Corey Schuler, RN, MS, CNS, DC
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Assessing stress is complicated business. Many disciplines are asking profound and perhaps age-old questions about the differences between men and women and how they go about dealing with stress. There are questions for epidemiologists, biopsychologists, geneticists, basic scientists, as well as social scientists. With lots of questions come lots more questions.
Self-reported stress was not associated with the cortisol response. Women are being treated at a rate of 1.5-2 times the frequency of men for mood and stress response goals.1 Some studies suggest that women are more likely than men to seek professional treatment, especially if they are also diagnosed with one or more comorbidities.2
Although limited, data available has suggested that there is no significant gender differences for response to oral agents.3,4 Yet, evidence shows that prescribing habits of practitioners vary for the same situation when treating women.5 A gender difference is noted in the absorption, bioavailability, and distribution of agents used to support the stress response.6,7 Imaging studies have suggested women with a distinct fear response and high harm avoidance scores as compared to men have a more active and larger anterior cingulate cortex.8,9 Whether these pieces of information are clinically meaningful is up for debate, but so goes the nature of science.
I am fascinated by the results of the Trier Social Stress Test (TSST). It is an established tool that attempts to measure stress response by inducing a social/ evaluation-type threat. This is done in a biopsychology laboratory by subjecting participants to a mock job-interview. The TSST measures acute, sub-maximal stress responses.
In biopsychology circles, the 1995 Kirschbaum study in Psychosomatic Medicine was a real eye-opener.10 In this study, male and female participants either received social support by their romantic partners, by an opposite-sex stranger, or no support immediately before the TSST.
The support was provided verbally. Designers of the study describe the support as “focusing on positive appraisals and information on effective self-presentation.” I imagine it to be like a pre-game pep talk. What investigators found surprised the biopsychology community. Social support attenuated the stress reaction only for men. Men showed a lower cortisol response when supported by their partners and men benefitted when supported by strangers to some degree. Women, however, did not benefit from social support as the study was designed. In fact, there was a tendency for increased levels of cortisol when obtaining support from their partners. This is the physiologic response to stress. Participants were asked to rate their stress and all participants reported a moderate level of stress. That’s an important nugget of information. Self-reported stress was not associated with the cortisol response.
The initial conclusions of this experiment might be that the effectiveness of social support is based on the gender of who is receiving the intended support and by familiarity with the support provider. However, the study was confounded since male participants were always supported by females and vice versa.
So, does this mean that verbal “pre-game” social support is less useful for women in dealing with stress? What about social support in general for women? Does it mean that men, as romantic partners, are less equipped to provide support? Are these results due to physiological, psychological, or sociological variables? Good questions which remain largely unanswered.
There does seem to be gender differences in stress responses. Data from female twin registries surveys suggest the potential role of genetic versus environmental factors in the stress response.11-13 The potential role of female reproductive hormones and related cycles in the development, course, and outcome of stress response in women is also very intriguing.14,15
For the practicing clinician, most of this information has to be set aside at the time of the patient encounter to address her concerns and goals. I do my best to paint a picture of the individual’s response to stress using various tools including examining the HPA axis. A few of the practical tools I use include the Holmes and Rahe’s Personal Stress Inventory which asks patients to check off major life stressors over the past year. The Hamilton Anxiety Rating Scale is a clinician observation tool that attempts to quantify visible stress responses. The good ol’ visual (or more commonly verbal) analog scale has limited utility but is not without value.16 It is so easy that almost everyone uses it and is a natural part of the clinical discussion.
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