Analyze how anxiety impacted your health through social, and environmental triggers.

The goal of this activity is to help you reflect on anxiety and worry triggers. Analyze how anxiety impacted your health through social, and environmental triggers. Then, create a brief plan to manage your stress to academic, financial, social, and career goals. You will be asked to do this in a 3 step process.

First, select time in your life where you struggled with worry or anxiety. Describe what triggered this feeling, what you were thinking, and how that impacted your health. This should be about 1 paragraph of information or 50-100 words.

Second, analyze what about the environment or others contributed to anxiety in this situation (i.e., comparison to others, not meeting expectations from yourself, or not knowing how things would turn out). In this time period, what made the feelings/thoughts worse or better. This should be about 1 paragraph of information or 50-100 words.

Third, create your plan. What did you do during that time to manage the stress (health choices, socially, behaviorally, financially)? Was it effective? What would you have changed or done the same if new anxiety developed? This should be about 1 paragraph of information or 50-100 words.

The guidelines for the activity include:

This should be in 12-point Times New Roman font

It should be double spaced

It should be done with the course lecture and content as a reference. PLEASE REFERENCE ATTACHED SOURCES

Sources- watch

Requirements: 300 words, APA format | .doc file

Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=vach20Journal of American College HealthISSN: 0744-8481 (Print) 1940-3208 (Online) Journal homepage: https://www.tandfonline.com/loi/vach20The Evaluation of a Mind/Body Intervention toReduce Psychological Distress and PerceivedStress in College StudentsGloria R. Deckro MD , Keli M. Ballinger MS , Michael Hoyt MA, CHES , MarilynWilcher , Jeffery Dusek PhD , Patricia Myers , Beth Greenberg MA , David S.Rosenthal MD & Herbert Benson MDTo cite this article: Gloria R. Deckro MD , Keli M. Ballinger MS , Michael Hoyt MA, CHES , MarilynWilcher , Jeffery Dusek PhD , Patricia Myers , Beth Greenberg MA , David S. Rosenthal MD &Herbert Benson MD (2002) The Evaluation of a Mind/Body Intervention to Reduce PsychologicalDistress and Perceived Stress in College Students, Journal of American College Health, 50:6,281-287, DOI: 10.1080/07448480209603446To link to this article: https://doi.org/10.1080/07448480209603446Published online: 24 Mar 2010.Submit your article to this journal Article views: 6043View related articles Citing articles: 135 View citing articles

JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 50, NO. 6 The Evaluation of a Mind/Body Intervention to Reduce Psychological Distress and Perceived Stress in College Students Gloria R. Deckro, MD; Keli M. Ballinger, MS; Michael Hoyt, MA, CHES; Marilyn Wilcher; Jeffery Dusek, PhD; Patricia Myers; Beth Greenberg, MA; David S. Rosenthal, MD; Herbert Benson, MD Abstract. The authors examined the effect of a 6-week mindhody intervention on college students’ psychological dis- tress, anxiety, and perception of stress. One hundred twenty-eight students were randomly assigned to an experimental group (n = 63) or a waitlist control group (n = 65). The experimental group received 6 90-minute group-training sessions in the relaxation response and cognitive behavioral skills. The Symptom Checklist- 90-Revised, Spielberger State-Trait Anxiety Inventory, and the Perceived Stress Scale were used to assess the students’ psycho- logical state before and after the intervention. Ninety students (70% of the initial sample) completed the postassessment mea- sure. Significantly greater reductions in psychological distress, state anxiety, and perceived stress were found in the experimental group. This brief mindhody training may be useful as a preventive intervention for college students, according to the authors, who called for further research to determine whether the observed treat- ment effect can be sustained over a longer period of time. Key Words: cognitive behavioral therapy, college students, ran- domized clinical trial, relaxation response, stress tress is a major issue for college students as they grapple with a variety of academic, personal, and S social pressures. In annual surveys between 1985 and 1995, increasing numbers of students reported feeling overwhelmed.’ Although a certain level of stress is neces- sary and results in improved performance, too much stress Gloria R. Deckro is director; research and training, education initiative with the MinoYBody Medical Institute, Hirrvard Medical School; where Marilyn Wilcher is senior vice president; Jeffery Dusek is associate director for clinical research; Patricia Myers was associate director of the afiliate program; Beth Greenberg was director; curriculum and administration, education initiative; and Herbert Benson is president. David S. Rosenthal is director of the Harvard University Health Service, of which Keli M. Ballinger is program manager of wellness and Michael Hoyt is coordinator of health promotion and outreach. Dr Dusek is also an instructor in medicine at the Harvard Medical School, where llr Benson and Dr Rosenthal are associate professors of medicine. negatively affects health.24 In this study, we sought to eval- uate the effectiveness of a simple mindbody intervention in reducing some of the negative psychological impacts of stress in a college population. Over the 100 years since Walter Cannon5 identified the fight or flight response as the physiological reaction to a threat, the concept of stress has been extensively researched and discussed. In college students, increases in stressful life events have been shown to be associated with anxiety and depression? and the level of stress experienced by college students has been documented as a predictor of suicidal ideation and hopeles~ness.~ Research in college students supports a relationship between heightened levels of stress and behavior patterns that may compromise Excess stress also influences physical health. It is now widely believed that the cause of many disease conditions is a complex interaction among genetic and behavioral fac- tors, and stress.I0,” In college students, excess stress is asso- ciated with increases in headaches,I2 sleep disturbance^,”.’^ and the common cold.15 Given these findings, an effective approach to managing stress in college populations is called for. In our study, we used a prospective randomized controlled design to evaluate the effect of a 6-week mindbody intervention on a self- selected group of students. The skills taught in the interven- tion can be broadly divided into relaxation response and cognitive behavioral techniques. The Relaxation Response The relaxation response (RR) is an integrated set of phys- iological changes that are the opposite of the fight or flight (stress) response described by Cannon5 in 1914. These include decreases in oxygen consumption, heart rate, arter- ial blood pressure, and respiratory rate,I6 and changes in central nervous system activity.” The fight or flight response is triggered automatically by physical or psycho- 28 1

DECKRO ET AL logical stress. By contrast, one can consciously elicit the RR by repeating a word, sound, prayer, phrase, or muscular activity while passively ignoring distracting thoughts. In addition to immediate physiological effects, regular elicitation of the RR has been associated with more endur- ing changes. Studies by Hoffman” and Lehmann20 suggest reduced responsivity to the stress hormone norepinephrine after 4 to 6 weeks of daily RR practice. In essence, regular practice of the RR increases one’s resilience to stress. Clinical interventions based on elicitation of the RR have been successfully used to treat a variety of medical disor- ders that may be caused or exacerbated by stress, including anxiety,?! insomnia,22 pain,’3 and diseases with a psychoso- matic component.‘4 Cognitive Behavioral Techniques Cognitive behavioral interventions (CBI) are based on the premise that emotions are influenced by thoughts and that many negative thoughts often contain distortions and exaggeration^.^^.^^ In fact, many believe that at times stress is caused more by the way we think about a problem than by the problem itself.27 By becoming aware of negative thoughts and challenging them, an individual can break the cycle whereby thoughts contribute to negative emotional states. Research has shown that CBIs are effective in treat- ing depression,28 anxiety,29 and panic disorder^.^” Studies in College Students Although higher education communities are increasingly implementing programs to address student stress, the lack of rigorous research evaluating their impact has been surpris- ing. Few researchers use validated health-outcome mea- sures; and even fewer use a randomized controlled design. We found only 4 studies measuring psychological outcomes and meeting these criteria, and 3 of the 4 focused on specif- ic student populations. Two studies in nursing students demonstrated benefits: Heaman” demonstrated that a 5- week relaxation response and cognitive intervention signifi- cantly decreased anxiety (N = 40), and Johan~son~~ evaluat- ed a 6-session (RR and CBI) program (N = 76) and found significant reductions in anxiety and depression. In a study of behavioral medicine students (N = 28), as tit^^^ showed a decrease in psychological distress following an 8-session mindfulness intervention. In the fourth study, Nicholson and colleagues34 examined the effect of a 3-session stress man- agement program on general well-being and anxiety in col- lege students (N = 56) and failed to show significant effects. Our goal was to expand on previous research by offering our intervention across the college population and to use a combination of validated measures to give a broader picture of psychological distress and perceived stress. The interven- tion we used was based on validated clinical program^^?-^^ that had been adapted and pilot tested in the college popula- tion. Our experience, together with student feedback, led us to believe that a program consisting of 6 90-minute sessions would be optimal. It would allow us to cover the cumculum and give students support in making behavioral change with- out putting excess demands on their time. We hypothesized that college students who attended a 6-week RR and CBI intervention would demonstrate reductions in psychological distress, anxiety, and the perception of stress. In addition, the students would increase health-promoting behaviors, com- pared with those in a waitlist control group. METHOD Outcome Measures Our primary outcome measure was change in psycholog- ical distress measured by the Global Severity Index of the Symptom Checklist-90-R from baseline to postintervention. Secondary measures were changes in anxiety, measured by the State Trait Anxiety Inventory; in perceived stress, mea- sured by the Perceived Stress Scale; and in health-promot- ing behaviors, measured by the Health-Promoting Lifestyle Profile 11. Recruitment After obtaining approval from the University Institution- al Review Board, we recruited students through the use of direct mail, fliers posted on campus, and an advertisement in the college newspaper. The study program was called Maximize Your Potential. We offered students a $25 stipend for their participation. Approximately 150 students expressed interest, and 130 came to the university health services, where we told them individually about the study. Of those, 128 students signed an informed-consent form and completed the baseline battery of assessment tools. Every student received an informational sheet explaining counseling services available at the school. We randomly assigned 128 students (51 men and 77 women) to experimental or control conditions, and all com- pleted the pretraining assessments. A majority of the students were undergraduates: 25% were freshmadsophomores, 4 1 % were junior/seniors, and 34% were graduate students. Their ages ranged from 17 to 60 years (M = 24 y, median = 2 1 y). Students in the control group (n = 65) received no inter- vention during the study and were put on a waiting list. Stu- dents in the experimental group (n = 63) attended 6 90- minute weekly group-training sessions. Each member of the training team, which consisted of staff members from both the MindA3ody Medical Institute and the University Health Services (UHS), conducted evening sessions at UHS. Stu- dents selected 1 of 3 evenings to attend the training group and were encouraged to attend all sessions; we allowed them to switch evenings when they encountered scheduling conflicts. Intervention The intervention covered the curriculum outlined in Table 1. The format of the 6 sessions was consistent across the 3 training groups. Trainers followed a training manual. Each 90-minute training session consisted of the following: lecture, discussion, and demonstration of new material group discussion of weekly practice experience of mindhody (RR and CBI) skills JOURNAL OF AMERICAN COLLEGE HEALTH

MIND/BODY INTERVENTION TABLE 1 Contents of a 6-Week MindlBody Intervention for College Students Relaration-response-based skills Cognitive behavioral interventions Diaphragmatic breathing Identifying automatic thoughts Guided imagery Challenging cognitive distortions Progressive muscle relaxation Affirmations Brief relaxation exercises (“minis”) Goal setting Yoga stretches Mindfulness Lecture und discussion topi<:s Stress, stress symptoms, and coping Mindhody connection Physiology of stress and the relaxation Weekly discussion of relaxation practice Individual practice Daily relaxation-response practice Completion of practice log response The emphasis was on teaching a variety of RR and CBI skills that each student could integrate into his or her life on a regular basis. We gave students a manual covering the course curriculum and a CD with a selection of 10-minute RR exercises. They were encouraged to praclice skills out- side the sessions and were asked to complete daily logs recording RR practice that they would submit each week. The trainer also sent weekly relaxation reminders to each participant by e-mail. During the week following the final session, trainers readministered the questionnaire battery to both experimen- tal and control groups. The full 6-week training program was then offered to the control group. Measures Symptom Checklist-90-Revised (SCL-90-K) Spielberger State-Trait Anxiety Inventory (STAI) Perceived Stress Scale (PSS) Health-Promoting Lifestyle Profile 11 (HPLPII) A demographic and health habits survey Psychological Distress The SCL-90-R3s is a widely used standardized psycho- logical inventory measuring current psychological distress. It consists of 90 questions, each rated on a 5-point Likert- type scale for increasing level of distress, ranging from nor at all (0) to extreniely (4). Scoring the SCL-00-R yields 3 global indices of distress: Global Severity Index, Positive Symptom Distress Index, and Positive Symptom Total. The 9 factor scores are somatization, obsessive-compulsiveness, interpersonal sensitivity, depression, anxiety, hostility, pho- bic anxiety, paranoid ideation, and psychoticism. We chose the Global Severity Index (GSI) as the primary outcome measure because it is the best indicator of current psycho- logical distress. We used adult nonpatient norms for scoring College stu- dents have been reported to score higher on the SCL-90-R than do adult samples.36 However, because the mean age of VOL 50, MAY 2002 our student sample was 24 years and the sample also includ- ed a group of graduate students, we decided to use adult norms. Internal consistency coefficients for SCL-90-R sub- scales are satisfactory, ranging from .79 to .90. Test-retest reliability is in the range of .80 to .90. Anxiety The STA13’ is a widely used self-report anxiety scale con- sisting of 20 “state” and 20 “trait” statements. State anxiety is a measure of how participants feel at the current moment, whereas trait anxiety is a measure of how they generally feel. Participants can choose responses ranging from not ar all (1 ) to very much so (4). Scores for each scale range from 20 to 80. The test-retest reliability for the state scale ranges from .16 to .62 and is higher for the trait scale, which ranges from .65 to .86. The Perceived Stress Scale3x is a 14-item self-report scale that measures the degree to which situations in one’s life are perceived as stressful. Respondents are asked to rate on a 5- point scale how often they have felt or thought a certain way, ranging from never (0) to very often (4). PSS has been validated for use with college students. Internal consistency coefficients for the PSS range from .84 to 36, and test- retest reliability is .85. The HPLPI139 uses 52 questions, each rated on a 4-point scale, to measure health-promoting behaviors. Its 6 sub- scales are health responsibility, interpersonal relations, nutrition, physical activity, spiritual growth, and stress man- agement. Reliability coefficients for the subscales range from .702 to .904. We obtained the total score by averaging the scores of all 52 questions. The alpha coefficient for this score is ,922. RESULTS Characteristics At entry to the study, the students reported experiencing high levels of stress. More than two thirds of the sample (69%) reported “having excessive stress,” and nearly two 283

DECKRO ET AL thirds (62%) rated themselves as being “more anxious than most people.” Insomnia, commonly associated with stress, was identified as a current problem by nearly one third (3 1 %) of the students, and nearly one half (45%) said that they did not feel rested upon awakening. At entry into the study, 49 (38%) students reported using some form of relax- ation, and 62 students (48%) said that religious or spiritual practice was important to them. Training Of the 128 randomly assigned participants, 90 (70%) completed both the pre- and posttraining assessments (46 from the intervention group and 44 from the control group). However, 38 (30%) discontinued participation or dropped TABLE 2 Preintervention Scores for Students Who Completed Pre- and Postintervention Assessments and for Students Who Dropped Out of the Study Completed Dropped out (n = 90) (n = 38) Measure M SD M SD SCL-90-R GSI 64.07 10.34 64.68 9.99 State 45.39 12.44 45.13 11.78 Trait 47.77 11.87 49.16 10.96 Total 29.86 8.42 29.70 6.18 Total 2.44 0.45 2.45 0.37 Nore. SCL-90-R = Symptom Checklist-90-Revised; GSI = Glob- al Security Index; STAI = Spielberger State-Trait Anxiety Invento- ry; PSS = Perceived Stress Scale; HPLPII = Health-Promoting Lifestyle Profile 11. All ps > .lo. STAI PSS HPLPII out of the study (17 from the intervention group and 21 from the control group). Students who gave a reason for dropping out of the study cited lack of time to attend the training sessions or conflict with other activities as the pri- mary reasons for their discontinuing participation. Of the 46 intervention participants who completed the pretest and posttraining questionnaires, 20 (43%) attended all 6 training sessions, 2 1 (46%) attended 3 to 5 sessions, 5 (1 1 %) attend- ed 2 or fewer sessions. Statistical Analyses We found no baseline differences between the experimen- tal and control groups on any of the psychological measures or on any of the demographic variables (age, gender, stress, insomnia, overall health, use of spiritual practices or relax- ation, and substance use). There were no baseline differences for students who completed pre- and posttraining assess- ments compared with those who dropped out of the study (see Table 2). In addition, we found no correlation between the number of training sessions students attended and their change scores on any of the psychological measures. We used SPSS statistical software, version 10.0, to analyze the data. Primary Outcome For the primary outcome measure, change in GSI score, we used an intent-to-treat analysis, assigning a 0-change score for values missing as a result of students’ dropping out of the study. This stringent analysis is often used in clinical trials. We calculated change scores by subtracting the post- training score from the preassessment score. The results indicated a significant improvement (p < .018) on the GSI for the intervention group, compared with the control group (see Table 3). In order that primary and secondary outcomes may be compared, we also report GSI scores for those stu- dents who completed both pre- and posttests. For the exper- imental group, the mean GSI fell from 64.15 to 58.00 postintervention, a change score of 6.15. For the control group, the GSI fell from 63.97 to 61.20, a change score of 2.77. The difference in change scores was statistically sig- nificant (p < .025). TABLE 3 Pretraining Score and Change Score Means for the Primary Outcome Variable Global Severity Index (GSI) From the Symptom Checklist-90-Revised (SCL-90-R) Pretraining Change score + Intervention Control Intervention Control (n = 63) (n = 65) (n = 63) (n = 65) Measure M SD M SD M SD M SD P SCL-90-R (GSI) 63.92 10.67 64.57 9.79 4.49 7.23 1.88 4.84 .018* Nore. A decrease in SCL-90-R scores denotes an improvement on the scale. +A change score of 0.0 was used in calculating the mean change score for all subjects who did not complete the postassessment (Intervention n = 17 and Control n = 21). *p < .05. 284 JOURNAL OF AMERICAN COLLEGE HEALTH

I TABLE 4 Pre- and Postintervention Score Means and Change Score Means for the Secondary Outcome Variables: The State-Trait Anxiety Inventory (STAI), the Perceived Stress Scale (PSS), and the Health Promoting Lifestyie Profiie ii (HPLPII) Intervention Control Change score Pre Post Pre Post Intervention Control (n = 46) (n = 46) (n = 44) (n = 44) (n = 46) (n = 44) Measure M SD M SD M SD M SD M SD M SD P STAI State 45.39 13.00 35.57 11.06 45.84 12.13 43.93 12.79 9.82 12.07 1.55 11.39 .mi** Trait 48.02 11.87 42.44 11.49 47.64 12.28 45.24 11.36 5.58 5.5 I 2.4 1 6.60 .O 1 7 Total 30.24 8.55 25.13 8.50 29.45 8.37 27.89 8.64 5.11 7.39 1.57 4.63 .008** Total 2.45 0.4 1 2.62 0.40 2.42 0.48 2.48 0.45 0.17 0.27 0.05 0.22 ,022 PSS HPLPII Note. Data are presented only for students who completed both the pre- and posttraining assessments. **Significant after the Bonferroni adjustment for multiple comparisons (p < ,0125).

DECKRO ET AL Secondary Outcomes We used data only from students who had completed both the pre- and posttraining assessments in our analysis for sec- ondary outcomes. Because we conducted multiple sec- ondary measures, we applied a Bonferroni correction, which resulted in a more stringent significance level (p < .0125). When we used this standard, we found significant decreases on 2 of the secondary outcomes: state anxiety as measured by the STAI and perceived stress as measured by the PSS (see Table 4). Differences on the trait anxiety and HPLPII indicated trends toward improvement for the intervention group, but they did not reach statistical significance. COMMENT Our findings in this study support our hypothesis that col- lege students who attended a 6-week RR and CBI interven- tion would demonstrate reductions in psychological distress, anxiety, and the perception of stress, compared with a wait- ing list control group. Our findings confirm those of authors who have previously demonstrated reductions in anxiety”.’* and also expand their findings beyond nursing students to the general college population. By showing a pattern of reduced psychological distress, anxiety, and perceived stress, the findings also expand on previous re~earch.~’-’~ We found a trend toward increases in health-promoting behav- iors, but it did not reach statistical significance. Although the title of our program, Maximize Your Poten- tial, did not mention stress, the majority of students who chose to enroll reported having “excess stress.” This self- report was supported by mean scores for state anxiety that were above the normal mean for college students3’ and mean scores for psychological distress considered high according to adult outpatient norms.3s The clinical rele- vance of our program is supported by the finding that, after the students participated in the intervention, the elevated mean scores for state anxiety fell to below the mean for col- lege students and the mean GSI fell into the nonclinical range for adults. As long ago as 1982, a survey conducted at the Universi- ty of Pittsburgh showed that students were more interested in learning how to manage stress than in any other health program.40 Psychological distress is widespread on college campuses and some students who may be reticent to seek counseling may be more willing to avail themselves of mindhody programs. In view of the high stress levels on college campuses and the negative impact of excess stress on both health and behavior, we suggest that offering vali- dated programs to address this problem is of the utmost importance for colleges. Study Limitations Although our study validates a brief RR and CBI inter- vention, it is important to point out some limitations. First, students who elected to take part in the study were self- selected and may not represent the college campus as a whole. Our sample had a higher proportion of women and a relative predominance of undergraduate students because 286 we aimed our recruitment efforts toward undergraduates. Unless such programs become an integral part of student orientation or are otherwise made compulsory, participants will always be self-selected. In future studies, it would be interesting to examine how self-selected students might dif- fer from the campus population at large. Second, the 30% dropout rate could have had an effect on the outcome if students who dropped out were significantly different from those who remained in the study. It is, how- ever, reassuring that participants who dropped out of the study did not differ significantly from the rest of the sample on any of the baseline measures. Third, despite our having allowed students to switch train- ing groups in an attempt to improve attendance, only 43% of the students attended all 6 training sessions. Students cited scheduling conflicts, too much work, and midterm exams as their main reasons for missing sessions. Analysis showed no correlation between the number of sessions a student attend- ed and the change scores on any of the psychological mea- sures. This may not be surprising because even during weeks when they were unable to attend, most students continued to maintain logs of relaxation practice. In future studies, atten- dance may improve if we do not schedule training during midterm periods. Fourth, the study sample included a broad age range of students. Given the potentially wide range in stress levels and health conditions across these age groups, it may be important to look separately at undergraduate and gradu- ate students in future studies. Finally, our intervention combined training in a variety of mindbody skills with group support and daily skill practice. We made no attempt to identify the relative efficacy of the different components. Conclusion We evaluated a reproducible, easily implemented, low- cost intervention in reducing psychological distress, anxi- ety, and the perception of stress in a self-selected student population. Our findings indicate that a 6-week RR and CBI training program for students can significantly reduce self- reported psychological distress, anxiety, and the perception of stress. In addition, we found a trend toward improve- ments for the intervention group on trait anxiety and health- promoting lifestyle profiles. Future studies should examine the sustainability of the effect of this intervention over time and determine whether students need continued support if they are to maintain the benefits they reported. NOTE For further information, please direct correspondence to Gloria R. Deckro, MD, MindiBody Medical Institute, 110 Francis Street, Suite 1 A, Boston, MA 02215 (e-mail: gdeckro@caregroup. harvard.edu). REFERENCES I. Sax LJ. Health trends among college freshman. J Am Coff 2. Yerkes RM, Dodson JD. The relation of strength of stimuli Health. 199195 1252-262. JOURNAL OF AMERICAN COLLEGE HEALTH

MIND/BODY INTERVENTION to the rapidity of habit-formation. Journal of Comparative Neu- rology & Psychology. 1908; 18:459-482. 3. Anderson CA, Arnoult LH. An examination of perceived control, humor, irrational beliefs, and positive stress as moderators of the relation between negative stress and health. Basic & Applied Social Psychology. 1989;10(2):101-117. 4. Frazier PA, Schauben LJ. Stressful life events and psycho- logical adjustment among female college students. Measurement and Evaluation in Counseling & Development. 1994;27: 280-292. 5. Cannon WB. The emergency function of the adrenal medul- la in pain and major emotions. Am J Ph,vsiol. 1914;33: 356-372. 6. Segrin C. Social skills, stressful life events, and the devel- opment of psychosocial problems. J Soc Clin Psvchol. 1999; 18: 14-34. 7. Dixon WA, Rumford KG, Heppner PP, Lips BJ. Use of dif- ferent sources of stress to predict hopelessness and suicide ideation in a college population. Journal of Counseling Psycholo- 8. Sadava SW, Pak AW. Stress-related problem drinking and alcohol problems: A longitudinal study and extension of Marlatt’s model. Canadian Journal of Behavioural Science. 1993;25(3): 446464. 9. Naquin MR, Gilbert GG. College students’ smoking behav- ior, perceived stress, and coping styles. J Drug Educ. 1996; 10. McEwen BS. Stellar E. Stress and the individual: Mecha- nisms leading to disease [review]. Arch Intern ,Wed. 1993;153: 11. McEwen BS. Protective and damaging effects of stress mediators [review]. New Engl J Med. 1998;338(3 1:171-179. 12. Labbe EE, Murphy L, O’Brien C. Psychosocial factors and prediction of headaches in college adults. Hcadache. 1997; 13. Farnill D, Robertson ME Sleep disturbance, tertiary-transi- tion stress, and psychological symptoms among young first year Australian college students. Australian Psychologist. 1990;25: 14. Giesecke ME. The symptom of insomnia in university stu- dents. JAm Coll Health. 1987;35:215-221. 15. Stone AA, Bovbjerg DH, Neale JM, Napoli A, Valdimars- dottir H, Cox D, et al. Development of common cold symptoms following experimental rhinovirus infection is related to prior stressful life events. Behav Med. 1992;18: 115-120. 16. Wallace RK,

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