work stress

Chronic Stress & Memory Erosion

The Bright Side of Stress?

Stress is a necessary human experience that keeps us alive.[1] It can be defined by the physical and mental responses we use to combat stressors experienced in our lives, such as threatening situations, insecurity, a tumultuous relationship or academic and work responsibilities.[2] We learn from previous stressors (e.g., avoiding sketchy alleyways we know of, or the signs of “red flags” in a relationship.) These adaptations are how short-term stress can beneficially inform our memory and subsequent learning. Stress-induced fears, anxieties and physiological signals cause us to react to danger or threats so that we know how to avoid a stressor again.

When the brain processes an imminent stressor, the sympathetic nervous system and hypothalamic-pituitary-adrenocortical (HPA) axis react to release adrenaline and glucocorticoids.[3] The sympathetic nervous system activates physiological responses for a fight or flight response. For example, pupils dilate and heart rate increases. The HPA axis regulates the stress response through structures such as the hypothalamus and hippocampus, an important structure for memory, via steroid hormones like cortisol.[4] By a negative feedback loop, the hippocampus’ cortical receptors are activated for the memory and biological learning of a stressful event.[5] As a result, memory is improved following an acute stress response so that our learning is improved for future similar stressful situations.[6,7] 

When Stress Becomes Problematic

While research indicates that short-term or acute stress can promote behavioral adaptations and improve spatial memory, in the same study by Lin et al. (2022), prolonged durations of stress led to behavioral and cognitive impairment in animal models.[8] Relatedly, in humans, long periods of stressful life events lead to cognitive and memory declines in older adults.[9] Additionally, prolonged (i.e., chronic) stress can increase risk of disease and mortality.[10,11] 

Chronic stress causes the body to be constantly out of balance (i.e., allostasis) in response to trying to restore balance (i.e., homeostasis) through energy expenditure.[12] The cumulatively created effect of chronic stress is referred to as allostatic load (when allostasis is repeatedly activated with a lack of adaptation or conclusion of the stress response.)[13] These chronic and repeated stress responses increase cortisol, which negatively affect components of memory (like navigation and long-term memory retention), and structurally damages neurons necessary for memory.[14,15] This leads the human body to be in a constant state of neurological disruption that is not restored, resulting in negative impacts on one’s memory.[16-22]  

Despite these negative health impacts, chronic stress remains an extremely common experience. According to the American Institute of Stress (2022), 94% of American workers say they are stressed at work while 55% of Americans report that they are stressed during any given day.[23] While some degree of stress in life is vital, an allostatic load can decrease well-being and cognition, and should be reduced to promote one’s health and overall life.

What Chronic Stress Looks Like

Chronic stress has particularly negative effects on the hippocampus (related to forming and sustaining memory), amygdala (related to emotional regulation) and neurons in the prefrontal cortex (related to problem-solving and planning).[24] Duman (2004) notes that by using physical restraints on rats, chronic stress was found to decrease neuron length and branching in the hippocampus.[25] Furthermore, increased glucocorticoid circulation leads to decreased neural plasticity (i.e., when neurons adapt and connect to process or establish information), and decreased growth of neurons in the hippocampus.[26] Brain-derived neurotrophic factor (BDNF) signaling, a marker of neural plasticity, is also reduced in the prefrontal cortex and hippocampus following chronic stress.[27] 

Chronic stress essentially impairs memory consolidation and retrieval, making reactivating and forming new information more difficult and less frequent.[28] Memory for spatial and navigating information was found to be impaired due to chronic stress, as well.[29] The body’s homeostatic regulation in response to a prolonged stressor additionally causes chronic neuroinflammation.[30] For these reasons, allostatic load leads to an increased risk of developing certain disorders such as post-traumatic stress disorder (PTSD), depression and neurodegeneration; these risks increase with age and cortisol levels.[31] 

Signs of chronic stress include:[32-34]

  • Emotional dysregulation

  • Decreased memory for events, general knowledge and navigation

  • Social withdrawal

  • Depressive symptoms

  • Increased anxiety and constant worrying

  • Fatigue or low energy

  • Immune system dysregulation and impaired disease resistance

  • High blood pressure

  • Digestive problems

 When chronic stress becomes persistently life-impairing, it can be a significant factor in several disorders, such as those involving anxiety, emotional disruption and cognitive problems. Stress-related cognitive impairment is found in several conditions and disorders:

  • PTSD symptom severity is associated with cognitive decline.[35] 

  • Chronic stress is a risk factor for dementia.[36]

  • In middle age, those with depression and high allostatic load have a higher risk of cognitive decline.[37] 

  • Childhood psychological stress (i.e., childhood poverty) is associated with a greater risk for anxiety-related symptoms and allostatic load in adolescence and adulthood with intensity relating to the duration of the allostatic load.[38] 

  • Impaired memory in depressed individuals is often attributed to chronic stress and its duration.[39]

Those with anxiety and mood disorders tend to experience psychological stress for lengthy periods. This is why high allostatic load is a factor for memory problems as the brain’s hippocampal neurons atrophy or degenerate and plasticity is disrupted by exhausted homeostatic energy expenditure. 

Perceptive Differences 

While individuals with mood or anxiety disorders are more vulnerable to chronic stress and memory impairment, stress responses can still vary by person and are not exclusive to those who experience such disorders. Chronic stress itself is also not a disorder, but a comorbid risk factor for memory impairment that can look different for everyone.

Internal beliefs vary per individual and are subjective, causing certain situations to be stressful to some and not to others, and leading to varied effects on memory. For example, students’ perceived high stress is found to be partially reliant on low self-efficacy (i.e., belief in self-success) and high emotional attention.[40] Additionally, high stress and cortisol levels lead to worsened memory performance such as declarative memory (i.e., memory for general knowledge and events), and cortisol is found to be in higher levels in females than males.[41,42] This is because cortisol levels are impacted by ovarian hormones such as estrogen.[43] Therefore, higher baseline cortisol levels may lead to high cortisol release when responding to stress.[44] For such reasons, cortisol administration is a way of inducing depression in animal models in addition to physical and social stressors due to chronic exposure. Other individual differences (such as age) may impact perceived stress as in older adults; egocentric stressors (e.g., self-health and financial stressors) were found to be detrimental to cognitive functioning as opposed to non-egocentric stressors.[45] 

Societal stressors may also impact the rate and intensity of the stressors that different groups face. For example, individuals of a sexual minority often experience increased impairment in psychosocial adaptation and overall quality of life likely due to negative stereotyping or stigma consciousness.[46] Menhinick & Sanders (2023) note that fear of violence is also an imminent physical stressor that many LGBTQ+ individuals and racial minorities experience, which can induce chronic stress, depression and PTSD.[47] 

Solutions to Mitigate and Overcome Chronic Stress

Several methods can be employed to tackle chronic stress. A social-psychological approach may look at the stressors that arise from social norms. From such a perspective, effortful social change can alleviate minority stress and threats, which removes the fault from the individual experiencing the neurological effects of stressors and targets the creation of the stressors themselves, such as violence and microaggressions arising from biases.[48] 

In terms of regenerating neurological functioning, Hernandez & Brinton (2022) found that allopregnanolone (a neurosteroid) may activate the GABA-chloride complex and can help to promote neurogenesis or the formation of neurons in the brain.[49] Relating to diet, Szala-Rycaj et al. (2023) found that chicory root insulin and topinambur powder, when supplemented long-term, can alleviate anxiety and cognitive disorder-like symptoms that were induced through chronic stress in animal models.[50] Additionally, Duman (2004) notes that antidepressants such as selective serotonin reuptake inhibitors (SSRIs) have been shown to reflect a reversal of neuron atrophy in the hippocampus and promote neural plasticity as well.[51] Note: it is important not to start or stop taking any medications or supplements without first discussing them with your physician and/or pharmacist.

Several evidence-based psychotherapies are effective at preventing and overcoming the effects of chronic stress. Acceptance and Commitment Therapy (ACT) is an approach that focuses on the awareness of mental states and thoughts with particular effectiveness for mood and anxiety disorders.[52] Mindfulness-Based Therapy (MBT) additionally reduces stress through attention to physical experiences and meditation.[53] This modality directly targets psychological stress reduction by promoting relaxation and building mindfulness skills. Cognitive Behavioral Therapy (CBT) is effective in treating stress-related disorders such as PTSD, anxiety, and depression by utilizing cognitive-restructuring of negatively-formed or maladaptive thoughts and behaviors that cause stress.[54] 

Due to the variety of potential stressors that one can experience and the individuality of perceived stress responses, it is possible that a combination of stressor-targeting and personal psychological support is necessary for both avoiding chronic stress and memory impairment, in addition to recovering from chronic stress. In everyday life, acute stress is beneficial for memory and the body, but chronic stress that takes both physical and psychological forms should be avoided as much as possible. Lowering chronic stress may further be promoted through prioritizing safety, relaxation, nutrition, time in nature, engaging in therapy to find ways to cope with stressors, and decreasing time on social media.[55] 

Moreover, this responsibility to avoid chronic stress is not always carried solely by the individual but is also held by a network of people that socially impact each other’s lives every day. In order to reduce the negative memory and health effects of chronic stress, both the individual and the environment by which they interact should be addressed. Stress and memory research continues to rapidly evolve, and may eventually be able to determine how to quantify, possibly by time and neural information, dangerous amounts of allostatic load on the brain and the processes of memory.  

If one is experiencing prolonged or chronic stress that is impacting daily life and overall well-being, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Phoebe Elliott

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Hadany, L., Beker, T., Eshel, I., & Feldman, M. W. (2006). Why is stress so deadly? An evolutionary perspective. Proceedings. Biological sciences, 273(1588), 881–885. https://doi.org/10.1098/rspb.2005.3384

2 American Psychological Association. (2023). Stress. In APA Dictionary of Psychology. https://dictionary.apa.org/stress?amp=1 

3 Lenart-Bugla, M., Szcześniak, D., Bugla, B., Kowalski, K., Niwa, S., Rymaszewska, J., & Misiak, B. (2022). The association between allostatic load and brain: A systematic review. Psychoneuroendocrinology, 145, 105917. https://doi.org/10.1016/j.psyneuen.2022.105917

4 Peavy, G. M., Salmon, D. P., Jacobson, M. W., Hervey, A., Gamst, A. C., Wolfson, T., Patterson, T. L., Goldman, S., Mills, P. J., Khandrika, S., & Galasko, D. (2009). Effects of chronic stress on memory decline in cognitively normal and mildly impaired older adults. The American journal of psychiatry, 166(12), 1384–1391. https://doi.org/10.1176/appi.ajp.2009.09040461

5 Ibid.

6 Lenart-Bugla et al. (2022)

7 Peavy et al. (2009)

8 Lin, L., Zhang, J., Dai, X., Xiao, N., Ye, Q., & Chen, X. (2022). A moderate duration of stress promotes behavioral adaptation and spatial memory in young C57BL/6J mice. Brain Sciences, 12(8) doi:10.3390/brainsci12081081

9 Peavy et al. (2009)

10 Bobba-Alves, N., Juster, R. -., & Picard, M. (2022). The energetic cost of allostasis and allostatic load. Psychoneuroendocrinology, 146 doi:10.1016/j.psyneuen.2022.105951

11 Selye, H. (1950). Stress and the general adaptation syndrome. British medical journal, 1(4667), 1383–1392. https://doi.org/10.1136/bmj.1.4667.1383

12 Bobba-Alves et al. (2022)

13 Lenart-Bugla et al. (2022)

14 Akan, O., Bierbrauer, A., Kunz, L., Gajewski, P. D., Getzmann, S., Hengstler, J. G., Wascher, E., Axmacher, N., & Wolf, O. T. (2023). Chronic stress is associated with specific path integration deficits. Behavioural brain research, 442, 114305. https://doi.org/10.1016/j.bbr.2023.114305

15 Kirschbaum, C., Wolf, O. T., May, M., Wippich, W., & Hellhammer, D. H. (1996). Stress- and treatment-induced elevations of cortisol levels associated with impaired declarative memory in healthy adults. Life sciences, 58(17), 1475–1483. https://doi.org/10.1016/0024-3205(96)00118-x

16 Peavy et al. (2009)

17  Bobba-Alves et al. (2022)

18 Lenart-Bugla et al. (2022)

19 Prieto, S., Nolan, K. E., Moody, J. N., Hayes, S. M., Hayes, J. P., & Department of Defense Alzheimer’s Disease Neuroimaging Initiative (2023). Posttraumatic stress symptom severity predicts cognitive decline beyond the effect of Alzheimer's disease biomarkers in Veterans. Translational psychiatry, 13(1), 102. https://doi.org/10.1038/s41398-023-02354-0

20 Perlman, G., Cogo-Moreira, H., Wu, C. -., Herrmann, N., & Swardfager, W. (2022). Depression interacts with allostatic load to predict cognitive decline in middle age. Psychoneuroendocrinology, 146 doi:10.1016/j.psyneuen.2022.105922

21 Duman R. S. (2004). Neural plasticity: consequences of stress and actions of antidepressant treatment. Dialogues in clinical neuroscience, 6(2), 157–169. https://doi.org/10.31887/DCNS.2004.6.2/rduman

22 Kirschbaum et al. (1996)

23 The American Institute of Stress. (2022). What is Stress? https://www.stress.org/daily-life 

24 Lenart-Bugla et al. (2022)

25 Duman (2004)

26 Ibid.

27 Ibid. 

28 Lenart-Bugla et al. (2022)

29 Akan et al. (2023)

30 Craddock, T. J. A., Michalovicz, L. T., Kelly, K. A., Rice, M. A., Jr., Miller, D. B., Klimas, N. G., . . . Broderick, G. (2018). A logic model of neuronal-glial interaction suggests altered homeostatic regulation in the perpetuation of neuroinflammation. Frontiers in Cellular Neuroscience, 12 doi:10.3389/fncel.2018.00336 

31 Palego, L., Giannaccini, G., & Betti, L. (2021). Neuroendocrine response to psychosocial stressors, inflammation mediators and brain-periphery pathways of adaptation. Central Nervous System Agents in Medicinal Chemistry, 21(1), 2-19. doi:10.2174/1871524920999201214231243 

32 National Institutes of Health. (2022). Stress. In The National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress 

33 Mariotti A. (2015). The effects of chronic stress on health: new insights into the molecular mechanisms of brain-body communication. Future science OA, 1(3), FSO23. https://doi.org/10.4155/fso.15.21

34 Yaribeygi, H., Panahi, Y., Sahraei, H., Johnston, T. P., & Sahebkar, A. (2017). The impact of stress on body function: A review. EXCLI journal, 16, 1057–1072. https://doi.org/10.17179/excli2017-480

35 Prieto et al. (2023)

36 Ibid.

37 Perlman et al. (2022)

38 De France, K., Evans, G. W., Brody, G. H., & Doan, S. N. (2022). Cost of resilience: Childhood poverty, mental health, and chronic physiological stress. Psychoneuroendocrinology, 144 doi:10.1016/j.psyneuen.2022.105872 

39 Dillon, D. G., & Pizzagalli, D. A. (2018). Mechanisms of Memory Disruption in Depression. Trends in neurosciences, 41(3), 137–149. https://doi.org/10.1016/j.tins.2017.12.006

40 Navarro-Mateu, D., Alonso-Larza, L., Gómez-Domínguez, M. T., Prado-Gascó, V., & Valero-Moreno, S. (2020). I’m not good for anything and That’s why I’m stressed: Analysis of the effect of self-efficacy and emotional intelligence on student stress using SEM and QCA. Frontiers in Psychology, 11 doi:10.3389/fpsyg.2020.00295

41 Kirschbaum et al. (1996)

42 Wolf, O. T., Schommer, N. C., Hellhammer, D. H., McEwen, B. S., & Kirschbaum, C. (2001). The relationship between stress induced cortisol levels and memory differs between men and women. Psychoneuroendocrinology, 26(7), 711–720. https://doi.org/10.1016/s0306-4530(01)00025-7

43 Edwards, K. M., & Mills, P. J. (2008). Effects of estrogen versus estrogen and progesterone on cortisol and interleukin-6. Maturitas, 61(4), 330–333. https://doi.org/10.1016/j.maturitas.2008.09.024

44 Wolf et al. (2001)

45 De France et al. (2022)

46 Dispenza, F. (2023). Chronic illness and disability among sexual minority persons: Exploring the roles of proximal minority stress, adaptation, and quality of life. Psychology of Sexual Orientation and Gender Diversity, doi:10.1037/sgd0000642

47 Menhinick, K. A., & Sanders, C. J. (2023). LGBTQ+ stress, trauma, time, and care. Pastoral Psychology, doi:10.1007/s11089-023-01073-z

48 Riggs, D. W., & Treharne, G. J. (2017). Decompensation: A novel approach to accounting for stress arising from the effects of ideology and social norms. Journal of Homosexuality, 64(5), 592-605. doi:10.1080/00918369.2016.1194116

49 Hernandez, G. D., & Brinton, R. D. (2022). Allopregnanolone: Regenerative therapeutic to restore neurological health. Neurobiology of Stress, 21 doi:10.1016/j.ynstr.2022.100502

50 Szala-Rycaj, J., Szewczyk, A., Zagaja, M., Kaczmarczyk-Ziemba, A., Maj, M., & Andres-Mach, M. (2023). The influence of topinambur and inulin preventive supplementation on microbiota, anxious behavior, cognitive functions and neurogenesis in mice exposed to the chronic unpredictable mild stress. Nutrients, 15(9) doi:10.3390/nu15092041

51  Duman (2004)

52 Wersebe, H., Lieb, R., Meyer, A. H., Hofer, P., & Gloster, A. T. (2018). The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. International journal of clinical and health psychology : IJCHP, 18(1), 60–68. https://doi.org/10.1016/j.ijchp.2017.09.002

53 Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and depression: A meta-analytic review. Journal of consulting and clinical psychology, 78(2), 169–183. https://doi.org/10.1037/a0018555

54 Hofmann, S. G., Asnaani, A., Vonk, I. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive therapy and research, 36(5), 427–440. https://doi.org/10.1007/s10608-012-9476-1

55 National Institutes of Health. (2022). Stress. In The National Center for Complementary and Integrative Health. https://www.nccih.nih.gov/health/stress

Deactivate Stress by Implementing CBT

Why Am I So Overwhelmed?

Stress is an unfortunate, yet inevitable, reaction to the pressure of life experiences that exceed one’s coping abilities. Work-related stress is one of the most prevalent experiences of heightened cortisol levels. However, several other areas of life can bring about feelings of stress such as relationships, health-concerns, bereavement, and difficulties with children.[1] Prolonged feelings of stress can have an impact on one’s behavioral, physical, and psychological health. For instance, heightened levels of stress can cause:[2]

While it is normal to experience stress during one’s life, an excessive amount of cortisol (i.e., the stress hormone) can lead to physical and psychological illness if not handled properly.[3] 

One way of understanding the origin of one’s stress is to analyze how specific personality traits and attitudes influence an individual’s ability to cope with stressors. For example, the concept of “locus of control” by Rotter (1960) suggests that individuals' perception of control over their lives has a significant impact on their behavior.[4] Individuals with an internal locus of control perceive themselves as having more power over their actions and greater understanding of what they can control in life. Whereas, individuals with an external locus of control perceive that they have little to no control over what happens in life and can potentially chalk negative events up to being unlucky.[5] When stressful situations maifest for external locus of control individuals, they are more likely to face the experience with a negative mindset such as, “Bad things always happen to me, I can’t cope anymore,” instead of deciding what they can do about it. 

The Power of CBT

Cognitive Behavioral Therapy (CBT) is a well-researched and evidence-based approach used to treat a range of mental health issues (e.g., depression, anxiety, substance use and eating disorders).[6] Cognitive theory suggests that a link exists between one’s feelings, thoughts, and behaviors. Therefore, CBT is utilized to help clients change problematic thinking patterns and in turn positively impact one’s feelings and behaviors.[7] Research has investigated the influence of CBT approaches on daily stressors. For example, a study by Barrett and Stewart (2021) investigated the efficacy of CBT in reducing work-related stress by instructing participants to identify occupational stressors as well as maladaptive patterns of thinking, feeling and behaving when responding to stress. CBT techniques were found to significantly decrease both stress and burnout among employees.[8] 

The American Psychological Association (2023) notes that CBT helps to reduce symptoms of stress through numerous techniques, including:[9] 

  • Gaining understanding of the link between thoughts and behaviors

  • Identifying and eliminating cognitive distortions

  • Developing problem-solving skills

  • Increasing self-confidence

  • Facing one’s fears

  • Learning to calm one’s body and mind

Daily CBT Practice

While CBT is best and ideally done under the guidance of a licensed mental health professional, there are steps individuals can take on their own to potentially reduce or lessen symptoms of stress. For instance, journaling is one activity that helps to identify feelings and thoughts that can lead to problematic behaviors. Being present and writing down thoughts can lead to a more logical understanding of thought patterns, potentially breaking the cycle of cognitive distortions.[10] Moreover, relaxation techniques such as meditation and yoga have been shown to target muscle tension and chronic pain. Clinical Psychologist, Michael Messina (2023), notes that incorporating breathwork and meditation into one’s daily practice can minimize overall anxiety and everyday stressors.[11] 

Eliminating Cognitive Distortions

Cognitive distortions are exaggerated patterns of thought not based on facts or logic. Distortions often perpetuate a negative filter for one’s perspective of themself and others.[12] For example, “Polarization” is a cognitive distortion that shows up as all-or-nothing thinking and causes one to view situations in terms of absolute. Polarization can lead to dwelling on mistakes or assuming that one will never be able to succeed instead of acknowledging an error and trying to move past it.[13] 

The unraveling of cognitive distortions is a primary goal of CBT that can be accomplished without the help of a therapist. Cognitive distortions must be identified and challenged to effectively reduce harmful automatic thoughts.[14] Once cognitive distortions have been identified, cognitive restructuring can take place by questioning how the distorted thoughts originally took root and why they are believed. For example, if a belief exists that having a high-paying job is the only way to be a respectable person, it is likely that the believer will think that they cannot be respected by others without a high-paying job. Instead of accepting faulty beliefs that lead to negative thoughts about oneself, one should stop to consider what actually makes a person “respectable,” including perspectives that have not been considered before.[15]

Other common examples of cognitive distortions include:[16]

  • Control Fallacy - Either feeling responsible for everything in your own life and other people’s lives, or feeling no control over anything.

  • Catastrophizing - Jumping to the worst possible conclusion in every scenario no matter how improbable it may be.

  • Overgeneralization - Turning one negative event into a never-ending pattern of loss and defeat. The terms, “always,” “never,” “everything,” and “nothing” tend to be frequent in one’s train of thought.

  • Shoulds - Having ironclad rules you set for yourself and others with no exceptions.

  • Discounting the Positive - Actively rejecting and invalidating good things that happen in your life.

To reduce the prevalence of cognitive distortions in one’s daily thought process, it is helpful to:[17] 

  • Become Aware - Step away, become present, and focus on your thought process.

  • Replace Absolutes - Replace absolute words like “always,” “never,” “everything,” and “nothing” with “sometimes”.

  • Avoid Labels - Instead of labeling yourself as “lazy,” consider, “I just didn’t clean today.” One action does not have to define you.

  • Look for the Positive - Think of three positive aspects per situation to build a new habit of thinking positively.

  • Invalidate Negative Thoughts - Investigate and question the validity of your thought process and realize that thoughts are not facts.

If feelings of stress are chronic and impact one’s everyday life, steps should be taken to reduce such negative experiences by contacting a licensed mental health professional for further guidance.[18]

Contributed by: Tori Steffen

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 Puertas-Gonzalez, J. A., Mariño-Narvaez, C., Romero-Gonzalez, B., Sanchez-Perez, G. M., & Peralta-Ramirez, M. I. (2022). Online cognitive behavioural therapy as a psychological vaccine against stress during the COVID-19 pandemic in pregnant women: A randomised controlled trial. Journal of Psychiatric Research, 152, 397–405. https://doi-org.ezproxy.snhu.edu/10.1016/j.jpsychires.2022.07.016

2 Mayo Clinic. (2021). How stress affects your body and behavior. Stress management. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-symptoms/art-20050987

3 Puertas-Gonzalez et al., (2022)

4 Lopez-Garrido, G. (2023). Locus of Control Theory in Psychology: Definition & Examples. Simply Psychology. https://www.simplypsychology.org/locus-of-control.html

5 Puertas-Gonzalez et al., (2022)

6 American Psychological Association. (2023). What is cognitive behavioral therapy? American Psychological Association. https://www.apa.org/ptsd-guideline/patients-and-families/cognitive-behavioral 

7 Ibid.

8 Barrett, K., & Stewart, I. (2021). A preliminary comparison of the efficacy of online Acceptance and Commitment Therapy (ACT) and Cognitive Behavioural Therapy (CBT) stress management interventions for social and healthcare workers. Health & Social Care in the Community, 29(1), 113–126. https://doi-org.ezproxy.snhu.edu/10.1111/hsc.13074

9 American Psychological Association (2023)

10 Messina, M. (n.d.). Practice cognitive behavioral therapy at home. Dr. Messina & Associates: Clinical Psychologists. https://www.drmessina.com/blog/practice-cognitive-behavioral-therapy-at-home

11 Ibid.

12 Ackerman, C. (2023). Cognitive distortions: 22 examples and worksheets. PositivePsychology.com. https://positivepsychology.com/cognitive-distortions/#experts-cognitive-distortions

13 Hartney, E. (2022). 10 cognitive distortions you'll learn about in therapy. 10 Cognitive Distortions That Can Cause Negative Thinking. Very Well Mind. https://www.verywellmind.com/ten-cognitive-distortions-identified-in-cbt-22412

14 Ackerman, C. (2023). CBT techniques: 25 cognitive behavioral therapy worksheets. 9 Essential CBT Techniques and Tools. https://positivepsychology.com/cbt-cognitive-behavioral-therapy-techniques-worksheets/#cbt-tools

15 Ibid.

16 Hartney (2022)

17 Ackerman (2023) Cognitive distortions

18 Mayo Clinic (2021)