extent, common meanings in both the biological and psychological sciences.
Stress is the body’s reaction to a change that requires a physical, mental or emotional adjustment or response. Stress can be defined in terms of all people responding in the same biological way to the same stimulus, or as dependent upon the person’s response to the stressor. Any perception of a stress stimulus triggers the person’s physiological and psychological responses to situations or events that disturb the equilibrium.
Stress is any event that a human being perceives as harmful or threatening. The body reacts to stress with ‘fight or flight’ response. Stress hormones like adrenalin, dopamine, cortisol, noradrenalin, and endorphins are released in the blood when one experiences stress.
The term stress had none of its contemporary connotations before the 1920s. In the 1920s and 1930s, the term was occasionally being used in biological and psychological circles to refer to a mental strain, unwelcome happening, or, more medically, a harmful environmental agent that could cause illness. Walter Cannon used it in 1926 to refer to external factors that disrupted what he called homeostasis. Homeostasis is a concept central to the idea of stress.
Environmental factors, internal or external stimuli, continually disrupt homeostasis. Factors causing an organism’s condition to waver away from homeostasis can be interpreted as stress. A life-threatening situation such as a physical insult or prolonged starvation can greatly disrupt homeostasis.
Psychologists have defined stress in a variety of ways. Contemporary definitions of stress regard the external environmental stress as a stressor, the response to the stressor of distress, and the concept of stress as something that involves biochemical, physiological, behavioural and psychological changes.
While there is little consensus among psychologists about the exact definition of stress, it is agreed that stress results when demands placed on an organism cause unusual physical, psychological, or emotional responses. In humans, stress originates from a multitude of sources and causes a wide variety of responses, both positive and beneficial (Eustress) and negative and harmful (Distress).
The most commonly used definition of stress was developed by Lazarus and Launier (1978), who regarded stress as a transaction between people and the environment and described stress in terms of ”person-environment fit”.
Stress typically describes a negative concept that can have an impact on one’s mental and physical well-being, but it is unclear what exactly defines stress and whether or not stress is a cause, an effect, or the process connecting the two. With organisms as complex as humans, stress can take on entirely concrete or abstract meanings with highly subjective qualities, satisfying definitions of both cause and effect in ways that can be both tangible and intangible.
Both negative and positive stressors can lead to stress. The intensity and duration of stress changes depending on the circumstances and emotional condition of the person suffering from it (Arnold. E and Boggs. K. 2007). Humans may all be faced with the same stressor (stimulus) but the stress response that they show will depend on their individual differences or gender or culture.
Stress is an extremely adaptive phenomenon in a person which contributes to his/her survival, activities, and performance.1 Physical and psychological stress can induce a number of immunological alterations in the cell mediated.2 Stressors may influence the immune system through their impact on neuroendocrine, autonomic and central nervous system.3 Psychological stress may influence the functions of the immune system both indirectly through hormonal changes, and directly through nervous regulation during brief but acute stressful periods.4 Exposure to psychological stressors can modulate the primary antibody response.5,6 (4)
Some common categories and examples of stressors include: Life experiences such as poverty, unemployment, clinical depression. Obsessive compulsive disorder, heavy drinking, or insufficient sleep can also cause stress. Students and workers may face performance pressure stress from exams and project deadlines.
The medical student:
Medical students are frequently individuals with a long-standing need for caring, a capacity to tolerate, being in a providing, dispensing, and nurturing relationship with other people.
It is not uncommon for medical students to have chosen medicine after a death of a family member or close friend, sometimes with the quite conscious desire to learn how to fight wasteful death.
The goal of medical education is to graduate knowledgeable, skilful and professional physicians. The medical school curriculum has been developed to accomplish these ambitions.
Medical students are a highly self-selected group who arrive in medical school with a set of developed abilities, motives, adaptive styles, and values that must be taken into account if we are to understand the impact of their medical studies on them.
Teams of sociologists have studied the ways medical students organize themselves to excel and to manage the vast amounts of information that they should learn. They consider success in medical school as the first step to a future of helping others and they are not about to jeopardize that.
Medical students as a group are attracted to medicine partly because of their special sensitivity to and concern on three psychological issues: death, suffering, and care. Secondly, medical students are distinguished by a preference for certain adaptive techniques, styles, and defences-specifically by a propensity to counter, master, and overcome sources of anxiety, a tendency to react to stress and anxiety. (3)
Stress and medical studies:
There is extensive literature demonstrating that medical students begin medical school with mental health profiles similar to their non-medical peers. Since the healing profession is distinctively motivated to confront the issues of suffering, death and care, issues that most of their fellows anxiously avoid, through the course of medical school, they experience substantial deterioration in their mental quality of life, due to stress and anxiety.
Medical students have to deal with stressors specific to medical school in addition to normal stressors of everyday life which explains this high prevalence of anxiety. (1)
Medicine is a kind of training which is emotionally demanding and therefore medical education can be regarded as stressful. High levels of stress have been found in medical students in various studies. Amongst medical students, stress has been reported to be caused by academic pressure, perfectionist standards, increased psychological pressure, mental tension and too much work load. The demanding nature of medical practice requires involvement with the most personal or emotionally draining aspects of life (human suffering, death, sexuality and fear) and these are considered to be stressors. Stress during medical school can lead to problems later in professional life compromising patient care. (1)
Studies suggest that medical students experience a high incidence of stress with potential adverse consequences on academic performance, competency, professionalism and health.
Medical students experience substantial stress from the beginning of the training process. Students use various coping mechanisms to process stress that vary by year in training and source of stress. The specific coping strategies that students use may determine the effect of stress on psychological and physical health and may determine whether stress has a positive or negative influence.
Strategies that centre on disengagement such as problem avoidance, wishful thinking, social withdrawal and self-criticism have negative consequences and correlate with depression, anxiety and poor mental health. In contrast, strategies that involve engagement such as problem solving, positive re-interpretation, reliance on social support and expression of emotion enable medical students to respond in a manner that leads to adaptation, which can reduce stress.
Medical education has deleterious consequences. Trainees (students, interns, and residents) suffer high levels of stress, which lead to alcohol and drug abuse, interpersonal relationship difficulties, depression and anxiety, and even suicide. Medical students have mean anxiety scores one standard deviation above those of non-patients. (12)
Studies which have tried to identify the sources of stress among medical students generally concern three main areas : academic stress: enormous syllabus to be covered in a limited time, sudden change in their style of studying, flooding of medical science with new concepts, lack of proper guidance, thought of failing in exams, inadequate time allocated to clinical posting, insufficient bed side teaching, social stress : relationship with peer groups, hostel friends, senior teachers, displacement from home, expectations of parents, peer pressure, change in the medium of education, physical stress : inadequate hostel facilities, hostel food etc. (5)
Anxiety is also associated with feeling of loneliness, peer competition, long hours and loss of social time. The majority of stressful incidents in traditional curricula are related to medical training rather than to personal problems. (7)
Stress may not only impair the quality of life of medical students but can also influence patient care and the complex psychodynamics of the doctor- patient relationship. (5)
Stress is receiving increased attention because of the realization that tired, tense, anxious doctors may not provide as high quality care as do those who do not suffer from these debilitating conditions.
A medical career can be particularly stressful due to the combination of involvement with life and death and the high expectations of medicine and of doctors held by both the public and doctors themselves. Partly as a result of these pressures and the need to acquire a substantial body of knowledge and skills, medical students experience considerable anxiety at various stages in the curriculum (Arndt et al., 1986; Firth, 1986; Firth-Cozens, 1987; Kidson & Hornblow, 1982; Moss & McManus, 1992; Tooth et al., 1989). Such anxieties may result in, for example, reduced examination performance (Tooth et al., 1989), increased alcohol consumption (Firth, 1986) and attempted suicide (Warren & Wakeford, 1990). (6)
Some students may perceive factors such as nutrition, exercise routines, sleep patterns, social activities, having a child to care for, job responsibilities, finances as stressors that they need to overcome in order to achieve a higher academic standing. By themselves, these constraints may have no effect at all on a student, but when combined, a student could perceive them as stressful and these stress factors could have a dramatic effect on a student’s academic performance.
Exam stress during medical studies:
Medical students are repeatedly subjected to rigorous examinations in order to check their potential to be a doctor as they have to deal with human life every single day. They have chosen a career which demands not only responsibilities but also ethical and legal liability for other’s lives. The onus of this responsibility and sheer volume of syllabus places a medical student under tremendous stress prior to professional exams. This stress may manifest with varying magnitude of anxiety (Kidson and Hornblow, 1982) and decrease in psychological health (Aktekin et al, 2001). (13)
To a student, the prospect of sitting for an examination could be identified as a stressor and the resulting emotional and physiological state could be described as an exam stress. (4)
Many students experience anxiety before a test or exam; a little bit of nervousness can actually enhance performance. However, if stress levels rise to the point where they inhibit performance on the test, then this is considered exam stress. 92% of students said that they got worried during exam time; one fifth of students surveyed revealed that they had suffered anxiety attacks as a result of pre-exam stress. Furthermore, 61% of those questioned cited lack of sleep/insomnia as a result of stress, 51% said that they suffer from headaches or migraines and 47% admitted turning to the one of the world’s best comforts, food. (10)
Here below are some of the symptoms of exam stress, which can vary widely in intensity. Some test-takers experience only mild anxiety, and still perform well, but others are left nearly unable to function, failing the test or even experiencing a panic attack.
Physical symptoms of exam stress include tremors, sweating, dry mouth, nausea, rapid heartbeat and even fainting. Milder cases include symptoms of “butterflies in the stomach”, but severe cases can lead to physical illness which must be treated.
Behavioural and cognitive symptoms include defiant avoidance of exam situations, or just a little fidgeting. In some cases, exam stress can become so severe that the student is forced to drop out of school entirely just to avoid testing. Many students attempt self-medication with alcohol or drugs; still others report “blanking out” completely, or experiencing difficulty concentrating, inability to control thoughts and a negative outlook, which are all common behavioural / cognitive symptoms of exam stress.
Emotional symptoms of exam stress include low self-esteem, anger, depression and feelings of despair. The students taking the test often feel unable to do anything about their situation, so they may berate or belittle themselves about their performance and their feelings.
Exam stress is reported to have a significant impact on the well-being of the student and is associated with changes in the mental and physical health such as increasing anxiety, increasing negative mood and changes in the functions of the immune system. (4)
In other words, the exam is one of the stressful events associated with lowered immune system function.14 Academic examinations have often been used in stress research because they are predictable, standardized, and discrete examples of real-life stressors. It was demonstrated that this stress caused a significant neurohormonal change.
A small but significant increase in their emotional distress is indicated by an increase in anxiety during the final examination.
Glucocorticoids can downregulate the immune activity, but acute stresses were reported to increase the cortisol level.19 Results show that the exam stress can result in significant increase in the cortisol level. (4)
According to a study conducted by Shamsdin, et.al. (2010) on thirty five university medical students, two blood samples were provided from each participant one month (first stage) and one hour (second stage) before the exam. The results show that stress has determining effects on the immune response. The exam stress can result a significant increase in the cortisol level. So, these changes may indicate the alterations of immunological status and presence of stress in an immunosuppressed individual, affecting his / her health. “Under stressful conditions, the hypothalamus releases corticotrophins into the blood circulation and when it reaches the anterior lobe of the pituitary gland, adrenocorticotrophic hormones are released into the blood circulation. When this reaches the adrenal gland, lucocorticoids are released which are chemicals that modulate or regulate the immune response. Since lymphocytes have receptors for glucocorticoids as well as other steroid hormones associated with responses to stress, the brain and immune system are sufficiently well connected to one to influence the other”.
Exam stress involves a combination of physiological over-arousal, worry and dread about test performance, and often interferes with normal learning and lowers test performance. It is a physiological condition in which people experience extreme stress, anxiety, and discomfort during and/or before taking a test. Exam stress is prevalent amongst the student populations of the world, and has been studied formally since the early 1950s.
During states of excitement or stress the body releases the hormone adrenaline. This hormone is responsible for preparing the body for danger, or the fight or flight response. Adrenaline is known to cause the physical symptoms one might experience that accompany exam stress such as increased heart rate, sweating, and rapid breathing.  Symptoms of exam stress can range from moderate to severe. Students who exhibit moderate symptoms are still able to perform relatively well on exams.  Other students with severe stress will often experience panic attacks. Student expectations are one major mental factor. For example, if a student believes that he or she will perform poorly on an exam, he/she is far more likely to become anxious before and during a test. (9)
Exam stress is the emotional reaction that some students face before exams. The fear is not irrational, but excessive fear interferes with performance. Many researchers suggest that a little worry is good for students because it keeps them task oriented; however excessive worry on the other hand can be very debilitating and interferes with the results if not managed appropriately. (2)
Exam stress is a set of responses that includes excessive worry, depression, nervousness and irrelevant thinking to a class of stimuli from an individual’s experience of assessment / test and outcome. It is experienced by many students while undertaking any exam. There are four main areas of reported stresses which can contribute to exam stress including life style issues, lack of required information, studying style and psychological factors. (2)
Life styles related issues include inadequate rest, insufficient physical activity, poor nutrition and lack of time management are found to be the contributing factors leading to exam stress as reported by many authors.
Psychological factors which contribute significantly to exam stress are negative and irrational thinking about exams, outcomes of exams and feelings of no control over exam situation (e.g. going blank during exam) are reported by many authors. Students’ perception of extensive course load is also reported to cause exam stress in medical students. Examination system itself is a major stress factor for medical students. (2)
In other words, the phrase “exam” is the same stimulus, but some medical students will be feeling very worked up about the exam, others will be more ‘laid back’. The internal and behavioural response will be different for each of them. Psychologists try to find out the factors affecting this interaction and stress management depends on the perceived interaction and response.
Gender is likely to be an important factor in students’ anxiety. Women are reported to be more anxious than men, both overall and for most individual situations. (6)
Anxiety levels increase in medical students just before exams, with female students found to be more anxious than males, shows a study undertaken by the Armed forces Medical College (AFMC), Pune, India (Pahwa, et. al., 2008). (14) According to this study labelled ”A study of exam related anxiety amongst medical students” pre-exam anxiety levels are seen to be higher in female than male population indicating greater increase in anxiety levels amongst females. This is in agreement with other studies that substantiate presence of sex differences in exam related anxiety, with female students having higher test anxiety than male students (Chapell et al 2005, Eller et al 2006). (13)
Females are more likely to report concern and stress due to self expectation, a feeling of lack of competence and a tendency to over report symptoms. (1)
Comparison of rankings between 1992 and 1995 Birmingham students shows that rankings were consistent over time for both genders, particularly for the higher ranked questions. More detailed analysis of the 1995 data shows that individual female students were more likely to have higher total scores than male students. (6)
All stress factors were more common among female students with statistically significant differences in factors which included: studying all night before exams, feeling no control over exam situations, improper nutrition and lack of exercise.
Personality and stress:
Mental health professionals believe personality plays a significant role in how individuals perceive stress (Martin, 2011). Lazarus and Folkman (1984) define stress as a product of the relationship between the person and the environment. Stress occurs when a person appraises a stressful event as exceeding his / her coping abilities or threatening his / her well being.
Personality can influence both health related and everyday behaviours and is also related to an individual’s appraisal of a stressful experience (Booth-Kewley, 1994).
Stress is not a simple, stimulus-response reaction; rather it is the interaction between an individual and the environment, involving subjective perception and assessment of stressors, thus constituting a highly personalised process. Specific inherited characteristics, early experience in life, and in particular, learned cognitive predispositions make individuals more or less susceptible to the effects of stressors. Resilience and vulnerability to stressors as well as intensity of stress response mainly depend on age, gender, intelligence, and many other characteristics of personality (19). (Psychiatrike. 2011. Stress and personality. Lecic-Tosevski D, Vukovic O, Stepanovic J. psychiatric Department, Belgrade University, School of Medicine, Belgrade, Serbia.)
Research has indicated that certain personality traits can make individuals more vulnerable to stress. There is a number of personality traits that could be described which measure human personality. A broad and comprehensive way of identifying the traits and structure of human personality is the Five Factor model (Digman, 1990). J.M. (1990). (“Personality structure: Emergence of the five-factor model”.Annual Review of Psychology 41: 417-440).
Five Factor Model:
This model has originated in a decades-long factor-analytic research tradition (13). Most researchers’ goal was to create a brief inventory that would allow efficient and flexible assessment of the five dimensions when there is no need for more differentiated measurement of individual facets. (6)
Big Five has proven useful as a framework for organizing any findings on adult personality in areas such as behavioural genetics and industrial psychology. (6)
The five factor model of personality is better understood as a lexical and factor analytic derived personality approach (Haslam, 2007). McCrae and Costa (1991) claim that this model provides a “comprehensive taxonomy of personality traits”. However this model has not always been regarded as noteworthy (McAdams, 1992).
McCrae and Costa have conducted a lot of research on the model, including cross-sectional and longitudinal research designs (Cavanaugh & Blanchard-Fields, 2006) and they argue that the model includes a large number of traits found in language and scientific theory. Thus, this model allows for a systematic approach to personality (12).
The five factors model is more than a simple classification of basic personality traits. By the late 1980s, Costa and McCrae were convinced that they and other researchers had found a stable structure of personality. (11)
In McCrae and Costa’s (1996, 1999, 2003) personality theory , behaviour is predicted by understanding the three central or core components and the three peripheral ones. The three central components include (1) basic tendencies, (2) characteristic adaptations, and (3) self-concept. (11)
The five factors are labelled by McCrae and Costa (1992) as extraversion, neuroticism, agreeableness, conscientiousness, and openness to experience.
These dimensions make up the personality traits of the five-factor model, which is often referred to as the “Big Five” (Goldberg, 1981).
The first of the five factors is extraversion. Extraversion has a different importance in different measures. Sometimes it is based on assertiveness, sometimes on spontaneity and energy. Sometimes it is based on dominance, confidence, and agency (Depue & Collins 1999), sometimes on a tendency toward happiness. Extraversion is often thought to be implying sociability (Ashton et al. 2002). Others see a sense of agency and a sense of sociability as two facets of extraversion (Depue & Morrone- Strupinsky 2005). Finally, others argue sociability is a by-product of other features of extraversion (Lucas et al. 2000). A connection has also been made between extraversion and the approach temperament; thus, some now view extraversion as reflecting a relative sensitivity of a general approach system (Depue&Collins 1999, Caspi& Shiner 2006, Caspi et al. 2005, Elliott&Thrash 2002, Evans & Rothbart 2007).
People who score high on extraversion tend to be affectionate, jovial, talkative, joiners, and fun-loving. In contrast, low extraversion scorers are likely to be reserved, quiet, loners, passive, and unable to express strong emotion (11).
The second factor, neuroticism, refers to the ease and frequency with which a person becomes upset and distressed. Moodiness, anxiety, and depression indicate higher neuroticism. Measures often include items or facets relevant to hostility and other negative feelings, but they are dominated by vulnerability to anxiety and general distress. Neuroticism has been associated with the avoidance temperament discussed above (Caspi & Shiner 2006, Caspi et al. 2005, Evans&Rothbart 2007), suggesting that anxiety and sensitivity to threat is its emotional core.
People who score high on neuroticism tend to be anxious, temperamental, self-pitying, self-conscious, emotional, and vulnerable to stress related disorders. Those who score low on neuroticism are usually calm, even-tempered, self-satisfied, and unemotional. (11)
The next factor is agreeableness. Agreeable people are friendly and helpful ( John & Srivastava 1999), empathic (Graziano et al. 2007), and capable of inhibiting their negative feelings (Graziano & Eisenberg 1999). Agreeable people become angry over others’ transgressions than do less agreeable people (Meier & Robinson 2004), and this probably short-circuits aggression (Meier et al. 2006). At the opposite pole is an oppositional or antagonistic quality. People who are low in agreeableness display their power to deal with social conflict (Graziano et al. 1996). Agreeableness as a dimension is often characterized as being broadly concerned with maintaining relationships (Jensen- Campbell & Graziano 2001).
People who score high on agreeableness tend to be trusting, generous, yielding, acceptant, and good-natured. Those who score low are generally suspicious, stingy, unfriendly, irritable, and critical of other people (11).
The most commonly used label for the next factor is conscientiousness, although this label does not fully represent the qualities of planning, persistence, and purposeful trying to achieve goals that are part of it (Digman & Inouye 1986). Other suggested names include constraint and responsibility, reflecting qualities of impulse control and reliability. Specific qualities included in this trait vary considerably across measures (Roberts et al. 2005).
Individuals who score high on conscientiousness are hardworking, conscientious, punctual, and persevering. In contrast, people who score low on conscientiousness tend to be disorganized, negligent, lazy, and aimless and are likely to give up when a project becomes too difficult (11).
Agreeableness and conscientiousness share an important property. Both suggest breadth of perspective. Many manifestations of conscientiousness imply taking future contingencies into account. Agreeableness implies a broad social perspective: taking the needs of others into account. It has been suggested that both of these traits have their origins in the effortful control temperament (Ahadi & Rothbart 1994, Caspi & Shiner 2006, Jensen-Campbell et al. 2002).
The fifth factor, most often called openness to experience (Costa & McCrae 1985), is the one about which there is most disagreement as far as content is concerned. Some measures (and theories) enrich this factor with greater overtones of intelligence, terming it intellect (Peabody & Goldberg 1989). The fifth factor involves curiosity, flexibility, imaginativeness, and willingness to immerse oneself in atypical experiences (McCrae 1996).
People who consistently seek out different and varied experiences would score high on openness to experience. They are creative, imaginative, curious, liberal and have a preference for variety. Those who score low on openness tend to support traditional values and to preserve a fixed style of living and they are typically conventional, down-to-earth, conservative, and not at all curious. (13)
Big Five and Medical students:
Most of the research on the Big Five is based on self and peer ratings, typically made by college students. (6)
Conscientiousness, agreeableness and openness have been shown to be related significantly to academic performance (Poropat, 2009). (15) Neuroticism, in contrast, has a negative significant relationship with academic performance. The relation between educational operation and neuroticism, particularly with regard to anxiety in stressful situations such as university examinations has been clarified 14 (18).
It is often claimed that, besides cognitive abilities, a mixture of personality characteristics is necessary for people to be successful in medical studies and eventually in the medical profession. However, there is debate as to which personality traits are typical of students in medical studies as compared to students in other academic fields 1-3. (5)
A study conducted by Nauert (2009) which was labelled “Personality profile of medical students” studied more than 600 Belgian students over their seven years of medical studies to determine what impact their personality had on their performance. The researchers employed a commonly used test to measure the Big Five personality traits.
Although the study was conducted in Belgium, the personality factors and the modern medical practices are similar around the world so personality should consistently relate to valued outcomes in medical education.
Personality traits can reveal a lot about how students perform during the different demands and emphases of a student’s medical studies. For example, trait conscientiousness was a good predictor of learning success throughout the medical studies of the students.
The researchers speculated that extraverted students are more likely to spend less time on studying than on their social relationships during the first years of medical school, which could hinder their academic performance and result in lower grades, whereas “students who scored well in persistence and conscientiousness experienced success in their studies” (Grohol, 2009).
Big Five and Stress:
Personality has been linked to the probability of experiencing stressful situations (Bolger & Zuckerman, 1995) and to