predict
individual observations in demand/control-ratio and ambulatory ASRD. The models are
specified in the Results section in more detail. In general, location (1 = home vs. 0 = other)
was treated as a Level-1 predictor throughout. Variables that had no natural zero in this
study (e.g., age, WHR, CAV, VIG) were centered prior to analysis to facilitate
interpretation of coefficients. Demand/control-ratio was rescaled by subtracting the value
1 (hence, a balanced ratio of demand and control was rescaled to zero). For ambulatory
ASRD, we also controlled for the effect of the time-covarying variable bodily movement,
which was treated as a Level-1 fixed effect. Moreover, we specified a continuous
autoregressive error structure (CAR1), which handles unevenly spaced assessments and
thus, has been recommended in ambulatory designs with non-stationary data recording
(Schwartz, & Stone, 1998). Of note, because this design involved non-stationary
measurement points (i.e., ecological momentary assessments could occur anywhere in a
time frame from 35 to 55 minutes), the statistical analysis needs to account for variations
in interrelationships between repeated measurements of varying length. The covariance
parameter estimate was significant in each model, suggesting that this assumption was
consistent with the data. Participants were treated as a random effects variable
throughout. Moreover, for predicting ambulatory ASRD we allowed heteroskedasticity with
respect to demand/control-ratio for each participant (random intercepts and random
slopes). These models proved superior when compared to more simple models according
to Log-Likelihood tests. Multilevel models were calculated by using the statistics program
R (Version 3.1.0; R Development Core Team, 2014), package “nlme” (Version 3.1-117;
Pinheiro et al., 2014).

Results
Predicting Stress in the Field Setting
Firstly, associations between coping and demand/control-ratio in everyday-life were
analyzed in order to examine whether the stress measure was independent of the coping
mode. Multilevel modeling was applied specifying a null model to estimate the proportion
of variance in demand/control-ratio that could be accounted for by individual differences
(ICC, type 1; Bliese, 2000). It was found that approximately 24% of the variance was due
to individual differences, suggesting that a substantial proportion of the variance was
dependent on intraindividual (i.e., situational) factors.
Next, demand/control-ratio was regressed on age, sex, location, CAV, VIG, and the
interaction of both these strategies. Moreover, heteroscedasticity with respect to location
was allowed (random intercept and random slopes for each participant). It was found that
neither age (b = 0.002, SE = 0.002; t = 0.77) nor sex (b = 0.02, SE = 0.03; t = 0.56) were
significantly associated with demand/control-ratio. When participants were at home as
compared to other locations, they showed a significantly lower demand/control-ratio (b =
-0.08, SE = 0.017, t = -4.61), documenting lower levels of stress. CAV was unrelated with
demand/control-ratio (b = -0.005, SE = 0.003; t = -1.52), but there was a significant positive
association with VIG (b = 0.007, SE = 0.002; t = 3.05), indicating that VIG was associated
with the reporting of more stress. Importantly, the interaction between CAV and VIG was
not significant (b = -0.0003, SE = 0.0003; t = -0.89), thus documenting that coping modes
did not systematically differ with respect to demand/control-ratio.

Predicting Ambulatory ASRD
Again, a null model was analyzed first in order to get an estimate of the proportion of the
individual variance of the ambulatory ASRD. The ICC(1) was .49, thus suggesting that
49% of the variance in response discrepancies throughout the recording period was due
to individual (i.e., trait-like) differences.
Next, ambulatory ASRD was regressed on several demographic and lifestyle-variables
(including bodily movement, age, sex, WHR, location, smoking at time of assessment),
and on demand/control-ratio, CAV, VIG and the interaction of the latter three variables.
Heteroscedasticity was modeled with respect to demand/control-ratio (random intercept
and random slopes for each participant). The result of this analysis is presented in Table
2. Bodily movement significantly predicted ASRD with higher amount of movement being
associated with relatively greater autonomic than subjective responses. Moreover, older
participants showed elevated ASRD as compared with younger participants and
momentary smoking was accompanied by elevated ASRD relative to not smoking. When
participants were at home as compared to other locations they showed a smaller response
discrepancy.
There were no main effects of CAV and VIG, respectively, but demand/control-ratio was
significantly negatively related with ambulatory ASRD, indicating that higher levels of
stress were accompanied by greater subjective than autonomic activation. Moreover, a
significant CAV x VIG interaction was found. This effect was examined further by centering
CAV at the standard deviation, thus allowing for simple slope analyses for individuals high
and low in CAV, respectively (e.g., Webster, Kirkpatrick, Nezlek, Smith, & Paddock, 2007).
For individuals high in CAV there was a significant negative association between VIG and
ASRD (b = -0.33, SE = 0.19, t = -2.07), documenting that higher use of vigilant coping
strategies among cognitive avoidant copers was associated with attenuated response
discrepancies. In other words, high-anxious copers (individuals scoring high on both
dimensions) showed a comparably low ASRD as compared to repressers (high CAV, low
VIG).
Importantly, the two-way interaction between CAV and VIG was further qualified by a
significant three-way interaction including demand/control-ratio2. A graph of this
interaction is depicted in Figure 1. This interaction was analyzed further by centering
demand/control-ratio at the standard deviation and recalculating the model for situations
with comparably low stress (-1 SD on demand/control-ratio) and comparably high stress
(+1 SD on demand/control-ratio). These analyses revealed that there was no reliable CAV
x VIG interaction when stress was comparably low (b = -0.03, SE = 0.16, t = -1.71, p =
.09), suggesting that coping modes did not differ during low-stressful situations. However,
with increasing levels of stress the coping modes differed significantly with respect to
ambulatory ASRD as became evident by a significant two-way interaction between CAV
and VIG (b = -0.05, SE = 0.02, t = -2.26, p = .03), documenting that repressive copers
showed comparably high ASRD during stressful situations.
Further analyses were conducted to examine the slopes between low stressful and high
stressful situations for each coping mode in detail. Therefore, both CAV and VIG were
alternately centered at the respective standard deviation and the model was re-calculated
several times. Specifically, 4 additional models were compared with respect to the main
effect of the stress measure (demand/control-ratio): low CAV, low VIG (non-defensives);
low CAV, high VIG (sensitizers); high CAV, low VIG (repressers); high CAV, high VIG
(high-anxious). Of note, there were significant main effects for each group; however, the
strongest stress-related decline in ASRD was found for non-defensive copers (b = -10.75,
SE = 2.15, t = -5.00, p < .0001), followed by sensitizers (b = -8.41, SE = 1.36, t = -6.18, p
< .0001) and high-anxious copers (b = -7.81, SE = 2.15, t = -3.64, p < .0001), whereas it
was considerably less pronounced in repressers (b = -3.84, SE = 1.68, t = -2.29, p = .022).
In a final step, the stress-dependent slopes between coping modes were compared by
centering either CAV or VIG at the standard deviation and calculating the three-way
interaction with the other mean-centered coping variable and demand/control-ratio. For
individuals with relatively low CAV-scores (1 SD below the mean) there was no significant
interaction between VIG and demand/control-ratio (b = 0.16, SE = 0.16, t = 1.01, p = .312).
In a similar vein, the two-way interaction between VIG and demand/control-ratio was not
significant for participants with comparably high CAV-scores (b = -0.27, SE = 0.19, t = -
1.46, p = .146). Both these models suggest that repressers (high CAV, low VIG) did not
show different slopes from low stress to high stress situations as compared to high-
anxious individuals (high CAV, high VIG). Moreover, sensitizers (low CAV, high VIG) did
not differ from non-defensive copers (low CAV, low VIG).
In sum, the findings of these models indicate that repressers generally showed higher
ASRD irrespective of the stressfulness of the situation as compared to high-anxious
individuals. Moreover, the stress-related decline in ASRD was moderated by coping
mode. Although there were no significant coping-related differences during low stress
situations, the decline towards high stress situations was less steep in repressers and
high-anxious copers. Hence, individuals with a repressive coping disposition showed the
highest level of ambulatory ASRD of all groups when stress was comparably high.
Discussion
The aim of this study was to examine the ecological validity of the discrepancy between
autonomic and subjective responses in repressive coping using ambulatory monitoring
technology. The hypothesis that repressive copers show a preponderance of autonomic
relative to subjective activation in stressful situations in daily life could be substantiated,
thus establishing ecological validity of the ASRD.
This finding support previous laboratory-based work on repressive coping and the
discrepancy between autonomic and subjective reactivity during stressful encounters
(e.g., Schwerdtfeger & Kohlmann, 2004). In particular, repressers showed a higher ASRD
as compared to the other coping modes. Of note, this effect was only evident when stress
in everyday-life was comparably high. There were no significant differences between
coping modes during low stressful situations. Hence, the findings of this study are
compatible with the vigilance-avoidance theory of repression (Derakshan et al., 2007).
According to this theory repressive copers are hypothesized to be rather attentive at an
early information processing stage, which may trigger exaggerated physiological reactivity
and spontaneous anxiety-related behavior during aversive encounters. They are avoidant,
however, at the later stages of information processing by showing interpretative biases of
their own behavior and physiology and impaired retrieval of threatening autobiographical
memories. Thus, the present findings could be interpreted in terms of a dynamic
information processing strategy exhibited by repressive copers, resulting ultimately in
elevated ambulatory ASRD.
It should be noted, though, that it remains debatable whether the early attention toward
threat is solely accompanied by elevated physiological reactivity in repressers. It has been

speculated that effort-related processes might result in response discrepancies as well,
and repressive copers have been suggested to invest more effort during self-threatening
tasks (e.g., Schwerdtfeger & Kohlmann, 2004). Moreover, Schwerdtfeger and Derakshan
(2010) could observe that disengagement from angry faces (i.e., use of cognitive avoidant
strategies) during a spatial cueing paradigm was associated with elevated
parasympathetic withdrawal during a public speaking task, thus suggesting that
attentional diversion might have physiological consequences as well. Future research
should aim to elucidate the physiological concomitants of the time line of threat processing
in repressive copers in more detail to help elucidating the mechanisms behind the ASRD.
To our knowledge this is the first report of a relationship between repressive coping and
ASRD in a real life setting without exposing participants to a standardized stress task (e.g.,
public speaking, standardized interview, picture viewing). Although this approach is
certainly hampered by the non-comparability of the stressors individuals face in their daily
life, it offers new insights into the ecological validity of this primarily laboratory-based
phenomenon. Importantly, individual (i.e., trait-like) differences accounted for
approximately 49% of the variance in ambulatory ASRD, thus supporting a previous study,
which could find that HR-based dissociation scores showed cross-situational consistency
and reasonable long-term stability throughout one year (Schwerdtfeger et al., 2006b).
Hence, the finding of the present study adds further support to the hypothesis that the
ASRD constitutes a relatively stable individual response characteristic related to
repressive coping.
Of note, the adapted approach to quantify response discrepancies in the field setting
resulted in an elevated ASRD when stress was low (comparably low demand and high
control) and a low ASRD when demand increased and control decreased (i.e., higher
stress), indicating that participants responded with a generally stronger increase of NA
during stress as compared to autonomic activation.
Previous research suggested that elevated ASRD might be associated with impaired
symptom perception (e.g., Papousek, Schulter, & Premsberger, 2002; Schwerdtfeger et
al., 2006a), thus constituting a plausible mechanism through which repressive coping
might impact health. In particular, an imbalance between ANS and subjective responding
during stressful situations could indicate impaired self-regulation (e.g., Schwartz, 1990).
Specifically, repressers might lack feedback from their body when they are stressed,
leading to flattened subjective responses. Attenuated NA in such situations could then
foster continued exposure to challenging environments, which could result in wear and
tear on the artery walls, ultimately leading to cardiovascular diseases. It is interesting to
note that there is some evidence for elevated risk for clinical events in repressers with
coronary artery disease (Denollet, Martens, Nyklicek, Conraads, & de Gelder, 2008). Of
note, only few studies examined the prospective validity of the ASRD in predicting more
proximal indicators of health. Although, Coifman, Bonanno, Ray, and Gross (2007),
among others, found that the ASRD was associated with better psychological adjustment
in bereaved individuals, Levin and Linden (2008) could not find evidence that a longterm-
stable blood pressure-based ASRD predicted ambulatory blood pressure 10 years later.
Thus, considerably more research is warranted to verify -- or falsify -- the clinical relevance
of this response style.
Limitations
The findings of this study should be interpreted in light of several caveats that need to be
emphasized: First, HR-based ASRD was calculated, thus caution needs to be taken when
comparing the present findings with other research on repressive coping that used blood
pressure (e.g., Kohlmann et al., 1996), skin conductance (e.g., Coifman et al., 2007;
Barger, Kircher, & Croyle, 1997), or endocrinological measures (e.g., Rohrmann et al.,
2003) to calculate response discrepancies. We decided to use HR for two reasons: First,
it is a robust and easy to use measure in ambulatory settings with comparably low
assessment reactivity (i.e., unlike oscillographic blood pressure measurement it can be
recorded continuously without further notice). Second, previous research could show that
the HR-based ASRD showed higher cross-situational consistency and longterm-stability
than the electrodermal-based ASRD (Schwerdtfeger et al., 2006b), thus having
psychometric benefits. Nonetheless, the clinical significance of HR-based ASRD as
compared to, for example, blood pressure-based dissociations, remains debatable.
Second, the operationalization of ambulatory ASRD in the present study might be
questioned. In order to overcome the problem of standardization across situations and
individuals, an alternative algorithm was used by relating both HR and NA to the potential
maximum prior to calculating difference scores. Unlike the classical z-standardized
difference score, the resulting ASRD is difficult to interpret on an absolute level. Hence,
only relative changes/differences can be construed. Hence, this procedure considerably
deviates from the standard approach in the literature, thus questioning comparability with
previous laboratory research. However, the traditional approach using z-standardized
reactivity scores for both HR and NA is not applicable for ambulatory data, thus
necessitating alternative quantifications. Obviously, studies are needed to directly
compare both measures of ASRD in combined laboratory and ambulatory research in
order to assure comparability across studies.

Third, it turned out that stress levels were rather moderate in this sample, thus,
questioning the usefulness of our stress quantification or, the eligibility of the study
sample. Specifically, most of the assessments were characterized by comparably high
levels of control and only moderate demands. According to Karasek (1998), a stress job
is characterized by rather high levels of demands and low levels of control. In the present
study most stressful episodes were presumably more comparable to “active jobs” in
Karasek’s terminology, implying both elevated demand and control. Therefore, the
findings need to be replicated in more stressful environments. Given the restriction of
variance in the present study the observed effects might even get more robust when stress
levels increase.
Finally, it should be emphasized that the comparably stronger increase in NA than
autonomic activation to stress might be partially explained by shared method variance,
because both demand/control and NA were assessed via self-report. Hence, the
experience of high demand, low control, and elevated NA might share the same
underlying construct (e.g., negative affectivity), thus challenging the interpretation of the
findings. This is a limitation of the study that could be circumvented in future research by
applying objective indicators of stress (e.g., via other-rated stress or interactive
psychophysiological monitoring allowing to detect and feedback episodes with
comparably high physiological activation; e.g., Fahrenberg, Myrtek, Pawlik, & Perrez,
2007; Myrtek, 2004).
Conclusions
Notwithstanding these limitations, the findings of this study considerably add to previous
laboratory-based findings on repressive coping and ASRD. It was found that repressive
coping was related to an elevated ambulatory ASRD during moderately stressful
situations, thus suggesting that the discrepancy of autonomic and subjective responses
to stress might generalize beyond the well-studied laboratory setting to everyday-life.

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Tables
Table 1: Descriptive Statistics for the Main Variables of the Study
M SD
Age 37.30 7.82

CAV 23.38 5.92
VIG 20.76 7.30
Waist to hip-ratio 0.81 0.09
Demand rating 3.21 1.14
Control rating 5.16 0.96
Stress (demand/control-ratio) 0.67 0.35
NA 8.68 3.77
HR 81.29 15.50
ASRD 20.59 13.11
Note: N = 114; CAV = cognitive avoidance; VIG = vigilance; NA = negative affect; HR =
heart rate; ASRD = subjective-autonomic response dissociation.

Table 2: Multilevel Model Relating Autonomic-Subjective Response Dissociation (ASRD)

to Level 1 and Level 2 Predictors
Parameter Estimate a T p
ASRD
Intercept 17.04 10.82 < .0001
Bodily movement 0.59 29.56 < .0001
Location (other = 0, home = 1) -2.00 -5.23 < .0001
Age 0.22 2.14 .034
Sex (-1 = male, 1 = female) -3.66 -1.96 .053
Waist to hip-ratio 7.77 0.72 .474
Smoking at time of assessment
1.91 2.56 .010
(0 = no, 1 = yes)
Stress (demand/control-ratio) -7.70 -8.13 < .0001
CAV 0.06 0.38 .708
VIG -0.15 -1.06 .292
CAV x VIG -0.04 -2.12 .036
CAV x demand/control-ratio 0.31 1.89 .059
VIG x demand/control-ratio -0.06 -0.42 .675
CAV x VIG x demand/control-ratio -0.04 -1.97 .049
Note: ASRD = Autonomic-subjective response dissociation, CAV = cognitive avoidance;
VIG = vigilance; NA = negative affect; HR = heart rate; a unstandardized regression
estimate
Figures
autonomic-subjective response discrepancy
26 Sensitizers
Non-defensive copers
24 High-anxious copers
Repressors
22
20
18
16
14
0
Stress- Stress+
Demand/control-ratio
Figure 1. Cross-level interaction of cognitive avoidant coping (CAV), vigilant coping (VIG)
and demand/control-ratio on autonomic-subjective response dissociation. Sensitizers are
characterized as being high on VIG and low on CAV; repressers, on the contrary, are high
on CAV and low on VIG; non-defensives are low on both dimensions while high anxious
copers are high on both dimensions. Values are derived from the multilevel models and
are adjusted for bodily movement, age, sex, waist to hip-ratio, and smoking at the time of
assessment. Please note that stress according to demand/control-ratio was quantified as
+1 and -1 SD from the mean for graphical reasons. Note also that response dissociations
are generally higher during non-stress as compared to stressful situations. This is due to
a stronger increase in negative affect relative to heart rate when stressful situations are
encountered.
Footnotes
1) This operationalization shows close resemblance with the well-established
classification of coping styles according to Weinberger, Schwartz, and Davidson (1979),
who cross-classified individuals according to their scores on trait anxiety and social
desirability questionnaires (for a methodological comparison of both approaches; see
Egloff & Hock, 1997). In short, individuals scoring low on anxiety and high on social
desirability have been designated repressers and those scoring high on anxiety and low
on social desirability have been designated sensitizers. Individuals with low anxiety scores
and low social desirability scores were classified as truly low anxious and those with high
scores in anxiety and high scores in social desirability as defensive high-anxious. Although
both approaches to the assessment of coping show similarities, the respective
terminologies are not directly transferrable and not synonymous.
2) Of note, the analysis was repeated with both HR and NA as dependent variables to
evaluate whether the significant interaction for ASRD could be deduced to a single
variable entering the discrepancy score. The three-way interaction was neither significant
for HR (b = -0.008, t = -0.51) nor for NA (b = 0.001, t = 1.78), thus suggesting that the
ASRD captured unique variance.

6 Study 4: Cognitive avoidant coping is associated with

higher IMT in middle aged adults.
Cognitive Avoidant Coping is Associated with Higher Carotid Intima

Media Thickness Among Middle-Aged Adults
Andreas R. Schwerdtfeger1*, PHD, Hubert Scharnagl2, PHD, Tatjana

Stojakovic2, MD, & Eva-Maria Rathner1, Mag.
1Department of Psychology, Health Psychology Unit, University of Graz, Austria

2Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of
Graz, Austria
Acknowledgements
ARS received funding by the German Research Foundation (DFG; Grant No. SCHW
1188/5-1). We are grateful to Daniela Thaler for the sonographic screening of the
participants.
Karl-Franzens-University Graz
Tel.: +43 316 380-4953
Fax: +43 316 380-9807
Abstract
Background: Cognitive avoidant coping (CAV) has been associated with elevated
autonomic stress reactivity, thus presumably elevating risk for cardiovascular diseases.
However, more direct evidence for this hypothesis is lacking.
Objectives: To relate carotid intima media thickness (IMT) to CAV in non-clinical
participants.
Methods: 124 participants (61 women) with a mean age of 37.52 years (SD = 7.93, MIN
= 30, MAX = 60) participated in the study. IMT was assessed by ultrasonic imaging and
CAV via questionnaire (Mainz Coping Inventory; MCI).
Results: Regression analysis revealed that although CAV was not significantly
associated with IMT, there was a significant interaction of CAV and age. Whereas for
younger adults there was no significant relation for older individuals CAV and IMT were
significantly positively associated.
Conclusions: Findings suggest that CAV could constitute a risk factor for cardiovascular
diseases with increasing age.
Keywords: Cardiovascular risk; cognitive avoidant coping; intima media thickness;
preclinical atherosclerosis
Introduction
An individual’s disposition “to inhibit the experience and the expression of negative
feelings or unpleasant cognitions in order to prevent one’s positive self-image from being
threatened” (1) has been referred to as repressive coping. One of the most striking
characteristics of this coping disposition is cognitive avoidance (CAV) of threat-related
information, which describes strategies to cope with stress to shield the individual from
stimuli that might threaten his/her self-esteem (2, see 3 for a review). Such strategies
include, but are not limited to, attentional diversion, re-interpretation of aversive events,
minimization, denial or self-enhancement (e.g., 3, 4). Unlike emotional suppression, which
characterizes behavioral control of emotion expression CAV refers to cognitive strategies
that aim to diminish the impact of threatening stimuli on the individual in order to reduce
emotional arousal (4).
Repressive coping and its major constituent, CAV have been discussed to be associated
with elevated autonomic reactivity to stressful encounters (e.g., 5, 6, 7). Specifically, it has
been found that these avoidant-related concepts are accompanied by elevated blood
pressure, heart rate and skin conductance responses to laboratory stress tasks.
Moreover, Schwerdtfeger and Derakshan (8) have shown that the habitual use of cognitive
avoidant strategies was associated with early engagement and subsequent
disengagement from angry facial stimuli, thus supporting the attention-avoidance theory
(3). In the same study it was also found that this attentional pattern was accompanied by
a comparably strong vagal withdrawal to the anticipation of a public speaking stressor,
thus suggesting stronger reactivity to the stress task.

Although there is meta-analytic evidence that various measures of repressive coping are
related to adverse health outcomes (9), more studies are needed to examine the
relationship with more proximal indicators of health. Specifically, according to the meta-
analysis associations with cardiovascular diseases (CVD; hypertension, heart attack,
coronary heart disease) seem to be fragile and rather heterogeneous, thus calling for more
studies on the relationship between repressive/ cognitive avoidant coping and health. It
should be acknowledged, however, that a comparably strong physiological reactivity as
found in individuals with a repressive coping disposition needs not necessarily be
accompanied by adverse health effects. For example, there is some evidence that
elevated cardiac reactivity to a laboratory challenge could be associated with lower signs
of preclinical atherosclerosis (e.g., 10, 11). Although prospective cohort studies could
provide the most robust evidence for the health-implications of repressive coping,
nowadays modern imaging techniques are available, which may reliably indicate future
disease risk, thus constituting a promising alternative. For example, the combined
thickness of the intimal and medial layers of the arterial wall (so-called Intima Media
Thickness; IMT) can be measured noninvasively using B-mode ultrasound technique
(e.g., 12). IMT has been discussed as a surrogate marker of atherosclerosis that elevates
future risk for CVD (for a meta-analytic review of prospective studies, see 13). Accordingly,
an increase in IMT of 0.1 mm increases the risk for stroke by approximately 13-18% and
for myocardial infarction by approximately 10-15%. Thus, vascular events can be reliably
predicted by IMT.
Importantly, there is evidence that emotional factors and the exposure to stressful
environments could impact IMT (e.g., 14, 15, 16, 17), thus demonstrating relevance of this
measure for research in behavioral medicine. Because exposure to stress always calls for
coping efforts, it seems plausible to assume that the way individuals encounter stressful
events should be related to IMT as well. Although -- to our knowledge -- the relationship
between repressive / cognitive avoidant coping and IMT has not been examined yet, a
recent research report suggested that unrealistic optimism, which is somewhat related to
repression (e.g., 18), was positively correlated with IMT in older individuals (19).
Moreover, other studies analyzed blood lipids that are closely related with IMT in
repressive and non-repressive individuals and found that repressive coping was
associated with a higher amount of low density cholesterol in men, thus indicating
increased risk for atherosclerosis (20, 21). Taken together, research using more proximal
indicators of vascular health (i.e., IMT) is missing although there is suggestive evidence
that individuals applying cognitive avoidant coping strategies might be at higher risk for
developing CVD.
Hence, the aim of this study was to examine the relationship between CAV and IMT.
Importantly, because preclinical atherosclerosis slowly develops throughout decades and
personality and lifestyle factors have been suggested to unfold their effects mainly in
middle-aged individuals (e.g., 22), we expected that the relationship between CAV and
IMT should be prevalent primarily in older but not necessarily in younger individuals.
Methods
Participants
Overall, 131 individuals with a mean age of 37.82 years (SD = 8.09) and a body mass
index (BMI) of 23.77 (SD = 4.00) participated in this study. There were 66 women and 65
men and 31 were smokers (24%). The majority was working full-time or part-time and had
higher education (university degree or high school diploma). Participants were recruited
via flyers, the university local mailing list, and personal communications with the incentive
of monetary compensation. Because the study was part of a larger research project
involving both laboratory-based and ambulatory psychophysiological assessment (please
refer to 23), individuals were compensated with up to 100.- Euros for study participation.
They were screened prior to the study for medication use and CVD by means of an online
questionnaire. Hence, only individuals without self-reported CVD (hypertension, ischemic
heart disease, cardiopulmonar disease, cerebrovascular disease) and without self-
reported cardiovascular and psychoactive medication were eligible for study participation.
Data of 124 participants could be used, because 7 participants did not keep the
appointments for sonography or blood withdrawal or exhibited otherwise missing data.
The descriptive statistics of the final sample can be found in Table 1. The study was
approved by the institutional ethics review board and was therefore performed in
accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.
Variables and Instruments
Coping
The German version of the Mainz Coping Inventory (MCI, 24) was applied to assess CAV.
The MCI has been developed to assess preferred coping strategies on a dispositional
level and has been well validated (e.g., 24, 25, 26). Unlike the Weinberger-approach,
which measures repressive coping rather indirectly by assessing participant’s anxiety
together with social desirability (2), the MCI measures CAV strategies (e.g., attentional
diversion, self-enhancement, denial) and vigilant coping strategies (e.g., information
search, anticipation of negative events) directly in four ego-threatening (public speaking,
exam, job interview, mistake on the job) and four physically threatening situations (dentist,
inexperienced driver, group of people, turbulent flight) of varying controllability. For each
situation five avoidant and five vigilant response options are given in a true-false format.
Answers were summed for cognitive avoidance items only to yield a measure of habitual
CAV. In this study, the average CAV score was comparable to that of a comparably large
North American sample (M = 20.90, SD = 6.74; 24). The reliability was acceptable
(Cronbach’s alpha = .79).
Demographic and lifestyle variables
Demographic (age, sex, marital status, parental history of CVD, highest education,
working status) and lifestyle variables (smoking, physical exercise) were assessed by
means of a questionnaire. In particular, participants were asked whether they smoked
(yes, no), whether they engaged in regular physical activity (i.e., “engaging in any bodily
movement produced by skeletal muscles activity that makes you sweat and out of breath”)
and whether one of the parents have/had any CVD. Moreover, working status and highest
education was assessed. Height and weight were measured objectively via a centimeter
belt and a scale, and BMI was calculated.
Preclinical Atherosclerosis
IMT measurement was carried out by a trained female sonographer using a B-mode
ultrasound imaging device (Vivid™ S5; GE Healthcare) equipped with a high precision
linear array transducer (5-13 MHz). Measurements were taken 1 cm distal from the carotid
bifurcation from the far wall of the arteria carotis at a length of 1 cm. IMT was automatically
quantified by the IMT software module, which allows automatic contour detection of the
borders of the intima and medial layers of the carotid arteries. Mean IMT was recorded for
both the left and right carotid artery and averaged prior to analysis.
Cholesterol, HDL-cholesterol (HDL-C), LDL-cholesterol (LDL-C), triglycerides
Blood samples were collected by a trained physician following a standardized protocol.
Blood samples were collected in fasting condition via a Vacuette-system (Greiner Bio-
One, Kremsmünster, Austria). After centrifugation (15 minutes at 4° celsius) serum
samples were analyzed for triglycerides, LDL-C, and HDL-C. Cholesterol and triglycerides
were measured using enzymatic methods and reagents from DiaSys (Holzheim,
Germany). The measurements were performed on an Olympus AU640 automatic
analyzer and were calibrated using secondary standards from Roche Diagnostics
(Mannheim, Germany). Lipoproteins (LDL-C, HDL-C) were determined by quantitative
agarose gel electrophoresis (Helena Bioscience Europe, Gateshead, UK).

Statistical Analysis
In order to analyze associations between IMT and CAV a hierarchical linear regression
model was calculated. Age, sex, BMI, smoking status, parental CVD, and regular physical
exercise were entered in step 1 followed by triglycerides and HDL-C/LDL-C-ratio in step
2. CAV was entered in step 3 and the interaction of age and CAV was entered in step 4.
Of note, CAV and age were centered prior to analysis to account for multicolinearity. The
level of significance was fixed at p < .05 (two-tailed). Residuals were normally distributed
as indicated by a Kolmogorov-Smirnov-test (K-S = .075, p > .05).

Results
Table 2 depicts the zero-order correlations between the main variables of this study.
Because several of the variables were not normally distributed Spearman-Rho-
correlations were used throughout. Correlations were low to moderate in size. Of note,
there was a moderate correlation between age and CAV (r = .23, p < .01), indicating that
older individuals scored higher on CAV than younger individuals. Sex and CAV were also
positively associated, documenting that men showed higher scores than women (r = .259,
p < .01). BMI, age, and sex were also significantly associated with HDL/LDL-ratio. Finally,
age, sex, BMI, CAV, parental history of CVD, triglycerides, and HDL/LDL-ratio were all
significantly associated with IMT, thus corroborating the inclusion of these variables in the
regression model.
The findings of the regression analysis are presented in Table 3. The final model was
significant, explaining approximately 55% of the variance [F(10, 123) = 13.91, p < .001].
As expected, age was significantly positively associated with IMT, suggesting more
atherosclerotic plaques with increasing age. Furthermore, a higher BMI and parental CVD
were associated with elevated IMT and, unexpectedly, a higher prevalence of regular
physical activity was associated with higher IMT. A more positive HDL-C/LDL-C-ratio was
accompanied by a lower IMT. There was no significant effect for CAV but the interaction
of CAV and age was statistically significant, suggesting that the association between CAV
and carotid IMT was moderated by age. In order to conduct simple slope analyses, age
was standardized at the standard deviation (+1SD, -1SD, respectively) and separate
regression models were run for each age group, thereby making use of the whole sample
size. For older individuals (≈ 46 years) the effect for CAV was highly significant (b = 0.005,
β = .35, p < .001), suggesting that with each 1-point increase in CAV the increase in IMT
equaled 0.005 mm. For the younger individuals (≈ 30 years) there was no significant
association between CAV and IMT (b = -0.001, β = -.04, p = .64). A graph of this interaction
is depicted in Figure 1, applying the tools cited in Preacher, Curran, and Bauer (27). In
addition, we calculated zero-order correlations with median-split groups using scatterplots
for identifying outliers (data not shown). The pattern of findings was homogeneous and
comparable with the regression approach. Specifically, whereas the correlation between
CAV and IMT for the younger group (≤ 34 years) was not significant (r = -.002, p = .99) it
was highly significant for the elder group (≥ 35 years; r = .41, p = .001), thus corroborating
the findings from the moderated regression approach.

Discussion
This study aimed to assess cardiovascular risk in individuals with varying scores on CAV
by applying sonographic imaging of the vessel walls of the carotid arteries (IMT). It was
found that although there was no main effect for CAV, age seemed to significantly
moderate this relationship. Specifically, whereas for younger individuals CAV and IMT
were not reliably associated, for older individuals elevated CAV scores were accompanied
by elevated IMT, thus implying higher cardiovascular risk.
Importantly, this finding supports the assumption that CAV as a major constituent of
repressive coping might have health-compromising effects (e.g., 9). In particular, it has
been suggested that cognitive avoidant and repressive coping are accompanied by
physiological dysregulations, affecting health and well-being (e.g., 28, 29). Several studies
found evidence for elevated or aberrant physiological stress responses in individuals who
have been designated repressive copers or who reported using cognitive avoidant coping
strategies (e.g., 30, 31, 32). These dysregulations have been discussed to damage health
(e.g., 7). This study moreover suggests that CAV-related health-effects might be more
prominent among older but not among younger individuals. Although this study is the first
one relating CAV with preclinical atherosclerosis, it is compatible with the result of a
recently published study reporting elevated IMT in older individuals (≥ 57 years) who are
overly optimistic about their health risk (19). Please note that unrealistic optimism and
repressive coping have been found to coincide (18).
Considering the meta-analytic finding of an increase in risk for stroke of 13-18%, and for
myocardial infarction of 10-15% with an increase in IMT of 0.1 mm (13), the clinical
significance of this difference remains debatable. In fact, for older participants the increase
in IMT with each unit of change in CAV was b = 0.005, suggesting that the lowest possible
(Min = 0) and the highest possible scorers on the CAV scale (Max = 40) could differ by
approximately 0.2 mm in IMT. With respect to the above mentioned meta-analysis of an
approximately 15% increase in CVD risk with each 0.1 mm thickening of the carotid walls
(13) it might then be concluded that given a linear relationship CAV could maximally
increase risk by approximately 30%, which may be considered a rather small effect given
a very large difference in coping.
It is interesting to note that there is evidence from other research showing that anxiety,
anxiety disorders and amygdala reactivity were associated with elevated IMT (e.g., 33,
34, 35), thus favoring the hypothesis that an anxious and hypervigilant disposition
constitutes a reliable risk factor for CVD (for a recent meta-analysis, see, 36). At a first
glance, the finding of the present study seems to contradict this line of research, because
repressive coping and the use of cognitive avoidant strategies have been found to be
related with lower self-reported anxiety (e.g., 3, 7). However, it should be noted that
repressive coping has been associated with elevated autonomic nervous system
responses that are more characteristic of individuals with a high anxious personality
disposition (e.g., 37). Moreover, Schwerdtfeger and Derakshan (8) could show that CAV
was correlated with early vigilance but late avoidance of threatening stimuli, thus
suggesting that at least during early stages of information processing an anxiety-related
attentional style is prevalent in cognitive avoidant copers. Taken together, it seems that
CAV and anxiety share similar physiological concomitants and that these outcomes could
be partially explained by common attentional factors.
Of note, IMT was positively associated with age and BMI (see also, 38, 39, 40, 41) and
negatively associated with HDL/LDL-ratio (e.g., 42, 43), which supports previous
research. Moreover, in line with expectations IMT tended to be lower when participants
reported no parental CVD, but the finding of a higher prevalence of self-reported physical
activity to be associated with elevated IMT was rather unexpected. In general, previous
studies cite evidence for attenuated carotid wall thickness in individuals with higher levels
of physical activity (e.g., 44, 45), although not every study could support this finding (e.g.,
46, 47). In our view, the divergent result in our study might be due to the rather rough and
simple measure of physical activity, which might have affected assessment validity.
Moreover, it should be noted that this study was cross-sectional in nature, thus it could
have been the case that at least some at risk-individuals might have decided on physical
activity as preventive behavior, thus blurring the relationship with IMT.
Limitations
Although the main finding of this study is coherent with evidence from previous studies
suggesting health-compromising effects of repressive coping and CAV, it should be
interpreted in light of several caveats. First, although the study sample included
participants of various ages (30 to 60 years), it should be emphasized that the mean age
was 37.6 years, thus indicating a middle-aged sample with relatively more younger than
older participants. Moreover, IMT was generally small in this sample not exceeding 0.85
mm. Previous research could show that carotid IMT strongly progresses beyond the age
of 45 (e.g., 48), and personality and lifestyle factors have been suggested to exert
influence in adulthood (22). Thus, it could be expected that associations between
personality and coping variables get stronger with increasing age of the sample.
Therefore, the findings of this study should be regarded preliminary and future studies
should recruit a larger sample of older individuals to allow a more powerful analysis on
the moderating role of age on the relationship between coping and health.
Second, it should be emphasized that this was a cross-sectional study that did not allow
a closer examination of the dynamics linking CAV with IMT. In particular, it could well be
that exaggerated physiological responses (in particular, blood pressure responses) to
diverse stressful encounters in cognitive avoidant and repressive copers might impact IMT
somewhat later in time. Other studies suggest that repressive coping might be associated
with elevated cholesterol levels (e.g., 20, 21), thus increasing risk for atherosclerotic
plaques. It should be noted, though, that this study controlled for blood lipids, thus
suggesting that other pathways from coping to morbidity might be involved as well.
Therefore, it seems inevitable to identify potentially intervening variables (e.g., health
behavior, physiological reactivity, genetic vulnerability) in individuals scoring high and low
on CAV-related strategies in order to get a better understanding of the pathways linking
repressive/ avoidant coping with health. Although worse health behavior might constitute
one pathway linking repressive coping with health, it is interesting to note that Myers (49)
found evidence for both worse and better health behaviors in repressive individuals,
depending on the controllability of the behavior. Moreover, prospective studies are needed
to unveil the dynamics of disease progression as related to repression and related coping
styles. For example, it has been shown that stress-related variables could predict IMT
progression across several years (e.g., 50). A similar approach could help strengthen –
or weaken – the hypothesis that CAV negatively impacts health. Finally, it should be
acknowledged that more research is needed to examine the specificity of this effect. In
particular, it has to be determined whether repressive coping in general, or more specific
avoidant strategies as assessed in this research, unrealistic optimism, or other related

emotion regulation strategies have similar consequences or contribute uniquely to
cardiovascular malfunction. According to Garssen (1) the specificity of repressive coping
and other related concepts needs to be established yet and comparative studies are
warranted in order to disentangle their respective health impacts.
Conclusions
Notwithstanding these limitations, the findings of this study suggest that CAV might impact
cardiovascular health with increasing age. The size of this effect might be considered
rather moderate; however, it should be kept in mind that several other biological and
lifestyle variables were controlled for. Certainly, replication studies are needed to evaluate
the trustworthiness of this effect. Future research is also needed to examine the specificity
of this effect and the pathways linking CAV and repressive coping with health in order to
delimit the usefulness of intervention programs.

Conflict of Interest
Andreas R. Schwerdtfeger, Hubert Scharnagl, Tatjana Stojakovic, and Eva-Maria Rathner
declare that they have no conflict of interest.
Declaration
All procedures followed were in accordance with the ethical standards of the responsible
committee on human experimentation (institutional and national) and with the Helsinki
Declaration of 1975, as revised in 2000. Informed consent was obtained from all
participants for being included in the study.

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Tables
Table 1: Descriptive Statistics (Means, Medians, Standard Deviations and Minimum and
Maximum Values) of the Main Variables
Percent
Sex women 49%
Marital single 22%
status
married /
71%
cohabiting
divorced 1%
missing 6%
Working Working full- 37%
status time
Working part- 21%
time
Self-employed 13%
Trainee 17%
Fractionally
employed / 12%
unemployed
Education University 53%
degree
High school 32%
diploma
Completed
6%
apprenticeship
Professional 6%
school
Other 3%
Smoking yes 24%
no 76%
Physical yes 73%
activity
no 27%
Parental yes 34%
CVD
no 66%
M Md SD Min Max
Age 37.52 34.35 7.93 30 60
BMI 23.76 23.09 4.01 16.73 36.03
CAV 23.37 24.00 5.94 7 35
Mean IMT 0.52 0.51 0.08 0.38 0.77
right
Mean IMT 0.52 0.51 0.09 0.35 0.87
left
Mean IMT 0.52 0.51 0.08 0.39 0.82
average
Triglycerides 97.76 82.50 57.22 25 352
(mg/dl)
HDL-C/LDL- 0.60 0.55 0.31 0.19 2.50
C-ratio
Note: N = 124; M = mean, Md = median, SD = standard deviation, Min = minimum value,
Max = maximum value, BMI = body mass index, CVD = cardiovascular diseases, CAV =
cognitive avoidant coping, IMT = intima-media thickness, HDL-C/LDL-C-ratio = ratio of
HDL-cholesterol to LDL-cholesterol.
Table 2: Zero-order Correlations (Spearman-Rho) Between the Main Variables of the Study
1 2 3 4 5 6 7 8 9
Age1 -
Sex2 (0 = m, 1 = w) .109 -
BMI3 .305** .359** -
CAV4 .234** .259** .162 -
Regular physical activity (0 = no, 1 = yes)5 .000 -.026 -.077 .020 -
Smoking status (0 = no, 1 = yes)6 -.102 -.140 -.087 .033 -.021 -
Parental CVD (0 = no, 1 = yes)7 .135 -.204* .059 -.201* -.113 .153 -
Triglycerides (mg/dl)8 .068 .155 .198* .080 -.090 .140 .188* -
HDL-C/LDL-C-ratio9 -.245** -.354** -.514** -.133 -.159 -.042 -.003 -.474** -
Mean IMT average10 .503** .209* .383** .229* .131 -.026 .202* .189* -.330**
Note: N = 124, * p < .05, ** p < .01.

Table 3: Regression Model Relating Carotid Intima Media Thickness (IMT) to
Demographic, Lipometabolism, and Coping Variables (specifically, Cognitive
Avoidant Coping, CAV)
Parameter b β t p F ∆R2 R2
Carotid Intima Media Thickness (IMT)
Step 1 17.25** .469 .469
0.005 <
Age .53 7.47
.001
Sex (-1 = women, 1 = 0.019
.13 1.71 .090
men)
BMI 0.004 .19 2.47 .015
Smoking status
-0.0003 -.002 -0.03 .978
(0 = no, 1 = yes)
Regular physical activity
0.029 .17 2.51 .014
(0 = no, 1 = yes)
Parental CVD
0.027 .16 2.25 .026
(0 = no, 1 = yes)
Step 2 3.31* .029 .598
-
Triglycerides (mg/dl) -.06 -0.81 .421
0.00008
HDL-C/LDL-C-ratio -0.049 -.20 -2.57 .011
Step 3 3.82 .016 .514
CAV 0.002 .14 1.95 .053
Step 4 9.42** .037 .552
CAV x Age 0.0003 .23 3.07 .003
Note. N = 124; BMI = Body Mass Index, CAV = cognitive avoidant coping, IMT = intima-
media thickness, CVD = cardiovascular diseases, HDL-C/LDL-C-ratio = ratio of HDL-
cholesterol to LDL-cholesterol; * p < .05, ** p < .01

Figures
Figure 1.
0.65
0.60
IMT (mm)
0.55
age +1SD
age -1SD
0.50
0.45
0.00
0 10 20 30 40
CAV
Figure 1. Significant interaction between cognitive avoidant coping (CAV) and age on
mean carotid intima media thickness (IMT). Older individuals showed a significant
increase in IMT with increasing scores on CAV, whereas for younger individuals a
negative, non-significant association could be observed. Values are adjusted for
covariates.
7 General Discussion
Technological interventions and the advent of the World Wide Web drastically changed
the way scientists were able to study human behavior over the last decades (Montag
& Diefenbach, 2018). For example, it became possible to measure an individual's heart
rate with small devices over several days, or by introducing GPS, an individual's
movement patterns can be observed unobtrusively. Of note, these changes are
occurring rapidly and will be accelerated in the near future.
Due to these new technological possibilities, a shift from controlled laboratory studies
towards momentary ecological assessments (EMA) in the field was possible, thus
complementing seminal research done primarily under laboratory conditions. The
research presented in this thesis spanned from 2013 to date and underpinned these
possibilities. Whereas the first studies were carried out with sensors attached to the
participants (studies 2-4), the last survey (study 1) used the individual’s smartphones
to assess daily usage time, and the device’s built-in sensors were already adequate to
model human behavior and mental states.
The research discussed in this thesis contributes to the knowledge about the
methodology of field assessments, such as the ecological validity of the ASRD and the
use of laboratory parameters of heart rate to predict ambulatory heart rate measures
(Schwerdtfeger et al., 2014; Schwerdtfeger & Rathner, 2016). Adding to that, it could
be demonstrated that in future smartphones might be a valid instrument to assess
mental states of individuals and differences between individuals (Messner et al., 2019).
Moreover, due to the possibility to assess reactions to daily stressors in the field, we
could glimpse into the processes that link coping styles to cardiovascular health and
disease (Schwerdtfeger et al., 2015). Although this thesis was able to close some
research gaps, future prospective studies are needed to confirm the results derived
from these cross-sectional correlative studies.
In the following, the embedding and relevance of our findings into the current literature
will be discussed. Furthermore, the core outcomes will be addressed, such as the
association of laboratory and field studies, the association of coping and
cardiovascular health, and the use of smartphones to assess mental states and
behavior in the field. The general discussion will end with a glimpse into the future
directions of assessments in the field.
7.1 Embedding of Relevant Findings into Current Literature
In this chapter, the embedding of the core findings of the four articles will be discussed.
Moreover, the limitations of each study will be presented with suggestions for future
research to eradicate these obstacles. This chapter ends with an overview of the
results this research could add to the current knowledge about stress and coping.
7.1.1 The Use of Smartphones to Assess Mental States
Study 1 gave insight into the possibility of predicting stress and mood levels via
smartphone usage. Overall, the prediction of mental states through smartphone usage
variables seems promising, but associations where small. Thus, the clinical relevance
remains questionable. This research found small negative, but significant associations
between stress and mood levels and smartphone usage parameters such as total
usage time, Facebook usage, call duration, or the number of daily SMS (Messner et
al., 2019). These findings are in line with the current literature (Alvarez-Lozano et al.,
2014; David et al., 2018; Lachmann et al., 2018; Sano & Picard, 2013; Tandoc et al.,
2015). On the other hand, some studies did not find an association between
smartphone usage and mood parameters (Elhai et al., 2018; Rozgonjuk et al., 2018;
Saeb et al., 2015). There are several ways to explain these contradicting findings:
Firstly, the associations between smartphone usage and state measurements of stress
and mood might be non-linear (Scherr, 2018). It might be possible that meager and
raised amounts of smartphone usage are detrimental to parameters of well-being as
well as mental and physical health. In the majority of parameters of psychological and
physical health, there is a range that can be associated with optimal functioning. The
same principle might apply to smartphone usage as a parameter of well-being. For
example, high stress could result in diminished (e.g., too occupied by the stressor to
use the smartphone) or accentuated (e.g., using the smartphone to gather information
about the stressor) use of one´s smartphone.
Secondly, the variance in measurement methods could contribute to these diverse
outcomes (Stone & Shiffman, 2002). So far, smartphone usage was parameterized
very differently across studies. Some studies account for total active user time such as
unlock events, app- use, etc., while others include passive user time as well, such as
listening to audiobooks or music. Moreover, some studies include only particular apps
(such as Facebook, messenger services, Instagram, etc.), other researchers
group apps according to their function (e.g., social networks, messenger services,
entertainment, etc.) (Chow & Ma, 2017; David et al., 2018; Frost & Rickwood, 2017;
McCord et al., 2014; Schwartz et al., 2014; Tandoc et al., 2015). Given these vast
differences in the parametrization of smartphone usage, the contradicting findings
concerning the association of smartphone use and mental states seem reasonable.
Likewise, self-reported affect is assessed differently across studies. While some
studies assessed the variables of interest twice a day over long periods, others apply
a sample rate of 10 times and more a day. Furthermore, self-reported affect is
sometimes collected via the core affect model (Russell & Barrett, 1999) and sometimes
via the PANAS (Watson et al., 1988) and on Likert scales ranging from 1-5 up to Likert
scales ranging from 1-10 (Alvarez-Lozano et al., 2014; Elhai et al., 2018; Rozgonjuk et
al., 2018; Saeb et al., 2015; Servia-Rodríguez et al., 2017). Therefore, agreements
about sample rates and questionnaire use would lead to better comparability of study
results.
Thirdly, there are first hints that distinct smartphone usage patterns (active versus
passive use) are related to diverse mental health outcomes (Burke et al., 2010; McCord
et al., 2014; Primack et al., 2017; Verduyn et al., 2017). Direct interaction on social
networks is associated with feeling socially included and less lonely, while passive
consumption of content (looking at pictures and posts of friends) is associated with
higher levels of loneliness and reduced well-being (Burke et al., 2010). Overall, the
heavy use of multiple social media platforms was related to adverse mental health
outcomes, such as symptoms of depression and anxiety (Primack et al., 2017).
Fourthly, smartphone usage patterns might not be able to distinguish stressed from
relaxed behavior (Messner et al., 2019). For example, a person showing little activity
on the smartphone might either sleep or be in a quarrel with his or her spouse. The
smartphone usage behavior would be the same; the experienced level of stress quite
different.
Fiftly, the content of the interaction with the smartphone might be a better predictor of
stress and mood (David et al., 2018; Przybylski & Weinstein, 2017). While overall
smartphone use is vastly associated with negative well-being, a lot of studies come to
conflicting results (David et al., 2018). If you take a closer look into the predictor “online
time”, it quickly becomes evident that time spent online is a slightly rough parameter.
More precise would be a look at the content individuals are producing (such as texts,
posts, etc.) or the content they are consuming (e.g., inspirational quotes, news, etc.).
It might be difficult to obtain informed consent on automated analysis of the content

because individuals might want to keep their privacy (e.g., consumption of porn, etc.).
Moreover, data safety would need to be given. Given an informed agreement, the
observation of the content individuals consume might be ethically acceptable. The
collection and analysis of content individuals produce is intrusive and raises ethical
concerns. It would easily be possible to track keyboard inputs on a person´s
smartphone and to analyze their word usage automatically and changes thereof to
monitor mental states. Such an approach would be challenging in itself, as one would
have to guarantee to save data transfer and the automated removal of sensitive data
(e.g., credit card numbers, names, laces). So far, international standards on privacy
and data safety are still missing (Mohr et al., 2017; Shilton & Sayles, 2016).
Sixthly, the intention or the reasons of use might elicit different emotional states (e.g.,
to study or for social comparison) (Harari et al., 2016; Tandoc et al., 2015). For
example, a person could use a google search to quickly gather information about a
stressor and then apply other adaptive strategies. Or, another person could indulge in
excessive google searches resulting in heightened anxiety and stress levels.
Seventhly, sensor variables like GPS, microphone, etc., could be more precise in
capturing mood and stress levels (Canzian & Musolesi, 2015; Servia-Rodríguez et al.,
2017). Smartphones can capture known natural stressors via their sensors, such as
brightness, noise, distance to other smartphone users, etc. Some research teams
already showed that arousal and stress levels could be predicted accurately from an
individual's voice or facial expressions (Cordaro et al., 2016; Lasalle et al., 2019;
Ringeval et al., 2016; Vogt et al., 2008).
Eightly, not the total amount of usage might be of interest, but the changes in usage
patterns over time. For example, a change in usage behavior due to the onset of a
depressive episode could be an initial increase in the use of social networks,
messenger services, and calls as a way of seeking help, followed by a collapse of

smartphone usage mirroring the social withdrawal of the individual. In line with that,
the automated detection of early warning signs for the onset of mental disease could
be fruitful to prevent the outbreak and guarantee early therapeutic interventions.
Ninthly, human rhythmicality should be taken into account when analyzing the data.
Individuals show different usage patterns between weekdays and weekends as well
as during the day due to diverse hormonal activities (Servia-Rodríguez et al., 2017).
Therefore, future confirmatory studies should use larger and more representative
samples to examine such questions. Moreover, clinical samples would be of interest
to study adaptive and maladaptive smartphone use in people with different
psychopathologies compared to healthy controls, and its consequences. As our study
found correlations between smartphone usage and parameters of well-being, a
prospective study design could shed light on the causality. Both directions seem to
have face validity; media consumption could be used to alter emotional and mental
states that impact on well-being, and media use could unintentionally influence current
emotional states (David et al., 2018; Zillmann, 1988a, 1988b).
7.1.2 The Association of Cardiovascular Parameters Assessed in the Field and under
Laboratory Conditions
Study 2 shed light on the association between CVR to a standardized laboratory
stressor and cardiovascular reactivity to daily stressors (Schwerdtfeger et al., 2014).
The main aim was to understand the reactivity hypothesis in depth. The theory behind
the association of CVR and cardiovascular health is the cardiovascular reactivity
hypothesis (e.g., Krantz & Manuck, 1984; Lovallo, 2010; Obrist, 1981; Schwartz et al.,
2003; Treiber et al., 2003). It is supposed that the wear and tear of heightened CVR in
the cardiovascular system causes health impairments in the long run. In extensive
cross-sectional and prospective studies, a positive association between the magnitude

of CVR to psychological laboratory stress tasks on future blood pressure status (Carroll
et al., 1995; Carroll et al., 2001; Carroll et al., 2003; Markovitz et al., 1998; Matthews
et al., 1993; Newman et al., 1999) as well as markers of atherosclerosis was found
(Barnett et al., 1997; Everson et al., 1997; Lynch et al., 1998; Matthews et al., 1998).
As suggested by Kamarck and colleagues (2003), a multilevel approach was used to
analyze our data. In studies that compare cardiovascular parameters in the field and
lab, a multilevel approach maximizes comparability through better management of
cofounding variables in the field (such as movement, etc.) without sacrificing the
benefits of daily life assessments.
In the research carried out, it was found that 39% of the variance in ambulatory CVR
was due to intraindividual differences. Men showed higher HR compared to women,
more bodily movement, and smoking was associated with higher HR. Being at home
was related to a lower HR, thus indicating highly accurate measurements. When
associating laboratory cardiovascular parameters with those recorded in the field, it
could be shown that baseline laboratory HR predicted ambulatory HR. The lab delta
score was not related to the ambulatory HR, pointing towards the limited
generalizability of CVR lab scores.
Moreover, there was an interaction of baseline HR and the ambulatory HR delta score,
indicating that the effect of CVR was moderated by baseline HR. In summary, the
ambulatory cardiovascular load was the highest in individuals with a high baseline HR
and elevated CVR and lowest in individuals with low baseline HR and elevated CVR
(Schwerdtfeger et al., 2014). This finding can be interpreted in a way that a high delta
of CVR in laboratory tasks is a vital sign of coping with a mental stressor when
accompanied by low ambulatory baseline HR. This process could be seen as an
analogy to the physical adaptions when exercising regularly. Individuals acquire quick
energy to master the stressor by elevated CVR and drop back rapidly to a relaxed
state.
Davig and colleagues (2000) also found that the correlation between real life and
laboratory stressors was higher when using absolute values of HR and BP. In this
study, the relationships were higher during the anticipation periods than in the actual
task periods (free speech task versus defensio). Overall, the magnitude of change in
the cardiovascular parameters was the greatest in the real-life stressor. This finding is
contrary to the results of the papers included in this thesis. In this data, the range of
subjective stress ratings was limited, pointing towards average but frequently occurring
stressors in the daily life of participants (Schwerdtfeger et al., 2014). Participants were
instructed to choose a typical day for study participation. Still, a more naturalistic
approach was used when compared to Davig and colleagues (2000), who observed
individuals while defending their Ph.D. thesis. The defensio of one´s Ph.D. thesis can
be seen as an extreme and rarely occurring social-evaluative stressor. The approach
used in the papers contributing to this thesis might mirror ordinary daily life stressors
better, as most individuals are not at all experiencing a defensio in life. Therefore, the
impact of CVR on such a stressor is unlikely to alter cardiovascular health.
To conclude, the findings in the presented research do not support the reactivity
hypothesis in general. Due to the fine-grained data assessments, it was found that
individuals who have both elevated baseline HR and elevated CVR might be at higher
risk for cardiovascular dysfunction. Higher CVR to laboratory stressors per se are not
mirrored by dysfunctional cardiovascular activities in daily life. In line with that,
Kamarck and colleagues (2003) explained that in individuals who show elevated CVR
in the lab and the everyday setting, a causal role of CVR in processes to cardiovascular
disease is plausible.
Therefore, future studies should try to understand the higher ambulatory heart rate
reactivity in individuals with a low baseline HR and diminished CVR. When taking
findings into account that state that blunted CVR could be maladaptive and
accompanied by adverse health outcomes, this group of individuals might also be at
high risk for the development of CVD and should, therefore, be studied in depth
(Lovallo, 2011; Lovallo et al., 2012; Phillips et al., 2013). Possibly they are depleted by
prolonged lifetime stress. Future confirming studies are needed to assess the clinical
relevance of the findings. Furthermore, studies using more than one assessment of
the ANS (such as blood pressure, cortisol, or skin conductance) on a larger sample
and with longitudinal study designs are needed.
7.1.3 The Ecological Validity of the ASRD in Repressive Coping
In study 3, the ecological validity of the ASRD in repressive coping was tested
(Schwerdtfeger & Rathner, 2016). The ASRD is a time stable trait-like (Levin & Linden,
2008; Schwerdtfeger et al., 2006b) response pattern in stressful situations, which is
characterized by a high CVR and low subjective reported stress levels (Schwerdtfeger
& Kohlmann, 2004). ASRD is associated with the habitual use of repressive coping
and is theorized to constitute a somewhat maladaptive form of coping as it averts the
use of more adaptive problem-focused ways of coping (Hock et al., 1996; Hock
& Krohne, 2004). As repressive coping is associated with adverse health outcomes,
especially for cardiovascular diseases (Mund & Mitte, 2012), the ecological validity and
clinical relevance of this response pattern were tested in this study (Schwerdtfeger
& Rathner, 2016).
As in studies 1 and 2, a multi-level model was applied to account for the nested data
structure (Goldstein, 1995; Laurenceau & Bolger, 2011; MacCallum et al., 1997;
Nezlek, 2012). These models take into account that multiple answers are nested within
persons, and therefore dependence between variables is present (Nezlek, 2001;
Nezlek et al., 2006). According to our findings, the null model implied that 49% of the
variance of ambulatory ASRD was due to intraindividual (trait-like) differences. Bodily
movement, age, and current smoking were associated with elevated ASRD while being
at home was related to lower autonomic activation. There was a significant CAV x VIG
interaction, indicating that high-anxious copers showed a comparably low ASRD when
compared to repressers. Moreover, there was a three-way interaction between CAV x
VIG x self-reported stress, showing that coping modes did not differ in stressless
situations. However, in high-stress situations, repressive copers showed comparably
high ASRD. Taken together, these results demonstrate that repressers show the
highest ASRD independent of the amount of experienced stress. When looking at
stressful situations, repressers exhibit the highest level of ambulatory ASRD. Our
findings could prove the ecological validity of the ASRD. Furthermore, the results are
in line with previous results obtained in controlled laboratory studies (Asendorpf
& Scherer, 1983; Barger et al., 1997; Brosschot & Janssen, 1998; Derakshan
& Eysenck, 2001; Gudjonsson, 1981; Kohlmann et al., 1996; Krohne & Fuchs, 1991;
Newton & Contrada, 1992; Rohrmann et al., 2003; Schwerdtfeger & Kohlmann, 2004;
Weinberger et al., 1979; Weinstein et al., 1968). Furthermore, the finding that high CVR
only occurs in repressers during stressful situations is following the vigilance-
avoidance theory of repression (Derakshan et al., 2007). The vigilance-avoidance
theory of repression states a two-stepped way of information processing of ambiguous
stimuli. In the early stage, repressers are highly vigilant and more likely to interpret
ambiguous stimuli as threatening. The initial stage is mainly subconscious but
accompanied by elevated CVR. In a later stage of information processing repressers
suppress the unwanted negative emotions so successfully that they show impaired
retrieval of negative autobiographical memories (Baumeister & Cairns, 1992; Cutler et

al., 1996; Derakshan et al., 2007; Fajkowska et al., 2011; Hock & Egloff, 1998; Hock
& Krohne, 2004; Holtgraves & Hall, 1995; Mendolia et al., 1996; Orbach & Mikulincer,
1996; Schimmack & Hartmann, 1997; Vendemia & Rodriguez, 2010).
There are four main theories to explain that phenomenon: Firstly, the superficial
encoding hypothesis by Davis (1990) states that repressers´ poor emotional memory
is caused by reduced emotional processing. Secondly, the frequency hypothesis by
Schimmack and Hartmann (1997) proposes that repressers feel less emotional
response and, therefore, do not establish links between affect and event
representations. Thirdly, the emotional discreetness hypothesis by Hansen and
Hansen (1988) suggests that repressers encode anxiety-related cues into less
complex cognitive-emotional structures. Therefore, the links between representations
of threatening events and insignificant emotions are weak. Those representations are
difficult to access due to their isolation. Fourthly, the repressive discontinuity
hypothesis by Hock and colleagues (1996) is characterized by a consecutive sequence
of stress-related information processing. Initially, repressers react unconsciously highly
sensitive to threat-related cues; this is followed by counteraction of suppression. Those
inhibitory processes lead to a poor memory concerning threats.
Moreover, there is still no direct evidence for the vigilance-avoidance theory of
repressive coping in relation to the cause of the higher CVR in repressers. The
elevated CVR could also stem from a higher effort of repressive coping strategies in
self-threatening tasks compared to other forms of coping (Schwerdtfeger & Kohlmann,
2004). Furthermore, attention withdrawal during stressful situations was proven to
elevate parasympathetic withdrawal leading to higher CVR in repressers
(Schwerdtfeger & Derakshan, 2010). Therefore, future research should investigate the
timeline of physiological responses and self-reported stress levels to threat in
repressers.
The clinical relevance of our findings might be worth investigating in further studies. So
far, a higher ASRD was associated with reduced interoception (Papousek et al., 2002;
Schwerdtfeger et al., 2006a). If so, repressers might lack the ability to perceive
stressful situations. This could lead to increased exposure to stressors in daily life.
When taking the diminished ability to memorize threats into account, a vicious circle
could be set in motion (Hock et al., 1996). But there is little research on the long-term
effect of ASRD on cardiovascular health. Two prospective studies report somewhat
positive outcomes. The first study found that individuals with high ASRD cope better
with the loss of a significant other (Coifman et al., 2007). The third study concludes
that the dissociation of CVR and self-reported affect might not be a significant predictor
of cardiovascular diseases (Levin & Linden, 2008).
7.1.4 The Association of Repressive Coping and Cardiovascular Health
In study 4, the association between repressive coping operationalized as CAV and
preclinical atherosclerosis was tested in cross-sectional study design. The main aim
was to gain insight into the effects of habitual high CVR on cardiovascular risk
(Schwerdtfeger et al., 2015). Some studies found that repressive coping and
specifically high CAV is related to elevated CVR in laboratory stress tasks, daily life
and during bereavement periods (Coifman et al., 2007; Kohlmann et al., 1996;
Schwerdtfeger & Derakshan, 2010; Schwerdtfeger & Rathner, 2016). Of note, this
association was found via several parameters of autonomic stress responses such as
heart rate, blood pressure, and skin conductance (Schwerdtfeger & Derakshan, 2010).
Moreover, there is meta-analytic evidence that repressive coping is associated with
adverse health outcomes such as cancer and hypertension (Mund & Mitte, 2012).
Nevertheless, some laboratory studies point toward possible health benefits of
repressive coping (Barnett et al., 1997; Heponiemi et al., 2007). Therefore, a close look
at the processes that might link repressive coping, elevated CVR, and health outcomes
was needed. It was found that CAV was associated with a higher IMT in older
individuals, indicating that the continual use of CAV over the lifespan is accompanied
by atherosclerotic processes over time. As a correlational cross-sectional study design
was used, in future prospective studies are needed to test the actual effect of time or
aging. As coping styles like CAV are theorized to be time-stable personality traits (Levin
& Linden, 2008; Schwerdtfeger et al., 2006b), experimental designs might be hard to
apply. One could think of longitudinal therapeutic intervention studies that aim to
change habitual coping styles to achieve better long-term health outcomes.
Moreover, the finding that repressive coping is related to higher risks of cardiovascular
disease is in line with meta-analytic evidence showing that repressive coping is
associated with adverse health outcomes (Mund & Mitte, 2012). One of the underlying
processes of this relationship might be a physiological dysregulation of stress
responses such as elevated or blunted CVR (Diamond et al., 2006; Gianaros et al.,
2009; Newton & Contrada, 1992; Schwartz, 1990).
The clinical relevance of these findings might be limited as the IMT thickness of
individuals with the highest and lowest score on the MCI could maximally differ 0.2mm
resulting in a maximum of 30% increased risk of cardiac events (Lorenz et al., 2007;
Schwerdtfeger et al., 2015). Of note, the IMT in our sample was generally small (m=
0.82mm). This might originate from the relatively young age of included individuals (m=
37.5; range= 30-60). There is strong evidence that IMT especially progresses after the
age of 45 (Spence, 2006). Thus, studies on a larger sample, including individuals over
the age of 45, are needed. As there are contradicting findings on the health outcomes
of repressive coping future research should aim to dissect the concepts of repressive
coping and CAV (Garssen, 2007; Mund & Mitte, 2012; Myers, 2010).
7.1.5 Summary of the Contribution of Own Research to the State of Art
My research could add the following knowledge to the current state in the field of Health
Psychology:
 Smartphones are widely used in one´s daily life and, therefore, might offer a
unique possibility to track parameters of an individual's health and well-being
unobtrusively over more extended periods. I could prove that this is also
possible in the passive tracking of experienced stress levels (Messner et al.,
2019).
 It was shown that lab induced stress, operationalized via CVR, cannot be
generalized generally to daily life CVR. The baseline laboratory HR was the best
predictor of ambulatory HR, and therefore, should be taken into account
(Schwerdtfeger et al., 2014).
 Moreover, it was proven that the discrepancy between self-reported stress
levels and the autonomous reaction to a stressor (ASRD) could be assessed in
the field (Schwerdtfeger & Rathner, 2016).
 The clinical relevance of repressive coping might be given with increasing time.
An association between cognitive avoidant coping and a marker of CVD (IMT)
with increasing age was detected (Schwerdtfeger et al., 2015).
Taken together, my research contributed to the knowledge about the health impact
of habitual coping with stress on cardiovascular health. CAV is associated with CVD
with increasing age. Moreover, my research deepened the knowledge of the
methodology of laboratory and field studies of stress and coping with stress. The
generalization of cardiovascular stress parameters assessed in the lab to daily life
CVR is not given, but the ASRD can be ecologically evaluated in the field.
Moreover, smartphones could be used to assess stress levels passively.
Nevertheless, more extensive research is needed to study the assessment of

stress and coping in the field and to broaden the knowledge of long-term health
outcomes of habitual coping modes.
7.2 The Association of Laboratory and Field Studies
There is an ongoing debate about the generalizability of laboratory-based research to
field studies. One large meta-analysis, including 217 lab-field comparisons from 82
meta-analyses of psychological research, leads to a differentiated view (Mitchell,
2012). The external validity of laboratory research was differing according to the
psychological subfield, research topic, and effect size. The overall covariation of effect
sizes was r = .71, varying from r = .28 (gender-focused research) to r = .97
(organizational research). Moreover, external validity differed by effect sizes. Smaller
effects were less likely to replicate in the field when compared to larger effect sizes.
This result points to the need for sample size planning in field studies. Thus, Mitchell
(2012) states that the external validity and clinical relevance of lab results as a whole
are questionable. Therefore, a closer look will be taken on the generalizability of coping
and stress research from the lab to daily life.
On the one hand, laboratory studies with a standardized stressor offer the possibility
to assess interindividual differences in the way people cope physically and mentally
with stressful events. On the other hand, laboratory studies are limited in their
generalizability (Davig et al., 2000; Johnston et al., 2008). The advantages of
laboratory studies are centered around standardization of measurement, study design,
and controllability over stimuli and confounding variables (Zanstra & Johnston, 2011).
Furthermore, lab stressors might not be ecologically valid, as the stressors, which can
be applied to participants, are limited by ethical considerations. Stressors and their
CVR might differ in amplitude, duration, and even the underlying mechanisms between
daily life and lab settings (Zanstra & Johnston, 2011). So far, it is common to build
theories based on experiments under controlled laboratory conditions and then to test
those theories in the field. Lately, it became modern to directly study in daily life and to
build theories from ambulatory (big) data. These possibilities will be discussed, in-
depth in chapter 7.5.
A common task to assess CVR in the lab is the free speech paradigm (Johnston et al.,
2008). A free speech stressor seems real-life valid but is not occurring over the lifetime
in such a frequency that it may contribute to the development of CVD. Therefore, the
generalizability of the lab assessed CVR to study the general effects of CVR on health
is questionable.
Moreover, assessments of CVR in real life are prone to misinterpretation as there are
various influences on cardiovascular parameters such as movement, metabolic
changes, circadian rhythms, and such. One way to account for confounding variables
is to assess them and include them in multilevel models. Nevertheless, unknown
confounding variables could still reduce data quality and limit interpretation (Kamarck
et al., 2003).
Of note, stressors in daily life vary remarkably between and within individuals.
Therefore, a comparison of the magnitude of daily stressors between individuals is
impossible (Schwartz et al., 2003; Treiber et al., 2003). Accordingly, it is not surprising
that the results regarding the generalizability of lab CVR to daily life CVR are mixed so
far (Kamarck et al., 2000). One way to obtain satisfying reliability is to repeatedly
assess CVR and use the aggregated lab scores to predict daily life CVR. Another
option to enhance reliability would be to measure CVR across multiple situations
(Kamarck et al., 2000).
One study relating five different laboratory stressors (tracking task, progressive
matrices, stressing video, social problem-solving task, and cold pressor test) to CVR
in the field suggests that the CVR to laboratory stressors does somewhat relate to CVR
in real life (Johnston et al., 2008). Furthermore, they found some support for
aggregating responses over several tasks to provide a more robust measure as
proposed by Kamarck and colleagues (2000). Of note, the cold pressure test was the
best predictor for ambulatory CVR. They concluded that most laboratory stressors are
valid to assess CVR leading to CVD over time in commonly stressed individuals
(Johnston et al., 2008). The findings presented here are in line with that, as it was
found that baseline laboratory HR predicted ambulatory HR. Moreover, the lab delta
score was not related to the ambulatory HR, pointing towards the limited
generalizability of CVR lab scores. Of note, the cardiovascular load in daily life was the
highest in individuals who showed both, elevated baseline HR and elevated CVR in
the lab. To conclude, our findings can only partly confirm the reactivity hypothesis
(Schwerdtfeger et al., 2014).
7.3 The Association of Coping and Cardiovascular Health: Implications and

Future Directions
In earlier studies, it was assumed that high CVR to a laboratory task might also impose
a risk for cardiovascular diseases in real life (Barnett et al., 1997; Everson et al., 1997;
Johnston et al., 2008; Kamarck et al., 1997; Lynch et al., 1998; Matthews et al., 1998;
Tuomisto et al., 2005; Zanstra & Johnston, 2011). The general hypothesis behind
stems from the cardiovascular reactivity hypothesis. The cardiovascular reactivity
hypothesis states that individuals who show elevated cardiovascular reactivity to
stressors are more prone to the development of cardiovascular disease (Krantz
& Manuck, 1984; Obrist, 1981; Treiber et al., 2003). As mentioned earlier, the findings
regarding the generalizability of CVR assessed in the lab to daily life CVR are mixed.
Results that support the cardiovascular reactivity hypothesis are studies that show
elevated CVR obtained from blood pressure in middle-aged individuals also in real life
when experiencing a stressful event (Matthews et al., 1992). When comparing lab
induced CVR with the defensio of 33 healthy males satisfying predictive quality was
found over several more biological (e.g., cold pressor test) and more psychological lab
stress tasks (van Doornen & van Blokland, 1992). Moreover, Kamarck and colleagues
(2000) could show that healthy individuals, who show elevated CVR to psychological
stressors in the lab tend to show elevated CVR during daily life stressors. Furthermore,
the accuracy of this correlation improved when aggregating observations across
multiple situations. A prospective study on the long-term effects of increased blood
pressure reactivity could show that CVR induced by psychological stress was related
to future systolic blood pressure and the need for antihypertensive medication
(Tuomisto et al., 2005).
There are several studies that conclude that a generalization from lab induced CVR to
daily life CVR is not given, thus questioning the external validity. One study on
musicians (n=29) undergoing a lab task (arithmetic and visual-verbal concepts task)
and a real-life stressor (musical performance in front of a jury) found no support for the
generalizability of lab-assessed heart rate and diastolic blood pressure reactivity (Abel
& Larkin, 1991). Another study on 24 females finding stronger correlations between
measurements of CVR obtained from blood pressure and heart rate within settings
(lab, classroom or at home) than between settings, concluded that the change in
environment is having an impact on CVR, thus limiting generalizability (Gerin et al.,
1998).
Nevertheless, CVR seems to be a stable measure of individual physical differences in
coping with stressors (Kamarck et al., 2000). Moreover, not only the magnitude of the
CVR but also the duration of the CVR response may play a vital role in the development
of CVD (Stewart & France, 2001). It could be that heightened CVR itself is not a
problem, when accompanied by a fast recovery, such as the strain on the heart when
exercising is in itself no problem when followed by an extensive recovery period.
Stewart and France (2001) found that CVR and cardiovascular recovery are modest
predictors of longitudinal changes in blood pressure.
Future directions in the investigation of long term health outcomes of cardiovascular
reactivity will be in the main domains: 1.) technical developments, 2.) theory building,
3.) more empirical research, and 4.) application of the findings (Zanstra & Johnston,
2011). The technical developments will be discussed in other sections: Smartphones
as a way of assessing stress and coping will be discussed exhaustively in chapter 7.4,
and the future technological directions of field assessments will be presented in section
7.5. The main research question remains: To what extend is CVR rooted in the
individual or the situations she or he experiences. Moreover, it is likely rooted in the
interplay of both sources. Far more research is needed on the influence of personal
characteristics such as age, gender, race, and socioeconomic status.
Moreover, longitudinal studies on large samples are required. So far, the hope that
ambulatory assessment will answer those questions was unfulfilled. Nevertheless,
future studies might try to implement the previous findings into clinical practice. One
could think of interventions that aim to help individuals at risk to recover quicker after
stressful events or interventions that help people to use more adaptive forms of copings
in their daily life might be worth examining. These interventions could be delivered face
to face, in blended care settings, or as guided/unguided online- or mobile-based
therapy.
7.4 Smartphones as a Way of Assessing Stress and Coping
In general, smartphones offer unique opportunities to collect a vast amount of data in
daily life (Montag & Diefenbach, 2018). Smartphone ownership is widespread all over
the world and specifically high in developed countries (Donner, 2008; Statista, 2018).
Overall, younger individuals are more likely to own and use a smartphone when
compared to the elderly, but the technological gap between generations is closing
(Albrecht, 2018). The average active smartphone usage time of a young adult in
Germany is 162 minutes (Montag et al., 2015). Thus, smartphones are not only giving
insight into online behavior, but they also track our offline lives via multiple integrated
sensors.
In the following, a closer look will be taken on the predictive power of different
smartphone sensors to assess psychological states (e.g., stress, mood, etc.). So far,
there are no studies known on the assessment of stress trough smartphones.
Therefore, the current literature on the assessment of other mental states through
smartphones will be reviewed.
Cornet and Holden (2018) reviewed 35 studies about smartphone-based passive
sensing for health and well-being. Of all included studies, 51% focused on mental
health, 14% on bipolar disorder, and 14% on depression. Throughout the 35 reviewed
papers, accelerometer, location (GPS), audio, and usage data were the most
commonly used sensors. GPS signal was mostly studied concerning depressive
symptoms. The sample sizes of the included studies varied from 5 to 171 participants,
indicating diverse statistical power to detect effects. The Android smartphone operating
system was used in 89% of the included studies. This is not surprising as the iOS
operating system does not allow access to data. Furthermore, android operating
smartphones are more widely used all over the world (88% versus 12% (Statista,
2018)). Instead of using single sensors, most studies combined multiple sensors to
overcome this severe limitation of past approaches (Mehrotra & Musolesi, 2017).
According to Cornet and Holden (2018), the reviewed studies yielded promising results
regarding the feasibility and validity of smartphone-based passive sensing as
significant associations between traditional and sensor-based measurements. They

conclude that future research has to address methodological shortcomings, privacy
issues, and the integration of results into routine clinical care.
A closer look on studies using GPS data shows that they can be used to track daily
movement patterns, which might reveal behavioral patterns of mental disease, e.g.,
changes in mobility in depressed individuals (Beiwinkel et al., 2016; Canzian
& Musolesi, 2015; Grünerbl et al., 2012; Grünerbl et al., 2014; Saeb et al., 2015).
Grünerbl and colleagues (2012) conducted a feasibility trial on ten bipolar patients via
an Android app assessing smartphone usage and found first evidence, that location as
well as motion patterns are reasonable indications of state transitions. For example,
time spent outside (4%) in a depressive episode increased to 13% in a "normal" state.
In a follow-up study, it was shown that the mental state of bipolar patients could be
predicted with an accuracy of 80%. Moreover, changes in mood could be detected with
a precision of 96% when using the acceleration sensor and GPS traces (Grünerbl et
al., 2014). Other studies using GPS data also took circadian movements, location
variance, and mobility between locations into account when analyzing the raw data.
They found high correlations between these mobility features and depression,
indicating that depressed individuals visit fewer locations and spend more time at home
(Saeb et al., 2016). Beiwinkel and colleagues (2016) observed similar movement
patterns in bipolar patients. Saeb and colleagues (2015) concluded that GPS signals
may be an essential and reliable predictor of depressive symptom severity and can
serve as early warning signs. If mental states like affect and mental disease can be
predicted through smartphone usage and sensors, the same approach might be used
to predict individual stress levels. Messner and colleagues (2019) could confirm this
assumption in a feasibility study, including 157 students. However, these findings can
only be interpreted as initial evidence due to the small numbers of included participants
as well as limited data analysis (e.g., no movement pattern evaluation, etc.).

So far, Servia-Rodríguez and colleagues (2017) conducted the most extensive study
about passive smartphone-based sensing and mood prediction. Smartphone sensor
data, usage data, and self-rated mood based on Russell's core affect theory (2003)
were assessed in 18,000 individuals over three years. Machine learning strategies
were employed to predict demographic user characteristics as well as users’ mood.
They were able to predict mood with an accuracy of 64% for valence and 60% for
arousal. Notably, significant correlations were higher when smartphone sensor data
was used instead of usage data.
Regarding the relationship between mental states and smartphone usage, findings are
mixed so far. Excessive smartphone use has been linked to sleep disturbances and
reduced mood (Demirci et al., 2015; Saeb et al., 2015; Thomée et al., 2011). Saeb and
colleagues (2015) revealed that higher phone usage duration and frequency of use are
related to higher levels of depressive symptom severity. Another study found that
smartphone use and sleep quality predicted depression and anxiety levels (Demirci et
al., 2015). Zillmann´s (1988a) mood management theory states that individuals
consume media to manage their mood, could explain the association between high
smartphone use and diminished mood. Individuals in a foul mood could use their
smartphones to pass the time and to escape their feelings (Adams & Kisler, 2013).
Taken together, smartphones are an integral part of modern life and can, therefore, be
used to track behavior and mental states. So far, the first studies show promising
results in the passive sensing of mental states and disease. The next chapter will
discuss current research about field assessments.

7.5 Future Directions of Field Assessments: Potential, Limitations and Ethical
Considerations
Recent biotechnological advances could complement traditional self-report measures
by including behavioral and biological data (Messner et al., 2019). In the future, the
separation between science and everyday life will be reduced, as smartphones and
other sensors get more weight in one´s daily lives (Conner & Mehl, 2015). Although
the promise of higher accuracy and objectivity in data collection is tempting at first
hand, the danger of abuse of highly sensitive data is given (Harari et al., 2016; Rubeis
& Steger, 2019). Any behavioral or biological data which can be obtained on the big
scale with a rather little cost and effort can be used to either assist individuals or person
groups (e.g., feedback on risky behavior or upcoming adverse events, etc.) or to
systematically penalize them (e.g., higher insurance rates for relapsed smokers, etc.).
One current example from China is the social ranking system of the government
rewarding and punishing its citizens according to their social credibility (Ma, 2018).
Therefore, international standards on what kind of data can be legally obtained, how it
can be transferred safely, where data can be stored securely, and with whom data can
be shared are urgently needed (Mohr et al., 2017; Shilton & Sayles, 2016). One current
effort to increase privacy and data safety is the general data protection regulation of
the European Union, which states that every data is owned by the person who
produced it. Therefore, the individual has maximal control over the handling of his or
her generated data. This approach might also enhance the acceptability of passive
sensing and any other form of behavioral assessment in the field (Shilton, 2009).
Nevertheless, current studies examining data sharing practices in health-related apps
show that the lack of international guidelines leads to questionable and intransparent
data sharing (Grundy et al., 2019; Huckvale et al., 2019). In a study focusing on the 24
most popular medical-related apps, it was found that 79% of these apps shared user
data with third parties (Grundy et al., 2019). Moreover, 67% of medical apps provided
services that collected and analyzed user data leading to a heightened risk for a privacy
violation. They conclude that end-users should be aware that their health data is
shared and that this makes them vulnerable to data misuse. One could, for example,
think about a stigmatized disease like HIV/AIDS and a tracking app for medication
intake or safe sex practices. Such information could be used against the individual from
health insurance and other individuals. Moreover, they suggest that developers should
be more transparent on which data is collected, where it is stored, and with whom it is
shared.
Another study looking at data sharing and privacy practices in depression and smoking
cessation apps found that 23 out of 25 apps stated in their privacy policy that data
would be shared with third parties. The transmission of data was detected in 33 out of
36 apps. Data was mainly shared with Google and Facebook, but end-users were only
informed in 50% respective 43% of cases about this specific practice. They conclude
that users are denied an informed choice about which data will be collected and to
whom it will be shared. Again, these practices are very problematic when thinking of
data misuse (Huckvale et al., 2019). For example, health insurance could be very
interested in real-life data of relapses into smoking. Taken together, these findings
support individuals' concerns about the use of technology to manage health (Nicholas
et al., 2019). Before implementing passive sensing or IMIs into health care systems,
an improvement of data security and data sharing practices must be given.
Preconditioned that data safety is given, big data analysis could enhance established
therapeutic approaches and assist in lifestyle changes by providing real-time feedback
on desired and unwanted behavior (Baumeister et al., 2018). Furthermore, this

somewhat objective way of behavior assessment could enhance diagnostics, assist in
treatment decisions, and give deeper insight into the development, onset, and
persistence of diseases and into the preservation of health (Onnela & Rauch, 2016;
Rathner & Probst, 2018).
The state of the art method to analyze “bigger” data are (deep) machine learning
approaches. These are approaches were the computer iteratively tries to find patterns
and associations in a training data set based on neural networks. If such patterns are
recognized, their accuracy is evaluated on a test data set. These models can easily be
made continuously self-adapting (Bengio et al., 2013; Längkvist et al., 2014; Miotto et
al., 2018; Mohr et al., 2017). Deep machine learning approaches are explorative in
nature. Therefore, those approaches can only lead to novel data-driven theories, which
can be subsequently tested in classical confirmatory studies (Oquendo et al., 2012).
Disadvantages of (deep) machine learning approaches are: 1.) the „black box”, as it is
hard to quantify what the machine learned, 2.) that large quantities of test data are
needed to build sufficient models, and 3.) it is time-consuming (Fatima & Pasha, 2017;
Singh et al., 2007). Therefore, explainable artificial intelligence is a rising field in
research.
Big and large data can be obtained via different devices such as computers, tablets,
smartphones, smartwatches, smart glasses, smart wear, etc. rather unobtrusively.
Either the actual digital trace or the sensors which are integrated into the hardware
such as GPS, microphones, etc. can be used to collect data. With the ongoing
biotechnological advances, these possibilities will increase in the future (Conner
& Mehl, 2015). At the moment, the combination of different body sensors, the so-called
body sensor networks (BNS), is extensively investigated. BNS are used to study
physical activity recognition, emotion recognition, and general health (Gravina et al.,
2017; Muzammal et al., 2020; Tian et al., 2019). For an overview, see the article of
Gravina and colleagues (2017) as well as Nweke and colleagues (2019).
So far, sensor variables allow inferences onto environmental conditions (e.g., light,
noise, etc.), characteristics of the person (e.g., gender, age, political orientation, etc.)
and an individual’s behavior (e.g., movement patterns, social interactions, etc.) (Harari
et al., 2016; Saeb et al., 2015; Saeb et al., 2016; Servia-Rodríguez et al., 2017).
Due to these current and future possibilities, researchers and governments should
develop ethical and legal frameworks on how to use data to benefit and not to harm
humanity. Data abuse is a significant threat to the beneficial use of passive sensing to
establish or improve health (Mohr et al., 2017; Shilton & Sayles, 2016).
8 Synopsis and a General Conclusion

Due to the rapid development of technology, the cost-effective collection of real-life
longitudinal data on the big scale is becoming a reality and will be used by companies,
governments, and scientists to study human behavior (Montag & Diefenbach, 2018).
Moreover, the amount of data being digitally collected and stored is ample and
expanding fast (Murdoch & Detsky, 2013). Due to novel technological interventions
and, therefore, the availability of big affordable data, the way scientists can study
human behavior is changing rapidly. These unique opportunities entail a great
responsibility to manage and handle data carefully and to prevent the misuse of highly
sensitive data (Harari et al., 2016; Mohr et al., 2017; Rubeis & Steger, 2019; Shilton
& Sayles, 2016).
Any biological and behavioral data is sensitive in nature. For example, tracking an
individuals' movement patterns via GPS or Bluetooth might give insight into changes
in mental health and well-being (Cornet & Holden, 2018; Mehrotra & Musolesi, 2017)
but would also reveal frequented places the individual would like to keep private (e.g.,
seeing at a medical specialist). Such private insights entail great responsibility in
handling data. Some studies have taken a closer look at data handling practices of
medical-related or health-behavior apps (Grundy et al., 2019; Huckvale et al., 2019).
They conclude that sharing health-related data is common and that theses sharing
routines are not made transparent for the end-users. This confirms end-users concerns
when using technology to monitor health. According to Nicholas and colleagues
(2019), individuals are more likely to share data about health information (such as
sleep, mood, and physical activity) than sensor data (e.g., location, social actions, and
communication logs). Moreover, insecurity about data safety is a significant inhibitor of
uptake of technical health management solutions (Messner et al., 2019). Thus, before
using a technical solution to monitor behavior and health, ethical aspects and data
security must be taken into account.
Nevertheless, the possible advantages of passively monitoring health via technological
devices (such as smartphones) outweigh data safety concerns, as those could be
handled well in the future. Future benefits of passively monitoring individuals' health
would be a.) early detection of disease onset; b.) the delivery of tailored interventions,
c.) evaluation of treatment, d.) improvement in adherence to data collection, e.)
reduction of recall biases and socially desired answer behavior (Messner et al., 2019;
Rathner & Probst, 2018).
Traditional laboratory studies are the counterpart of AA. Their advantages are
controllability of stimuli and cofounding variables, standardization, and fixed study
designs (Zanstra & Johnston, 2011). To date, it is common to infer from laboratory
studies to phenomenons in daily life. When especially looking at social-evaluative
stress and it´s physiological and physical consequences, the dominant theory linking
lab induced stress with health outcomes is the reactivity hypothesis. The reactivity
hypothesis states that accelerated CVR under stress assessed in the lab is associated
with adverse CVD outcomes over time (Krantz & Manuck, 1984; Obrist, 1981; Treiber
et al., 2003). Although this might be true on a rather general level (Johnston et al.,
2008), when taking a closer look into the CV parameters, it was found that CVR
assessed in the lab and in daily life were not associated. Only baseline laboratory HR
predicted ambulatory HR. Moreover, the lab delta score was not related to the
ambulatory HR, pointing towards the limited generalizability of CVR lab scores. Of
note, the cardiovascular load in daily life was the highest in individuals who showed
both, elevated baseline HR and elevated CVR in the lab. To conclude, our findings can
only partly confirm the reactivity hypothesis (Schwerdtfeger et al., 2014).

When thinking about the clinical relevance of this finding, it would be of interest,
whether the habitual coping mode of an individual might be associated with CVD over
time. Therefore, this research tested whether CAV is associated with CVD. A
relationship between CAV and a heightened reaction of the ANS to social–evaluative
stressors in the lab and in daily life was shown in previous studies (Coifman et al.,
2007; Kohlmann et al., 1996; Schwerdtfeger & Derakshan, 2010; Schwerdtfeger
& Kohlmann, 2004; Schwerdtfeger & Rathner, 2016). The risk for CVD was
operationalized via the IMT, a general parameter of (pre)clinical atherosclerosis
(Lorenz et al., 2007). It was found that CAV was associated with IMT with increasing
age, thus suggesting that CAV could be a potential risk factor for the development of
CVD over the lifespan (Schwerdtfeger et al., 2015).
When examining the ecological validity of assessing coping with stress in the field, this
thesis could demonstrate that the ASRD, as a form of repressive coping, in stressful
situations can be economically and validly retrieved in the field. The ASRD is a time
stable trait-like coping pattern of elevated autonomous stress reactions compared with
low levels of self-reported stress (Schwerdtfeger & Kohlmann, 2004). It was associated
with adverse health outcomes, such as CVD and cancer (Mund & Mitte, 2012). Future
research could assess ASRD in the field over extended periods to gain insight into the
processes linking habitual coping and the development, onset, and maintenance of
CVD.
In this thesis could be shown that coping and stress can be ecologically assessed in
the lab and field via diverse methods. Moreover, it was demonstrated that habitual
coping is associated with long-term health outcomes such as atherosclerosis.
Nevertheless, more extensive prospective research is needed to study the assessment
of stress and coping in the field and to broaden the knowledge of long-term health
outcomes of habitual coping modes.

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10 Curriculum Vitae
Mag.a Eva- Maria Messner (maiden name: Rathner)

Herrengasse 11
89610 Oberdischingen
Germany
Telephone: +49 (0)17630116053

E-Mail: eva-maria.messner@uni-ulm.de
Date of birth: 26.06.1984
2020 Maternity leave

2019 License to practice Psychological Psychotherapy in Germany
2019 Scientific exchange at the University of Technology Queensland,
Australia
2012-2019 Ph.D. study of Psychology at the University of Graz, Austria
2018 License to practice Psychological Psychotherapy in Austria
2018 Scientific exchange at the University of Otago (New Zealand) and
the University of Technology Queensland (Australia)
2016-dato Scientific staff at the University of Ulm, Clinical Psychology and
Psychotherapy, Germany
2013-2016 Scholarship holder of the Austrian Academy of Sciences at the
University of Graz, Health Psychology, Austria
2014 Scientific Exchange at the University of Otago
2012-2013 Scientific staff at the University of Vienna, Clinical Psychology and
Psychotherapy, Austria
2012-2018 Postgraduate Training in Systemic Psychotherapy, ÖAGG Austrian
Association for Group Therapy and Group Dynamics, Austria
2012 Further education as a Trainer in Yoga, Pilates, Zumba, Skiing,
Austria
2011-2012 Scientific staff at the University of Graz, Health Psychology, Austria
2011-2012 Officially recognized Trainer for Fitness and Athletics, BSPA
Federal Ministry of Education and Research, Austria
2010-2011 Postgraduate Training in Clinical and Health Psychology, KLIPS

University of Vienna, Austria
2011 Trainee in Health Psychology at the Viennese Programme for
Womens Health, Austria
2009-2010 Postgraduate Propaedeutic Psychotherapy Training, HOPP
University of Vienna, Austria
2010 Trainee in Clinical Psychology at the Psychosomatic Clinic
Eggenberg, Austria
2003-2009 Study of psychology (MA) at the University of Vienna, Austria
Research
Main research interests are: Systemic Psychotherapy; Internet- and mobile- based
Therapy (IMI); quality assessment of m-health apps (www.mhad.science); ambulatory
assessment; passive sensing (www.insightsapp.org); meta-analysis; voice and speech
analysis; stress, emotion and coping; psychophysiology of health and disease;
(https://www.researchgate.net/profile/Eva_Messner2).
Third party funds

Research Grant of the Society for Psychotherapy Research 2019: "The way we talk
and psychological health: Linguistic markers of patient-therapist interaction
and their association with patients’ psychological, interpersonal, and social
systems functioning" in cooperation with Priv.-Doz. Dr. Christina Hunger
(University of Heidelberg), Dr. Markus Wolf (University of Zürich), Dr. Dr.
Gudrun Salamon (Sigmund Freud University Vienna) und Prof. Dr. Johannes
Zimmermann (University of Kassel): 4.990,59$
Women´s fund of Ulm University 2019: 4.000€
Women´s fund of Ulm University 2018: 3.000€
Project fund of the „Systemic Society“ and the „German Association of Systemic
Therapy, Counselling and Family Therapy“2018 in cooperation with Priv.-Doz.
Dr. Christina Hunger (University Heidelberg) for the project “Meta-analysis on
the efficacy of systemic therapy in adults, children and youth”: 10.000€
Short term research stays (KUWI) of the University of Graz 2014: 3.000€
DOC scholarship of the “Austrian Academy of Sciences“ 2013 for the project “MiRNA
expression and verbal-autonomic stress response in surgery patients”:
115.000€
11 List of Publications
(h-index 7; https://scholar.google.com/citations?user=zy_LHpAAAAAJ)
2020
Schuller, B. W., Batliner, A., Bergler, C., Messner, E.-M., Hamilton, A., Amiriparian,
S., Baird, A., Rizos, G., Schmitt, M., Stappen, L., Baumeister, H., MacIntyre A.
D., & Hantke, S. (2020). The interspeech 2020 computational paralinguistics
challenge: Elderly emotion, breathing & masks. Proceedings INTERSPEECH.
Shanghai, China: ISCA.
Harrer, M., Adam, S. H., Messner, E.-M., Baumeister, H., Cuijpers, P., Bruffaerts, R.,
Auerbach, R. P., Kessler, R. C., Jacobi, C., Taylor, C. B., Ebert, D. D. (2020).
Prevention of eating disorders at universities: A systematic review and meta-
analysis. International Journal of Eating Disorders, 53, 813-833.
Kraus, J., Scholz, D., Messner, E.-M., Messner, M., & Baumann, M. (2020). Scared to
Trust? – Predicting trust in highly automated driving by depressiveness, negative
self-evaluations and state anxiety. Frontiers in Psychology, 10, 2917.
Messner, E.-M., Terhorst, Y., Barke, A., Baumeister, H., Stoyanov, S., Hides, L.,
Kavanagh, D., Pryss, R., Sander, L., & Probst, T. (2020). The German version of
the Mobile App Rating Scale (MARS-G): Development and Validation Study.
JMIR mHealth uHealth, 8(3), e14479.
Sander, L. B., Schorndanner, J., Terhorst, Y., Spanhel, K., Pryss, R., Baumeister, H.,
& Messner, E.-M. (2020). ‘Help for trauma from the app stores?’ A systematic
review and standardised rating of apps for Post-Traumatic Stress Disorder
(PTSD). European Journal of Psychotraumatology, 11(1), 1701788.
Sander, L. B., Baumeister, H. & Messner, E.-M. (2020). Smart-Therapy - Internet und
Apps in der Psychotherapie. Psychotherapie aktuell, 1, 20-25.
Schuller, B. W., Batliner, A., Bergler, C., Messner, E.-M., Hamilton, A., Amiriparian,
S., Baird, A., Rizos, G., Schmitt, M., Stappen, L., Baumeister, H., MacIntyre, A.
D., & Hantke, S. (2020). The INTERSPEECH 2020 Computational Paralinguistics
Challenge: Elderly emotion, breathing & masks. Proceedings of the Annual
Conference Interspeech 2020, Shanghai, China.
Stach, M., Kraft, R., Probst, T., Messner, E.-M., Terhorst, Y., Baumeister, H.,
Schickler, M., Reichert, M., Sander, L. B., & Pryss, R. (2020). Mobile Health App
Database - A repository for quality ratings of mHealth Apps. Proceedings of the
33rd IEEE International Symposium on Computer Based Medical Systems
(CBMS), Rochester, MN, USA.
Tammewar, A., Cervone, A., Messner, E.-M., & Riccardi, G. (2020). Annotation of
emotion carriers in personal narratives. Proceedings of the Annual Conference
Interspeech 2020, Shanghai, China.
2019
Baird, A., Amirparian, S., Cummins, N., Sturmbauer, S., Janson, J., Messner, E.-M.,
Baumeister, H., Rohleder, N., & Schuller, B. (2019). Using speech to predict
sequentially measured cortisol levels during a Trier Social Stress Test.
Proceedings of the Annual Conference Interspeech 2019, Graz, Austria (pp. 534-
538).
Baumeister, H., Pryss, R., Baumel, A., Pryss, R., & Messner E.-M. Persuasive e-health
design for behavior change. In: H. Baumeister & C. Montag (editors). Digital
Phenotyping and Mobile Sensing (pp. 261-276). Berlin: Springer.
Domhardt, M., Messner, E.-M., Ebert, D. D., & Baumeister, H. (2019). Internet- und
mobilbasierte Psychotherapie. In W. Rief, E. Schramm & Strauß. B. (Hrsg).
Psychologische Psychotherapie - Ein kompetenzorientiertes Lehrbuch.
München: Elsevier Urban & Fischer Verlag.
Knitza, J., Tascilar, K., Messner, E.-M., Meyer, M., Vossen, D., Pulla, A., Bosch, P.,
Kittler, J., Kleyer, A., Sewerin, P., Mucke, J., Haase, I., Simon, D., & Krusche, M.
(2019). German mobile Apps in rheumatology: Review and analysis using the
Mobile Application Rating Scale (MARS). JMIR mHealth uHealth, 7(8), e14991.
Messner, E.-M., Sariyska, R., Mayer, B., Montag, C., Kannen, C., Schwerdtfeger, A.,
& Baumeister, H. (2019). Insights: Future implications of passive smartphone
sensing in the therapeutic context. Verhaltenstherapie, 1–10.
Messner, E.-M., Probst, T., O´Rourke, T., Stoyanov, S., & Baumeister, H. (2019).
mHealth applications: Potentials, limitations, current quality and future directions.
In: H. Baumeister & C. Montag (editors). Digital Phenotyping and Mobile Sensing
(pp.235-248). Berlin: Springer.
Montag, C., Baumeister, H., Kannen, C., Sariyska, R., Messner, E.-M., & Brand, M.
(2019). Concept, possibilities and pilot-testing of a new smartphone application
for the social and life sciences to study human behavior including validation data
from personality psychology. Multidisciplinary Scientific Journal, 2(2),102-115.
Ringeval, F., Schuller, B., Valstar, M., Cummins N, Cowie R, Tavabi, L., Schmitt, M.,
Alisamir, S., Amiriparian, S., Messner, E.-M., Song, S., Liu, S., Zhao, Z., Mallol-
Ragolta A., Ren, Z., Soleymani, M. & Pantic, M. (2019). AVEC 2019 workshop
and challenge: State-of-mind, detecting depression with AI, and cross-cultural
affect recognition. Proceedings of the 9th Audio/Visual Emotion Challenge AVEC
2019, Amherst, MA, USA (pp. 2718-2719).
Sariyska, R., Rathner, E.-M., Baumeister, H., & Montag, C. (2018). Feasibility of linking
molecular genetic markers to real-world social network size tracked on
smartphones. Frontiers in Neuroscience, 12, 945.
Schwerdtfeger, A. R., Heene, S., & Messner, E.-M. (2019). Interoceptive awareness
and perceived control moderate the relationship between cognitive reappraisal,
self-esteem, and cardiac activity in daily life. International Journal of
Psychophysiology, 141, 84–92.
Stappen, L., Cummins, N., Messner, E.-M., Baumeister, H., Dineley, J., & Schuller, B.
(2019). Context modelling using hierarchical attention networks for sentiment and
self-assessed emotion detection in spoken narratives. Proceedings of the
ICASSP 2019, Brighton, United Kingdom (pp. 6680-6684).
Stegmaier, M., Raschke, A., Tichy, M., Messner, E.-M., Hajian, S., & Feldengut, A.
(2019). Insights for improving diagram editing gained from an empirical study.
ACM/IEEE 22nd International Conference on Model Driven Engineering
Languages and Systems Companion (MODELS-C), Munich, Germany (pp. 405-
412).
Sturmbauer, S. C., Hock, M., Rathner, E.-M., & Schwerdtfeger A. R. (2019). Das
Angstbewältigungsinventar für medizinische Situationen (ABI-MS). Diagnostica,
65(4), 253-265.
Tammewar, A., Cervone, A., Messner, E.-M., & Riccardi, G. (2019). Modeling user
context for valence prediction from narratives. Proceedings of the Annual
Conference Interspeech 2019, Graz, Austria (pp. 3252-3256).
2018
Rathner, E.-M., & Probst, T. (2018). Mobile Applikationen in der

psychotherapeutischen Praxis: Chancen und Grenzen. Psychotherapie im
Dialog, 19(4), 51–55.
Rathner, E.-M., Djamali, J., Terhorst, Y., Schuller, B., Cummins, N., Salamon, G.,
Hunger-Schoppe, C., & Baumeister, H. (2018). How did you like 2017? Detection
of language markers of depression and narcissism in personal narratives.
Proceedings of the Annual Conference Interspeech 2018, Hyderabad, India (pp.
3388-3392).
Rathner, E.-M., Terhorst, Y., Cummins, N., Schuller, B., & Baumeister, H. (2018).
State of mind: Classification through self-reported affect and word use in speech.
Proceedings of the Annual Conference Interspeech 2018, Hyderabad, India (pp.
267-271).
Schuller, B. W., Steidl, S., Batliner, A., Marschik, P. B., Baumeister, H., Dong, F.,
Hantke, S., Pokorny, F. B., Rathner, E.-M., Bartl-Pokorny, K. D., Einspieler, C.,
Zhang, D., Baird, A., Amiriparian, S., Qian, K., Ren, Z., Schmitt, M., Tzirakis, P.,
& Zafeiriou, S. (2018). The INTERSPEECH 2018 Computational Paralinguistics
Challenge: Atypical & self-assessed affect, crying & heart beats. Proceedings of
the Annual Conference Interspeech 2018, Hyderabad, India (pp. 122-126).
Terhorst, Y., Rathner, E.-M., Baumeister, H., & Sander, L. (2018). “Hilfe aus dem App-
Store?”: Eine systematische Übersichtsarbeit und Evaluation von Apps zur
Anwendung bei Depressionen. Verhaltenstherapie, 28(2), 101-112.
2016
Schwerdtfeger, A. R., & Rathner E-M. (2016). The ecological validity of the autonomic-
subjective response dissociation in repressive coping. Anxiety, Stress & Coping,
29(3), 241-258.
2015
Schwerdtfeger, A. R., Scharnagl, H., Stojakovic, T., Rathner, E.-M. (2015). Cognitive
avoidant coping is associated with higher carotid intima media thickness among
middle-aged adults. International Journal of Behavioral Medicine, 22(5), 597-604.
Schwerdtfeger, A. R., Schienle, A., Leutgeb, V., & Rathner, E.-M. (2015). Does cardiac
reactivity in the laboratory predict ambulatory heart rate? Baseline counts.
Psychophysiology, 51(6), 565-572.
12 Author Disclosure
Funding
This research was partly funded by the German Research Foundation (DFG; Grant
No. SCHW 1188/5-1). Furthermore, this work was funded from 2013-2016 by the
Austrian Academy of Sciences (ÖAW; https://www.oeaw.ac.at/en/), the KUWI
scholarship for the research stay at the University of Otago (2014) of the University of
Graz, the Women´s fund of Ulm University for the research stays in Australia and New
Zealand in 2018 and 2019.
Contributions
This accumulative doctoral thesis was developed and written by myself under the
supervision of Univ.-Prof. Dr. Dipl.-Psych. Andreas Schwerdtfeger. My contributions to
the included papers were as followed:
The paper „Insights: Future implications of passive smartphone sensing in the
therapeutic context.” (Messner, Sariyska, Mayer, Montag, Kannen, Schwerdtfeger,
Baumeister, 2019) was drafted and handed in by myself. For this paper, I developed
the research idea, the technology, collected the data, prepared the data, and
calculated the models in cooperation with Benjamin Mayer. All co-authors revised the
manuscript and the adaption after the peer-review.
For the article, “Does cardiac reactivity in the laboratory predict ambulatory heart rate?
Baseline counts.” (Schwerdtfeger, Schienle, Leutgeb, & Rathner, 2014) I collected the
data, prepared the data, prepared the descriptive statistics, discussed the results, and
was assisting in writing the first draft as well as the revisions.

My contributions to the manuscript “The ecological validity of the autonomic-subjective
response dissociation in repressive coping” (Schwerdtfeger, & Rathner, 2016) I
collected the data, prepared the data, prepared the descriptive statistics, discussed the
results, was assisting in writing the first draft as well as the revisions.
For the article „Avoidant Coping Is Associated with Higher Carotid Intima-Media
Thickness Among Middle-Aged Adults.” (Schwerdtfeger, Scharnagl, Stojakovic, &
Rathner, 2014) I collected the data, prepared the data, prepared the descriptive
statistics, discussed the results, and was assisting in writing the first draft as well as
the revisions.
Conflicts of Interest
With this, I declare no conflicts of interest.

The Psychophysiology of Stress and Coping

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The Psychophysiology of Stress and Coping

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The psychophysiology of stress and coping:

Is the discrepancy between autonomous

Eingereicht am: 31.7.2020

As a psychotherapist, trained in systemic therapy, I do not believe in isolated

never dreamed of achieving.

me develop as a free spirit. Warm gratitude to my families, it means the world to me to

unconditional love. I have no idea what I would be without you.

such as Andreas Schwerdtfeger, Thomas Kubiak, Harald Baumeister, Christian

Cummins, and Björn Schuller, who stimulated my research. My gratitude to my student

private adventures in this new chapter in my life.

to stressors contributes to adverse health outcomes. When dealing with stressors,

Furthermore, the association between coping and cardiovascular health will be

second study (n = 111), the association between cardiovascular reactivity (CVR)

of the autonomic-subjective response dissociation (ASRD) in repressive coping was

strategies in healthy individuals (n = 124).

Results: Smartphones could be used in the future to unobtrusively assess mental

accompanied by increased CVR, an interaction of CAV with markers of atherosclerosis

the long-term effect of heightened CVR on health.

Discussion: This thesis adds knowledge regarding the methodology of the

Keywords: stress, coping, ambulatory assessment, passive sensing, smartphone

wiederholte und lang andauernde Exposition zu adversen gesundheitlichen Folgen

führen. Der habituelle Gebrauch spezifischer Bewältigungsstrategien ist mit

gesundheitlichen Folgen verbunden. Diese Dissertation diskutiert neuartige Ansätze

zur Erhebung von Stress und Bewältigungsstrategien im täglichen Leben. Darüber

hinaus wird der Zusammenhang zwischen habituellen Bewältigungsstrategien und

kardiovaskulärer Gesundheit diskutiert.

Erhebung von subjektivem Stresserleben untersucht, indem das

Smartphonenutzungsverhalten von 157 Personen acht Wochen lang erfasst wurde. In

gemessenen kardiovaskulären Reaktivität (CVR) erfasst. In der 3. Studie wurde die

ökologische Validität der autonom-subjektiven Reaktionsdissoziation (ASRD) bei

Herz-Kreislauf-Erkrankungen mit kognitiv-vermeidendem Coping (CAV) assoziiert, um

die klinische Relevanz der habituellen Anwendung von Coping-Strategien bei

gesunden Personen zu untersuchen (n = 124).

Ergebnisse: Smartphones könnten in Zukunft verwendet werden, um psychische

Herausforderungen mit sich bringt, da sensible Daten in großem Umfang erhoben

gesundheitlichen Folgen von habituellen Bewältigungsstilen im Alltag zu untersuchen.

Schlüsselwörter: Stress, Coping, Ambulantes Assessment, Passive Datenerhebung,

1.1 Stress ................................................................................................................ 2

1.1.1 Stress in the meaning of episodic events or acute stress ........................... 3

1.1.2 Stress defined as significant life events ...................................................... 4

1.1.3 Chronic stress ............................................................................................. 5

1.1.4 Daily stressors............................................................................................. 5

1.2 Stress and Age .................................................................................................. 6

1.3 Stress and Mental Health .................................................................................. 7

1.4 Stress and Physical Health................................................................................ 8

1.5 Focus on Stress and Cardiovascular Health ................................................... 10

1.6 Treatment and Prevention of Stress ................................................................ 11

1.7 Theories of Coping .......................................................................................... 13

1.7.1 Krohne´s Model of Coping Modes ............................................................. 14

1.7.2 Coping and Personality ............................................................................. 18

1.7.3 Coping and Age ........................................................................................ 19

1.7.4 Coping and Mental Health ......................................................................... 20

1.7.5 Coping and Physical Health ...................................................................... 22

1.9 Cardiovascular Variables in Stress and Coping Research .............................. 25

1.10 The Assessment of Stress and Coping ......................................................... 26

1.10.1 The Autonomic-Subjective Response Dissociation ................................. 30

1.10.2 The Association of Laboratory and Field Studies .................................... 32

2 Research Questions .............................................................................................. 35

therapeutic context ................................................................................................... 37

5 Study 3: The ecological validity of ASRD in responsive coping. .......................... 103

adults. ..................................................................................................................... 137

7 General Discussion ............................................................................................. 165

7.1 Embedding of Relevant Findings into Current Literature ............................... 166