( Article for my assignment) https://www.longdom.org/open-access/the-benefits-of-yoga-for-musculoskeletal-disorders-a-systematic-review-of-the-literature-2157-7595.1000122.pdf
Nissa
RESEARCHREPORT.pdf
Running head: STRESS AND IMMUNE DYSREGULATION
Stress and its Internal Effects on Human Immunity
Fatima Sultan - DH1909116 Alexa Sarmento - DH1909108 Rebecca Roche - DH1909098
Jasmine Sanchez - DH1909105 Lucy Santos - DH1909107
Submitted in partial fulfillment of The requirements for
RES/EBP Research and Evidenced Based Practice in Dental Hygiene
Toronto College of Dental Hygiene and Auxiliaries Toronto, Ontario
Instructor: Mihaela Sebescu, RDH, AdEdCert
March 9th, 2021
STRESS AND IMMUNE DYSREGULATION 1
Abstract Motivation: As a group of dental hygiene students who are in an accelerated program, we feel that the stressful environment that we experience has a negative impact on our overall health and wellness, causing immune dysregulation. This is an important topic that should be addressed, especially now as we are in the middle of a stressful pandemic and still full-time students. Problem Statement: This study will examine the educational stress levels of students attending TCDHA, and the impact the stress, and characteristics associated with stress, have an impact on immune dysregulation. Methodology: This study will involve a randomized, qualitative analysis of 50+ dental hygiene students from the Toronto College of Dental Hygiene. A 15-question closed-ended, multiple choice survey will be conducted to determine the result of how stress may affect the immune system of dental hygiene students. The independent variable is the external stress associated with attending TCDHA, and the dependent variable will be the students, and the impact on their immune system overall. Results: Our study determined that there is indeed a correlation between students attending TCDHA experiencing a high level of stress, and the impact of the stressor on the immune levels of that individual. Our research resulted in a positive correlation overall between stress, and the internal effects on the immune system in the human body - it was also determined that a large number of students feel that the stress at TCDHA is negatively impacting their immunity. Conclusions: Our study allowed us to conclude that since the students of TCDHA began the dental hygiene program, they have experienced increased levels of stress, an increase of sickness-induced behaviours and difficulty functioning everyday. Various stressors can extremely impact an individual's immune system. Keywords: stress, immunity, sleep, disease, school, dysregulation
STRESS AND IMMUNE DYSREGULATION 2
Introduction
Research has shown a direct relationship between stress and the dysregulation of the
body’s immune system. While experiencing stress is a normal factor in education, college
students like ourselves often experience the feeling of stress more often than normal
depending on the situations that we are placed in. Students have the responsibility of
completing numerous assignments and examinations that lead to heightened stress levels in
comparison to when we are on break or have completed school. We as a group wanted to
conduct a research study to discover whether or not in the event that an individual is
experiencing a compromised immune system, would the factors contributing to college stress
be more impactful than everyday stress on an individual’s health and immunity. The
importance for this exploring study between college stress and the immune system is to
enhance the ability to understand how to avoid certain stressors along with refraining others
from experiencing these effects in the future. Understanding these studies can be beneficial
for prevention and maintenance.
Literature Review #1- Lucy Santos
The main purpose of this literature review is to investigate the correlation of
perceived stress and immune-related diseases and health outcomes of students, specifically in
pharmacy students attending university. The article that was selected focuses on two
different levels of pharmacy students attending the University of Jordan. The groups
consisted of Pharmacy students in two undergraduate programs; B.Sc. in Pharmacy, a five
year program and B.Sc. in Doctor of Pharmacy (PharmD group) a six year program. The
study aims to explore how certain life stressors can suppress the immune system and its
ability to respond to these stressors.
STRESS AND IMMUNE DYSREGULATION 3
The methodology that was used was a pilot study using a cross sectional
survey using an interviewer administered questionnaire which was developed by comparing
previous survey data and literature used to in measure student life stressors. It was a
quantitative study that included a total of 222 students, 113 enrolled in the B.Sc. in Pharmacy
and 109 students enrolled in the B.Sc. in Doctor of Pharmacy group. The variables included
whether they were employed, their accommodation (who they were living with), their grade
point average as well as factors including exercising, their nutritional routines, smoking,
social activities and the amount of sleeping. Other variables also included, weight, height,
sex and marital status. Students were asked to compare their emotional and physical states
during their semester as well as the frequency and/or changes in their health. Bar graphs, pie
charts and regular charts were used to understand the concepts that were being measured in
terms of the students’ academic stress. The validity of the content of the questionnaire that
was administered to the students was also evaluated by an “expert committee of one clinical
pharmacist, two clinical immunologists, one statistician and a clinical psychologist, ensuring
its applicability to the students’ community at the University of Jordan” (Assaf, 2013).
The major finding of the study was that the students enrolled in the B.Sc. of Doctor of
Pharmacy (PharmD as they state in the article) “reported relatively higher levels of perceived
stress and lower emotional satisfaction and quality of life compared to the Pharmacy
students” (Assaf, 2013). The study correlates this higher level of stress to this particular
group of students as they have a more intensive program than the former group and not in
terms of the other variables that were mentioned above (external stressors) which did still
have an negative impact on their immune system but not as much as the intensity of the
program.
STRESS AND IMMUNE DYSREGULATION 4
There were however some limitations to the study; firstly that “the data was not
computed as scores” (Assaf, 2013) and that most of the participants were female however
most of the students in the Pharmacy program are of the female gender. The other limitation
was that the study was only conducted at one university in Amman, the capital of Jordan as
opposed to including more universities in Jordan. As mentioned, the author states that
perhaps more universities should have been included in the study, so it could have been a
larger-scale study as well as to include other levels of students as it only included 2 year
levels of students (the B.Sc. in Pharmacy and B.Sc. of Doctor of Pharmacy students). They
also state that a “further study is needed to identify other contributing factors to the high
stress and immune-related diseases affecting the both levels of Pharmacy students as well as
to investigate the actual effectiveness of strategies to improve stress levels and
immune-mediated diseases as students’ progress through their programs” (Assaf, 2013).
In conclusion, the author did draw the appropriate results from the study as the
PharmD students had a higher workload and were more stressed, however not all stresses
were study related. A correlation does exist with regards to a student’s immune system while
attending an intensive university program. Not only does the intensity of the program affect
the student’s health outcome but various external factors such as depression, their limited
social life, lack of exercise and not seeking any medical help, all contributed negatively to
their health. The author states the “results may help to increase the awareness of students to
get prepared to what they might face, and may enable them to reduce the program’s negative
effects,” and “ it may be advantageous to other universities with almost the same system of
teaching both programs” (Assaf, 2013). Overall the study proved that in fact there was an
increase for students to be susceptible to infections and other ailments. In my opinion, I do
concur with the author that there does exist a link with regards to one’s response to stress and
their immune system and even more so with this current pandemic.
STRESS AND IMMUNE DYSREGULATION 5
Literature Review #2- Jasmine Sanchez
This literature review conducted by Lorinda Turner and Julieta Galante explores the
relationship between immune dysregulation as a result of psychological distress experienced
among university students at the University of Cambridge during exam periods and whether
"mindfulness training” could alleviate their level of stress. The exploratory randomized trial
placed students into one of two groups. First, an 8-week mindfulness course where there were
27 participants and second, a mental health support group with the same number of
participants. Baseline measurements included psychological distress, immune cell
proportions, cytokines, CRP and serum cortisol during the exam period. There was only a
significant increase in the proportion of B-cells. All other measures had insignificant
associations (Turner et al., 2020).
After consent was obtained, students were randomly allocated to join the 8-week
mindfulness course which also included mental health support with the addition of pastoral
support and public health services. This was known as the intervention group. The control
group had the mental health support alone and were only offered the Mindfulness course 1
year later, if they were still students of the university. The recruitment for the mindfulness
course started in January of 2016 by conducting a 34- item basic questionnaire. If results
came back high it indicated increased distress. Furthermore, participants were to give two
22.5mL blood samples. The first sample was taken before individuals were randomized. This
was the baseline measurement and the second was taken 3-4 months after randomization,
during the exam period. At both time points, a questionnaire was collected within a week of
blood sampling. Other variables such as weight and height were also measured.
Participants’ changes to subjective experience were linked to stress-related
pro-inflammatory immune change. Whether the student participated in the mindfulness
STRESS AND IMMUNE DYSREGULATION 6
training or not, immune parameters were significantly increased during the exam period
compared with baseline measurements. As a result of using the highly sophisticated
technology of immunophenotyping, which examines 150 different immune subsets, the study
found that the two most significantly changed biomarkers were the increase in inflammation
and B-lymphocytes. B-cells increased during exam stress while cortisol response flattened.
This increase had a direct correlation with an increase in psychological distress.
There are a number of other studies that support the hypothesis that perceived distress
from final exams generates a dysregulated pro- inflammatory state characterized by increased
monocytes and activation of lymphocytes and an increase in pro-inflammatory humoral
immune factors (Turner et al., 2020). However, through my research I would say the
limitations this study has is that more evidence is needed to say that mindfulness training can
subside the effects of psychological distress on healthy university students' immune systems.
This study in particular was a small sample and I think would benefit from larger ones in the
future to obtain more significant results. I think it is important to use the resources available
to us as students in terms of support, whether it be academic, emotional, physical or financial.
The stresses of university are not uncommon but if we can deal with it in a healthy manner it
benefits not only our performance in school but our overall health as well.
Literature Review #3 - Rebecca Roche
This paper will examine a meta-analysis review conducted by Suzanne C. Segarstrom
and Gregory E. Miller. (2004). The purpose of this article was to determine the multiple types
of stress factors that affect the overall function of the immune system. The authors evaluate
the types of stress that connect with the actual event to identify how these stressors influence
the human immune system.
STRESS AND IMMUNE DYSREGULATION 7
This study was published in 2004 by the Psychological Bulletin. The article describes
the correlation between psychological stress and the parameters of the human immune
system. The results of the meta-analysis of hundreds of different research reports on this
hypothesis indicate that stressful events are associated with changes in the immune system
and specific characteristics are very important to determine the change that occurs
(Segerstrom & Miller, 2004).
The authors hypothesize that there is a relationship between multiple stressors and the
weakening of the immune system. The variables identified for this research are based on two
groups, one experiencing a more stressful environment and the other experiencing what is
defined as a non-stressful environment. A meta-analysis methodology was used to integrate
research findings. Articles for meta-analysis were identified through database literature
searches as well as searches of reference lists. The meta-analysis is based on effect sizes
derived from independent studies. These studies were composed of 319 different articles and
a total of 18,941 individuals that participated in these studies (Segerstrom & Miller, 2004).
The level of clinical evidence in this study is high as a meta-analysis ranks highest
power on the evidence pyramid. For the articles in this literature review to be considered,
they had to incorporate psychosocial stressors, measures of the immune system, and include
measures of stress. A quantitative study method was used to summarize the results of the
studies into single estimates. This was exploratory in nature; the paper uses multiple studies
with varying different levels of the effect of stress on immunity. The study included 12 tables
that involved different participants and their responses to different stressors, they also
included 3 funnel plots describing the relationship between effect size and sample size for
each immune outcome. These methods were determined to be a good way of indicating the
relation between the stressor and immunity.
STRESS AND IMMUNE DYSREGULATION 8
In conclusion, Segerstrom & Miller state that main stressors were acute and
time-limited, and they follow the temporal parameters of the fight-or-flight stressors. The
most chronic stressors were associated with significant decreases in almost all functional
immune measures examined. It was important to note that although the effects of chronic
stressors may be due to their duration, the most common stressors were involved with
changes in the identity of social roles in life. These stressors may also be persistent, rather
than intermittently present. Finally, chronic stressors may be much less controllable in the
future. These factors could contribute to the severity of the stressor both from a psychological
and physiological point of view. However, the authors do suggest further research to be
conducted that involve more scenarios and cases.
This research study helped demonstrate the differences and similarities that different
stressors have on the immune system. Although this article gave information regarding the
concept of stress affecting the immune system, it did not provide insight into how to properly
deal with stress to avoid these negative outcomes. Since dealing with stress is a big factor in
our daily lives, especially considering the current climate of the pandemic. Also, being in an
accelerated dental hygiene program, I know the struggle of being very stressed with large
workloads and tight timetables. Despite this, it was very interesting to see all of the different
types of stressors involved in this study and how they relate to your immune system given the
recency of COVID. Finally, this article helped with the creation of our survey questions
because it had a lot of accurate, valuable, and interesting information.
Literature Review #4 - Fatima Sultan
Psychological stress and tension has evidently been linked directly to the
dysregulation of multiple fragments of the human immune system. This may include an
increase in chronic illness, a decreased immunological age, and even a decreased ability to
STRESS AND IMMUNE DYSREGULATION 9
fight infections all due to immunosuppression caused by chronic stressors in all aspects of
life. However, the impacts of chronic stress differ from population to population, and the
actual situations that people may find themselves in. To elaborate more on this topic, a
meta-analytic study was conducted by Jennifer N. Morey, Ian A. Boggero, April B. Scott, and
Suzanne C. Segerstrom from the University of Kentucky to reflect on and analyze multiple
research studies based on the Current Directions in Stress and Human Immune Function. The
article was published on October 1st, 2015 in Volume 5 of the journal Current Opinions in
Psychology. The research done to complete this journal article directly pertains to the
association between psychological stress and the dysregulation of the immune system, as well
as the importance of understanding the reason behind the risk factors that contribute to the
decreased immunologic responses. The hypothesis implied by the authors of this
meta-analytic review article aimed towards developing a better understanding of the
stress-immune relationship between humans, and more specifically in early and late life,
ecological perspectives, as well as the manifestation of the direct correlation between stress
and immunity in clinical settings (Segerstrom et. al, 2015).
Due to the fact that there are a number of studies that were analysed and summarised
in this meta-analytic review, it also presents with a multiple amount of dependant, and
independent variables. In this situation, the findings of the individual studies and meta
analyses are treated as the dependent variables. The independent variables in this case are the
variables that cause the change in the dependent variables. In terms of the studies that were
analyzed by the authors of this title, the majority of the dependent variables were the
psychological or physiological outcomes of chronic or acute stress on the human body, or the
stress response, and the stressor was the independent variable – hence indicating the
relationship between the two. However, it is difficult to generalize between all articles a
single independent or dependent variable due to the differentiating natures of these studies.
STRESS AND IMMUNE DYSREGULATION 10
For example, in one of the studies that was analyzed, the independent variable was amount of
sleep due to stress, and the dependent variable was the physiological effect on the body, more
specifically the increase in neutrophil count leading to a reduced function of the immune
system. In another study that was conducted and analyzed in the meta-analytic review, the
independent variable was starvation as the stressor, and the dependent variable was the
immune response in terms of accelerating the time of death (Segerstrom et. al, 2015).
The methodologies evidently utilized in this meta-analytic review are experimental
methods. Since this research article was a meta-analytic review, in relation to the
evidence-based pyramid, this is the highest and most effective level of evidence that there is.
In terms of the methodologies of the research that was included in this research, it was a mix
of meta-analytic reviews, randomized controlled trials, and longitudinal studies where the
effects of chronic stress on immunity have been monitored in individuals over a certain
period of time. Ultimately, the methodology of this qualitative meta-analytic review was to
integrate the findings from numerous reliable primary research studies, and attempt to
summarize, and explain the several variations and limitations across the studies. By doing
this, the meta-analytic review creates insight into areas where there may be more research
required.
“Current Directions in Stress and Human Immune Function” evidently holds an
exploratory study design. This meta-analytic review was an explanatory study because the
research conducted in this review was done with a few articles and studies with the intention
of gaining a brief insight and familiarity into the relationship between multiple different
stressors and the immunological responses associated with them. It was implied that the
relationship displayed in the article and the findings showed promise for further discoveries
in terms of treating and preventing morbidity in humans suffering from chronic stress
(Segerstrom et. al, 2015). The authors used a number of preliminary studies to analyze and
STRESS AND IMMUNE DYSREGULATION 11
pull the most relevant details to be able to interest and motivate other researchers to conduct
further research.
Although there was no actual chart with numerical data on it, in order to ultimately
summarize the overall relationship previewed in the meta-analytic review, the authors did
choose to include a basic flowchart. It’s created in a way where it easily describes that stress,
immunity, and disease affect each other in reciprocal ways. However, the relationship and
cycle between these three factors can be disrupted by differentiating mediators - or
independent variables - in life that individuals may encounter, such as chronic or acute stress,
a good amount of sleep, external pressures, disease prevalence, etc. The addition of more
visuals, such as a bar graph for example to display the neutrophil count in relation to the
hours of sleep an individual may get, would make for better understanding of the overall
findings.
The authors of this particular article did draw a conclusion after completing the study
and the analysis of the multiple primary research sources. In conclusion, it was stated that
individuals who are consistently exposed to chronic stressors, including abuse and persistent
caregiving, exhibit signs of immune dysregulations in early or late life, that can present
themselves as chronically and very severe – ultimately leading to disease and even death due
to immunosuppression (Segerstrom et. al, 2015). It was also stated by the authors that the
quality of the stressor, as well as an individual’s characteristics play a huge role on how the
stressors are managed, and how they can make a human more or less susceptible to the
effects of immune dysregulation (2015). In my opinion, this was an appropriate conclusion to
make based on the initial aim of the study, which was to discover the relationship between
different stressors and the impact on the human immune system. The authors made a rational
decision when choosing their research design, a meta-analytic review, which really supported
their case and made the overall evidence strong and reliable.
STRESS AND IMMUNE DYSREGULATION 12
There were a couple major findings from this meta-analytic qualitative study. In
addition to the findings mentioned above, in cases of clinical populations it was discovered
that stress exposure can increase the likelihood of developing disease, or even exacerbate
pre-existing conditions (2015). However, due to the lack of research, the authors were unable
to draw more specific conclusions in terms of which diseases, or differentiate between
chronic or acute stressors.
There were a couple limitations that were discovered when reading and analyzing
“Current Directions in Stress and Human Immune Function”. One of these limitations was
that the research was simply not enough. The sample sizes were smaller, and therefore harder
to generalize in the total population. All situations, individual characteristics, coping
methods, current immune statuses, are things that are all specific to a single human body. No
one in the world has the same way that they take on stress, or the way their body deals with
that certain stressor. With this situation, making generalizations is very difficult, which is why
more and more research is required to really be able to have a grasp on this topic. It's easy to
discover what happens in one individual's body when they are attacked with chronic stress,
but someone with anxiety or depression, their body will handle that stress much differently
internally than someone who doesn’t suffer from these extenuating circumstances. Therefore,
the lack of research is definitely one of the major limitations of this study.
Throughout the meta-analytic review, the authors provided a number of avenues for
further study knowing that some areas are in fact lacking research. They provided insight into
where further research on this topic may be able to create some breakthrough discoveries.
When discussing the impacts of stress on clinical populations, it was mentioned that more
research done in this area can actually assist with treating, or even preventing morbidity. The
article ended off with the researchers mentioning that research done further holds promise for
STRESS AND IMMUNE DYSREGULATION 13
overall improving human health, as stress has become a worldwide disease that a lot of
individuals are unable to take a break from (2015).
“Current Directions in Stress and Human Immune Function” guided me to my
research question because it not only supported my beliefs in regards to stress, but it also
gave me more insight into what the immunological effects may be on my own body after
being in an high stress learning environment over the duration of 19 months of schooling.
This meta-analytic review made me question if being under so much stress at all times in
early life, would impact or alter my internal quality of life in the future, and if so, will it be
something that’s manageable, or something that could potentially kill me. Another thing that
really stood out to me was the claim in the article made towards the lack of sleep people
endure when under a great deal of stress, and how that could also lead to severe immune
dysregulation. Knowing myself, I believe that I have lost hours and hours on end of sleep the
nights before exams and tests, or even when I overthink about clients and clinic. Therefore,
coming to a conclusion about my research topic – The relationship between stress and
immunity in the human body.
Literature Review #5 - Alexa Sarmento
The effects of stress on immunity have various ways of presenting themselves, and
these aspects may have a huge impact on the overall function of the body. This theory was
greatly explained in this study by Ronald Glaser and Janice-Kiecolt-Glaser. These two
authors who both work for the ‘Institute for behavioral medicine research - College of
Medicine and Public Health and Comprehensive Cancer Center, Ohio State University’ have
a great interest in the overall effects of Stress and Immunity, and have spent many years
understanding the way the overall behaviour of the body when responding to stress. This
study was published on July 18th, 2009 on the internet site Discovery Medicine.
STRESS AND IMMUNE DYSREGULATION 14
The research conducted is concerning how stress can damage the immune system and
overall health in different ways. Different aspects such as various stressors, the many ways
stress can bring about infectious diseases, reducing benefits of vaccines, overall wound
healing process of the body and many other factors. The theory developed around the
research conducted is that the hormones released by the hypothalamic-pituitary-adrenal
(HPA) and the sympathetic-adrenal-medullary (SAM) axis can cause a direct impact on the
bi-directional interactions between both the Central Nervous System (CNS) and the immune
system, therefore altering the overall function of the immune system, compromising the
immune system's power to fight against negative effects on the body but also its power to
accept the additional assistance (vaccines) to the immune system. The variables noted in this
research are the occurrences in people who experience different events that can exceed their
maximum ability that they may withstand in regards to stress. Also, another important
variable are the hormones released by the two axis’ hypothalamic-pituitary-adrenal (HPA)
and the sympathetic-adrenal-medullary (SAM) and their ability to affect the CNS and
immune system.
Various methodologies were used in this study to carry out the overall research. Some
examples of experiments that were done begin from mice in restraint stress in an effort to
prove that stress can prevent the immune system from defending against infectious disease,
particularly in virus infections the mice were placed in plastic tubes where they could move
forward and backward but couldn't turn around, using the influenza virus, results found that
the restraint stress altered the innate and adaptive immune responses to the virus. Another
experiment was conducted to demonstrate the relationship with stress and vaccines these
were performed on medical students experiencing academic stress, they were inoculated with
the hepatitis B virus vaccine, antibody titers were obtained along with data from experiments
in which the virus specific T-cell response was also measured over 6 months the antibody and
STRESS AND IMMUNE DYSREGULATION 15
virus specific t-cell responses were down regulated in those medical students who had less
stress and anxiety, and more support other vaccine studies show that individuals who are
more distressed or anxious will be at a greater risk for weakened reposes to both viral and
bacterial vaccines, more likely to respond poorly to these pathogens, and in turn, placing
them at greater risk for infection and severe illness (worse for older individuals). Experiments
were performed on humans and animals that infer that stress plays a factor in the
pathophysiology of HIV and herpesvirus infection with the use of rhesus macaques and
simian immunodeficiency virus (SIV), they were able to assess the effects of stress. These
experiments were conducted on the impact of stress on the pathopsychology of herpes
simplex virus I (HSV-1) infection and Epstein-Barr virus (EBV) latency: with the use of
mice, they were able to explore the effect of restraint stress on the immune responses to
primary and secondary HSV-1 infections. It is important to keep in mind that these
experiments were carried out using mice in a laboratory (Rabin, 1999; Ader et al., 2001;
Cohen et al., 1999). This study determined that the more chronically stressed, more frequent
recurrences of reactivation of HSV-1 and HSV-2 (Ader et al., 2001; Glaser and
Kiecolt-Glaser, 2005; Cohen, 1999). The last three experiments conducted were done on
spousal caregivers of Alzheimer's disease patients in an effort to exhibit the impact of stress
on wound healing, prove the connection of stress and inflammation and explore the
connection between stress and inflammation and aging.
With the many studies conducted it would be assumed that this study was presented as
quantitative based on the different traits such as hormones and the various stressors , but due
to the different stats involved such as stress levels preventing wound healing 40% more
slowly in students etc, it could also be considered a qualitative study. This study would also
be considered an explanatory research for the particular reason that the author of this study
used previous studies and methods and put them together in attempts to prove that the overall
STRESS AND IMMUNE DYSREGULATION 16
theory that stress and its effect cause an overall impact on the immune system. This study
also includes WHY and HOW.
The author drew appropriate conclusions from the study due to the research he
conducted focusing on all the psychological stress and neuroimmune dysregulation helping
the readers understand the physiological changes that can occur to the body due to different
stressors. The conclusion made by the author may also allow new insights in the future for
different clinical applications of research that would help assist patients and use new
approaches in treating those with deficiencies due to stress and its effects on the immune
system. The authors conclusions got the overall message across, and that was that stress
indeed does have an effect on immunity.
Overall, the major finding of the study is that stress does in fact make a huge impact
on overall health of the immune system and its function. This was proven using the different
studies such as researching the different stress induced infectious diseases , impaired wound
healing, aging and inflammation or the impact stress puts on the ability of a vaccine to be
used at its full capacity and provide the most protection or benefits. Although the appropriate
conclusions were drawn from the study, some limitations were also involved. The limitations
to the study that were found were that the studies conducted to prove that specific factors that
relate to the human body’s immune system are hindered by stress were quite outdated, having
a more recent grasp on the connection between both stress and the immune system function
will the advancements in technology could have been beneficial to enhance the ultimate
findings. This study allowed for future enhancement on the study by stating that the
information in this article could be used to provide further insight into clinical applications of
the research being performed and potential for new approaches, “this information will
provide new insights into clinical applications of the research being performed and the
potential for new approaches for treating patients.” (Glaser and Kiecolt-Glaser, 2009). This
STRESS AND IMMUNE DYSREGULATION 17
study can be used as a guide for new explorations into the relationship between stress and the
immune system.
Finally, his study guided me to my research question/topic by allowing me to see the
actual proven relationship between stress and the immune system, through the numerous
studies conducted that catered to different factors concerning the immune system. This also
allowed me to open up my interests to the topic, creating more motivation to research my
topic and explore the science behind stress and immunity.
Discussion of Reviews
After reading all the literature reviews, we have found that all the studies do have a
correlation between stress and having a suppressed immune system. The immune’s system
deficiency decreases the body’s ability to combat any forgien invaders, causing it to be
vulnerable to infections and a host of other medical issues. The immune system helps our
body maintain homeostasis and the amount of stress associated with being in a higher
learning institution does contribute to having even higher levels of stress. The immune
system tries to over compensate and when it is overworked and our bodies don’t get sufficient
help to fight any infections. Added stress can also exacerbate any existing health issues one
may have. One of the main triggers would be psychological distress and we can see through
the research that there is a link between the two. As post secondary students we have
experienced first hand the effects of stress whether it be academic emotional, physical, or
financial and the negative outcome on our health.
The research however failed to mention how stress can be approached, what
techniques can be used to lower the stress levels in the participants. Some studies were also
older studies and mentioned that more research needs to be done with regards to this topic.
Not one of us found an article pertaining to students in a dental hygiene program however
while researching, we did find blogs and posts of former dental hygiene students stating how
STRESS AND IMMUNE DYSREGULATION 18
difficult and stressful the program was and the challenges they faced while attending school.
It would be interesting to see a larger scale study done on dental hygiene students to see how
it compares to the questionnaire we administered to our classmates.
In conclusion, we can confidently say that our research solidified the understanding of
the effects of stress on our health and unfortunately, it is a part of life that every human being
will deal with. We all have different definitions of stress and it affects everyone differently.
Being able to recognize our individual triggers should promote a positive reaction to be able
to subside those negative feelings. Unfortunately, there is not a “one size fits all” solution
when it comes to dealing with stress.
Methodology
The methodologies evidently utilized in this research study are experimental methods.
A randomized survey was put together to initiate our research and get insight into our
research question, in a non-biased way. An exploratory, quantitative, closed ended approach
was taken with this survey, to be able to detect in numbers how many people can relate, or
not relate with the question. Although there is research present on this topic, the population
targeted in this study was specifically the students of Toronto College of Dental Hygiene and
Auxiliaries, and the purpose was to gain more insight on the stress levels in this population in
relation to immunity. The survey consists of a total of 15 questions, conducted and
administered through the Microsoft Office Forms application. This program organized our
results into multiple different charts and graphs, giving us the freedom to interpret the data in
a way that works for us. Our population was a group of 70 TCDHA students, all
differentiating in age, gender, culture/religion, and semester group. The survey was sent out
via Facebook, to students part of the TCDHA community currently attending the college as
students. Once the survey reached 70 responses, it was removed from the Facebook group
and further participation was terminated. The survey attempts to understand the direct
STRESS AND IMMUNE DYSREGULATION 19
correlation between stress experienced by students, and the immune system through the
questions indicated in the survey. To be more specific, as research has shown, there is a
positive relationship between chronic stressors - such as school - and the dysregulation of the
immune system in the human body. Questions outlined in our survey, such as “Would you say
that you have been sick more often since you started attending college?” help us to gain more
insight into the factors of immunity and stress because it shows us a direct correlation. Other
questions outlined in our survey, such as “On average, how many hours of sleep do you get
per night, on a school night?”, help us to understand a more indirect correlation, and show us
just how the stress associated with school impacts an individual's sleeping pattern, therefore
affecting the immunity of an individual. In terms of ethics, our main goal when coming up
with the questions was attempting to have questions and answer options that are ethically
professional. The platform used ensured anonymity and confidentiality of all participants,
aside from the gender, age, and semester group of the individuals. When asking for the
gender, it was ensured that all options were present, including “prefer not to say”, so that no
boundaries were being crossed. All survey questions were realistic, and were things that may
or may not directly pertain to students of TCDHA.
The survey questions are as follows:
1. What is your gender? a. Woman b. Man c. Prefer not to say d. Non-binary
2. What semester are you in? a. Semester 1 b. Semester 2 c. Semester 3 d. Semester 4 e. Semester 4 Rep
3. How old are you? a. 18-24 b. 25-29 c. 30-34 d. 35+
STRESS AND IMMUNE DYSREGULATION 20
4. Does being in a dental hygiene program at TCDHA make you feel stressed out? a. Yes b. No c. Sometimes
5. On a scale of 1 to 5, 1 being the lowest, 5 being the highest, where would you say you fall on this scale with regards to your stress level?
a. 1 b. 2 c. 3 d. 4 e. 5
6. If you feel stressed out, are you: a. Mentally Stressed b. Physically Stressed c. Combination of both
7. If you are experiencing stress, which of the following would you say is the main cause?
a. Financial b. Clinic c. Didactics d. Personal Life e. All of the above
8. On average, how many hours of sleep do you get per night, on a school night? a. 1-2 hours b. 3-4 hours c. 5-6 hours d. 7-8 hours e. Not sure f. Can't remember
9. When you’re feeling stressed, what type of eating pattern do you find yourself following?
a. Binge-Eating Pattern b. Avoid-Eating Pattern c. Regular-Eating Pattern d. None of the above e. Not sure
10. Would you say you’ve been sick more often since you started attending college? a. Yes b. No
11. Would you say that when you are stressed, you have difficulty functioning day to day? a. Yes b. No
12. Were you aware that the effects of stress can cause sickness inducing behaviour such as fever, loss of appetite, depression, and changes in sleep patterns? Have you experienced any of these?
a. Yes and Yes b. No and No c. Yes and No d. No and Yes
13. Are you from out of the province and does being away from home/family affect how
STRESS AND IMMUNE DYSREGULATION 21
you cope with your stress? a. Yes and Yes b. No and No c. Yes and No d. No and Yes e. Other
14. Is it important to you to have daily exercise and/or a social life while in school to relieve your stress levels?
a. Yes b. No c. Not sure
15. Were you aware that chronic stress has a direct impact on an individual’s immune system, now and later in life?
a. Yes b. No
Data Analysis
This question was included to identify the genders of the students at TCDHA taking
our survey. The results showed that out of 70, 62 participants were women, and 8 participants
were men. No survey taker chose the options “prefer not to say”, or “Non-binary”. These
options were included in hopes to be inclusive of everyone, and to be ethically sustainable.
STRESS AND IMMUNE DYSREGULATION 22
Being a student at this college, it is evident to us just from being there that there is a
dominance of women, but we did also want to include as many males as we could to be
inclusive. Although research has proven that women are more vulnerable to the negative
effects of chronic stress and the depressogenic effects that come with it (Bekhbat & Neigh,
2018), we wanted to include men because they are a part of the TCDHA student community,
regardless of their immunological responses to being under stress. In order to get an accurate
representation of the student body, the few males in the school were included. However,
moving forward, it may be a good idea to survey men and women separately to compare and
contrast between the differences in responses.
This question was included into our survey to be able to identify which semester the
participants from TCDHA were in. From looking at this graph, it is evident that the majority
of students that took the survey are currently in Semester 4 (45/70 participants). 6 out of 70
STRESS AND IMMUNE DYSREGULATION 23
students were from Semester 1, 6 were from Semester 2, 12 were from Semester 3, and 1 was
a Semester 4 Repetition student. Although all semesters are tough at the college, with an
ongoing pandemic, completing clinic has stressed students out to another extent. Semester 4’s
are under pressure to not only do well in didactics, but find clients willing to come in during
the Covid-19 outbreak in order to be able to make up enough credits for graduation. Semester
1-2 students are currently not in the clinic working towards credits, and Semester 3 students
still have a whole semester ahead of them to be able to build up their credits. However, we
did want to include all semesters to be able to get an accurate representation of the TCDHA
population, even though the majority was still semester 4 students. Moving forward, we
would like to target a single semester to really be able to narrow down the stress levels
associated with a certain group at the school.
STRESS AND IMMUNE DYSREGULATION 24
This question was included to identify the different age groups within TCDHA. The
results showed that out of 70 participants 41 were between the ages of 18-24 years old, 21 out
of the 70 participants were between the ages of 25-29 years of age, and 8 out of the 70
participants were between the ages 30 and 34 years of age. As majority of the participants
were between the ages of 18-24 years of age, this does not come as a surprise as many people
not long out of highschool want to jump right into college and start their career within a
young age, and the dental hygiene program at TCDHA does not require any prerequisites
prior to entering the program like some other dental hygiene schools do, making it easier to
start college right out of high school.
This question was included to identify whether the students attending the dental
hygiene program at the TCDHA taking our survey were feeling stressed. The results showed
STRESS AND IMMUNE DYSREGULATION 25
that out of 70 students, 57 students or (81%) felt stressed, 13 students answered that
sometimes they felt stressed and none answered that they were not stressed. This question
was included to find if in reality students were in fact stressed. It is evident from the
responses that we received that being a student at this college, that the majority of students
found the dental hygiene program stressful and with not one person stating that they were not
stressed. Although this question may have certain limitations attached to it as all students
were aware that this was a fast-track program (18 months) and there would be limited time
off as opposed to studying at a school where the program was 2-3 yrs and not 18 months as is
our school. Students may have been aware that it was going to be demanding but only found
out once they were already in school how demanding it is of their time as well as how
stressful it actually is. There is a correlation with a literature review that was done with
regards to students who were in a pharmacy program at the University of Jordan, in both the
pharmacology students as well as our dental hygiene students both were stressed and the
workload was one of the main factors that increased the stress for both sets of students.
STRESS AND IMMUNE DYSREGULATION 26
Question 5 was included in the survey to give us an understanding of how stressed
dental hygiene students are at the TCDHA. Out of 70 students exactly half (35) of the
participants chose 5 being the highest on the scale. We chose to include this question in the
survey due to the direct correlation with question #4, if the students were stressed. We wanted
to find out the extent of the stressfulness and from the responses received it was evident that
half were very stressed and only 8% were at the lowest level on our scale, either answering a
1 or a 2. One other question that correlates with this question that was asked of the students
was regarding their stress was what was contributing/the cause of their stress which will be
discussed in question #7 as we wanted to dig a bit deeper as to discover the true meaning
behind what was causing their stress.
STRESS AND IMMUNE DYSREGULATION 27
This question was included to identify what type of stress students at the TCDHA
have when they are feeling stressed, whether they were mentally stressed, physically stressed
or both. The results showed that out of 70 participants, 57 participants (the majority) chose a
combination of being both mentally and physically stressed which isn’t surprising as we have
to use our brains for the theory portion of the course as well as use our body, specifically our
hands and have a good posture while in the clinic setting although when analyzing the data a
little closer the mentally stressed percentage of students was still significantly higher than
those who were just physically stressed. We can relate this question with the next one (#7) as
to what is the main cause however students still chose mentally stressed more which shows
that sometimes being mentally stressed takes what is perceived as a bigger toll on our health
than being physically stressed. What wasn’t taken into account was if any students had any
mental issues before starting the course, if they were taking any medication for their stress or
STRESS AND IMMUNE DYSREGULATION 28
if they were physically disabled or had any other health issues that may contribute to them
being more or less mentally or physically capable of being in the program. These variables
could have been significant to incorporate into our survey as they are also important
questions that could change the perception of dealing with mental and physical stress.
Question 7 was included to understand what type of stress students at TCDHA would
consider as the main cause of their stress. Results showed that 4% considered financial stress
their main cause, 36% considered clinic practice their main cause, 6% answered that theory
classes were the cause of their stress, personal life showed the lowest cause of stress at only
1% and 53% showed that all of the above were to blame for their stress. I believe the results
accurately illustrate the lifestyle students live. Most of us are from out of province (as we can
see from question 13 results), away from family or of age where we are not dependent on our
STRESS AND IMMUNE DYSREGULATION 29
parents anymore. Which means having the responsibility to be accountable for all aspects of
our lives. So it makes sense for the majority of the survey participants to answer all of the
above as their cause of stress. However, to break it down even further we can see that the
clinic option had the majority of votes when looking at each variable individually. Clinic
practice can be an overwhelming part of the program if not well prepared for and because of
the added factor of covid-19 it has changed the dynamic of clinic from previous semesters.
Students have had to learn new clinic protocols weekly because of the changing nature of
covid-19 and government regulations. With the public fearful of contracting the virus it has
made finding reliable clients a hard task to manage to fulfill graduation requirements.
Question 8 was included in the survey to give us an idea about how many hours of
sleep TCDHA students are getting per school night, given the heavy workload with both
clinic and didactics, alongside the stress associated with it. We chose to include this question
STRESS AND IMMUNE DYSREGULATION 30
in the survey due to the direct correlation between sleep, and overall human immunity. This
correlation was evident in our research prior to creating the survey questions. As per The
American Academy of Sleep Medicine, it is important for anyone over the age of 13 to be
getting a minimum of 7 hours of sleep per night (Darien, 2015). When the doctors conducted
a research study over a period of 12 months to monitor sleeping habits, they found that
“sleeping six or fewer hours per night is inadequate to sustain health and safety in adults, and
agreed that seven or more hours of sleep per night is recommended for all healthy adults.”
(Darien, 2015). It is evident that based on the research we conducted on the students at
TCDHA, the majority of students (38/70) are getting only 5-6 hours of sleep, and 13 students
are getting 3-4 hours of sleep. Only 18 students out of the sample of 70 are getting more than
7 hours of sleep, which indicates that most students are not getting enough sleep according to
The American Academy of Sleep Medicine guidelines. When connecting sleep back to
immunity, as mentioned prior there is a direct correlation. To elaborate, a meta analysis
described that “Other potential mediators, like getting good sleep, are increasingly being
recognized as important pieces of the stress-immunity puzzle. Even one night of total sleep
deprivation was recently found to significantly increase neutrophil counts and decrease
neutrophil function in healthy men.” (Segerstrom et. al, 2015). This statement outlines that
just one night of inadequate sleep leaves a person with decreased neutrophil function, which
is actually the first white blood cell in the bloodstream to defend against infections, diseases,
and/or anything foreign in the body that should not be there. With the decreased function of
these cells, you are left with a weakened immune system. Based on the research conducted
through our survey, 74% of students from our sample size of 70, are getting an inadequate
amount of sleep, that could actually be leading them to a weakened and compromised
immune system.
STRESS AND IMMUNE DYSREGULATION 31
This question was included to identify what type of eating patterns students at
TCDHA have when they are feeling stressed. The results showed that out of 70 participants
that 35 students found that they are “binge-eating” when stressed, 20 out of the 70
participants said that they found that they “avoid-eating”, 8 out of 70 participants said that
they kept the same “regular-eating pattern”, 3 out of the 70 participants choose “none of the
above” and 4 out of the 70 participants answered “not sure”. The majority of the participants
choose “binge-eating” which doesn’t come as a surprise as many people use food to comfort
themselves when they are feeling stressed, and as many dental hygiene students will agree
that this 18 month program does not come easy and is definitely stressful at times especially
during a pandemic.
STRESS AND IMMUNE DYSREGULATION 32
This question was included to identify if students attending TCDHA found
themselves getting sick more often since attending college. The results showed that out of 70
participants 47 students answered “no” while 23 participants out of the 70 answered “yes”.
The majority of the participants stated that they have not found themselves getting sick more
often since attending college, which is and is not a surprise due to the current pandemic
happening right now as the majority of the program is online - minus the clinical aspect. As
the topic of our research was the effects of stress on immunity and it was found that in some
cases high levels of stress can internally affect one's immunity, as stated above that our
theory classes are online people are less likely to take a “personal day” due to feeling unwell
or stressed that they need a break - I know personally since theory has started online I haven't
been as stressed as I was in semester 1 when theory was in class.
STRESS AND IMMUNE DYSREGULATION 33
This question was included within our survey with anticipation of determining if
individuals attending TCDHA who feel stressed, experience difficulty while trying to
function during their everyday tasks. 70 people participated in our survey, and for this
question, 58/70 answered yes to feeling difficulty functioning day to day, whereas 12/70
voted no. This determines that the majority of those participating feel as stress has a strong
impact on their day to day lives. This impact can interfere greatly on tasks needed to be
completed as the mind would be consumed with the thoughts of stress, therefore, not
allowing the individual to focus on what needs to be completed. This is an anticipated result
as stress can result in tremendous amounts of worry, and anxiety. This difficulty functioning
due to stress can also correlate to the effects of stress on the immune system because an
individual may present signs of weakness and fatigue, and without this motivation and
STRESS AND IMMUNE DYSREGULATION 34
constant worrying, it is common to lose interest in tasks needed to do, and to have difficulty
performing them at full ability when experiencing feelings of stress.
Incorporating this question into our survey allowed us to analyze the knowledge
individuals had on the effects of stress. Many people may not even realize that these different
symptoms they are experiencing are a part of facing situations of stress. During our research
we found that the majority of individuals were educated on the effects of stress on their
immune system. 47/70 people answered that they were aware that stress can cause sickness
inducing behaviours such as, fever, loss of appetite, depression and change of sleeping
patterns, and as well answered yes to experiencing these symptoms/behaviours. We also
received responses that determined some individuals (4/70) were not aware of these possible
behaviours and also never experienced them, while the remaining, 13/70 knew about these
possible behaviours, but never personally experienced them, while the remaining 6/70 were
STRESS AND IMMUNE DYSREGULATION 35
never enlightened around the possible behaviours, but do recall experiencing these symptoms
while feeling stress. The stress impacts the immune system in many ways, therefore, it is
expected that an individual can experience sickness like behaviours, due to their weakened
immune system. A program as intense as the Toronto College of Dental Hygiene and
Auxiliaries 18 month Dental Hygiene program, can cause an individual to become very
stressed, allowing us to have expected the results of the majority (47/70) feeling sick during
situations of stress.
Question 13 was included to find out if students attending TCDHA are from out of
province and if that played a part in affecting their stress levels. Out of the 70 participants, 44
answered yes to both parts of the question, 12 answered no and no, 4 answered yes and no, 8
answered no and yes and 2 individuals chose “other”. Being that the program is only 18
months long as opposed to other dental hygiene programs that require 4 years of education
STRESS AND IMMUNE DYSREGULATION 36
like in Alberta, it makes sense that the majority of the student body is from out of province.
The added aspect that you can apply right out of high school is another attractive point
persuading students to apply to TCDHA instead of other institutes. We can then correlate
being away from home as a reason stress levels are heightened. Students may not have the
support system they once had back home because they do not have family and friends they
can lean on or physically see when they need them. Students are faced with leaving loved
ones, pets or places of comfort, to experience something new and unfamiliar.
Question 14 was included in the survey to see if having an exercise routine and/or a
social life was important to students in order to relieve stress. Results showed that 58 out of
70 participants answered “Yes'' to this question, 5 answered “no” and 7 were not sure. It
makes sense that students would want to maintain an active lifestyle because through
research we can see the positive impact leading an active lifestyle has on your physical and
STRESS AND IMMUNE DYSREGULATION 37
mental health. Surrounding yourself with individuals who can sympathize with what you are
dealing with is an important thing to realize. As students we have so many other individuals
who are experiencing the same daily struggles of stress in our classmates. Connecting with
them and making friendships can help make the experience of school more enjoyable and
tolerable because we can find comfort and support in each other. Which has a direct
correlation with our pico question and how stress affects our immune systems and overall
health.
This question was included in the survey so that it could be identified whether or not
people are aware of the effects of chronic stress on the immune system, not only in early age
but later in life as well. Based on the results and the graph, the majority (57/70 participants)
of the TCDHA students that participated in the survey are in fact aware of the negative
consequences of chronic stress now and later. However, there were 13 participants that
admitted that they were unaware of the impacts. This question was included in the research
STRESS AND IMMUNE DYSREGULATION 38
because oftentimes, individuals having symptoms associated with immune dysregulation, are
attributed to other factors such as vitamin deficiencies, blood count, etc., and chronic stress is
disregarded simply because chronic stress is thought to be an external factor. Leading from
early life to older age, chronic stress has a lasting impact that can almost never be reversed.
To be more specific, “chronological aging coupled with chronic stress accelerated
immunological aging.” (Segerstrom et. al, 2015). With the addition of chronic stress on a
human body, this statement proves that immunological aging is in fact accelerated faster than
chronological aging, meaning the immune system ages and weakens faster as you get older
than an individual who doesn't suffer from chronic stressors. To provide further context,
“Cortisol is ordinarily anti-inflammatory and contains the immune response, but chronic
elevations can lead to the immune system becoming “resistant”, an accumulation of stress
hormones, and increased production of inflammatory cytokines that further compromise the
immune response.” (Segerstrom et. al, 2015). Thus, making it difficult for older adults to be
able to terminate cortisol production in the body in response to stress - ultimately leading to
compromisation of the immune responses. This is due to the chronic elevation of cortisol in
the body, due to the chronic stress, making the body more resilient later in life. Moving
forward, to improve this question, we would be more specific in terms of the impacts of
chronic stress on the body. For example, the addition of the term “physiological” would
pertain more to the bodily changes happening under the skin, and/or “psychological” would
pertain more to the mental health changes.
Discussion/Conclusions
Research has found that since students started the dental hygiene program at Toronto
College Of Dental Hygiene and Auxiliaries that their stress levels have shown an increase
due to a combination of different stressors such as financials, didactics, attending clinic and
as well as the added stress they have in their own personal life. It has also shown that the
STRESS AND IMMUNE DYSREGULATION 39
majority of students are both mentally and physically stressed but have found that they aren’t
getting sick more often since attending college, although they have not found themselves
getting sick they do acknowledge that being stressed out is causing them difficulty
functioning in day to day life. When comparing our study to the literature analyses, although
our sample size was smaller we were able to prove that stress and immunity do in fact have a
correlation. In one of our literature analyses, it was mentioned that “relatively higher levels of
perceived stress and lower emotional satisfaction and quality of life compared to the
Pharmacy students” (Assaf, 2013). This was a finding from one of the research papers, which
correlates with the findings of our research study as well, which proved that there are higher
levels of stress that every student is facing, being in such an intense program at TCDHA. To
add to this, one of our survey questions relating lack of sleep due to stress and the immune
system supported a research point made in one of our literature analyses. Overall we found
that students at TCDHA are not getting adequate amounts of sleep due to the stress of school
on school nights, and therefore it may be impacting their immune systems. “Other potential
mediators, like getting good sleep, are increasingly being recognized as important pieces of
the stress-immunity puzzle. Even one night of total sleep deprivation was recently found to
significantly increase neutrophil counts and decrease neutrophil function in healthy men.”
(Segerstrom et. al, 2015). This study found that the lack of sleep is associated with a poor
functioning immune system, and that a minimum of 7 hours is required rather than the
average of 5-6 hours that students are getting per night. Collectively, all literature analyses
aimed to prove what we were able to prove in this research project, which was that stress and
immunity have a direct correlation. As for if this research assisted us to answer our PICO
question, “in the event that an individual is experience a compromised immune system, is
college stress more impactful than everyday stress on an individual's immunity” yes, we do
believe that from the research we conducted, that it was determined that the majority of
STRESS AND IMMUNE DYSREGULATION 40
students found themselves stressed since attending college. These individuals find themselves
struggling to keep sane in their day to day life, while feeling/experiencing sickness induced
behaviours while feeling stressed such as loss of appetite, depression and changes in their
sleeping patterns. Overall, there is a direct connection between increased stress levels and
being a student in the dental hygiene program at Toronto College of Dental Hygiene and
Auxiliaries. We had 70 participants in our study, our study was biased because we only
surveyed students attending TCDHA. We could have expanded our survey questions to other
colleges, or other dental hygiene schools to receive more reliable results, as not every dental
hygiene student or student attending TCDHA took part in our survey. Our survey could have
been more reliable and had a more accurate result if we had more participants. We could have
included more in depth questions such as if any of the participants had any mental or physical
issues before attending the college, if they were taking any antidepressants or antianxiety
medications as adding a fast-track program such as ours on top of any mental/physical issues
may increase one’s stress level also leading to becoming ill. We could’ve also added some
questions regarding the current Covid pandemic and if in fact it was contributing to more
stress or if students had learnt to adapt to the new changes or if they were taking more
precautions in order not to become ill.
STRESS AND IMMUNE DYSREGULATION 41
References
Assaf A. M. (2013). Stress-induced immune-related diseases and health outcomes of
pharmacy students: A pilot study . Saudi pharmaceutical journal : SPJ : the official
publication of the Saudi Pharmaceutical Society, 21(1), 35–44.
https://doi.org/10.1016/j.jsps.2012.02.006
Boggero, I. A., & Morey, J. N., Scott, A. B., Segerstrom, S. C. (2015, October 1). Current
Directions in Stress and Human Immune Function. Current Opinion in Psychology, 5,
13-17. DOI: 10.1016/j.copsyc.2015.03.007
Glaser, R., & Kiecolt-glaser, J. (2009, July 18). Stress damages immune system and health.
Retrieved from
https://www.discoverymedicine.com/Ronald-Glaser/2009/07/18/stress-damages-immu
ne-system-and-health/
Segerstrom, S., & Miller, G. (2004, July). Psychological stress and the human immune
system: A META-ANALYTIC study of 30 years of inquiry. Retrieved February 09,
2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361287/
Turner, L., Galante, J., Vainre, M., Stochl, J., Dufour, G., & Jones, P. (2020, April 2). Immune
dysregulation among students exposed to exam stress and its mitigation by
mindfulness training: Findings from an exploratory randomised trial. Retrieved
February 08, 2021, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7118166/
Bekhbat, M., & Neigh, G. N. (2018). Sex differences in the neuro-immune consequences of
stress: Focus on depression and anxiety. Brain, behavior, and immunity, 67, 1–12.
https://doi.org/10.1016/j.bbi.2017.02.006
STRESS AND IMMUNE DYSREGULATION 42
Darien, I. (2017, November 07). Seven or more hours of sleep Per night: A HEALTH
necessity for adults. Retrieved March 05, 2021, from
https://aasm.org/seven-or-more-hours-of-sleep-per-night-a-health-necessity-for-adults/
