Stress and Quality of Life Normative and non-normative events help us understand how change and stress may impact our quality of life. Using the South University Library, locate 2 scholarly journal ar

Women with breast cancer had higher scores on PTG scales reflecting new possibilities, personal strengths, and spiritual changes than healthy women with AO. Chronic stress may hamper growth following adversities. Evaluation of chronic stress may help in targeting interventions for promoting posttraumatic growth.

KEYWORDS allostatic load, breast cancer, posttraumatic growth, psychological well-being, stress The process of adaptation to stressful life events can be different from person to person, leading to distress and psychopathology but also to positive changes, such as benefit finding and stress-related growth (Affleck & Tennen, 1996; Payne, Joseph, & Tudway, 2007), that are associated with psychological well-being (Durkin & Joseph, 2009). Based on a ‘‘cognitive processing model,’’ Calhoun and Tedeschi (1989) described the phenomenon of post- traumatic growth (PTG) for indicating possible positive changes in many life domains (more connected spiritually, greater intimacy and compassion for Received 20 May 2013; accepted 27 July 2013.

Address correspondence to Chiara Ruini, Department of Psychology, University of Bologna, Viale Berti Pichat, 5, 40127 Bologna, Italy. E-mail: [email protected] Journal of Loss and Trauma , 20:109–122, 2015 Copyright #Taylor & Francis Group, LLC ISSN: 1532-5024 print =1532-5032 online DOI: 10.1080/15325024.2013.830530 109 others, new possibilities in life, feeling personally stronger, deeper appreci- ation of life) that result from personal cognitive and emotional efforts in dealing with traumatic events. Research has focused mainly on severe life crisis to examine the relation between PTG and psychological distress (Barrington & Shakespeare-Finch, 2013; Linley & Joseph, 2004; Helgeson, Reynolds, & Tomich, 2006; Shakespeare-Finch & Armstrong, 2010).

However, a growing body of research suggests that PTG may also be observed after stressful events that are not necessarily traumatic, such as chronic illnesses (Dirik & Karanci, 2008), work-related stress (Hyatt-Burkhart, 2013; Paton, 2005), parenting of children with disabilities (Cohen Konrad, 2006), and childbirth (Sawyer, Ayers, Young, Bradley, & Smith, 2012).A number of investigations have documented that PTG also can be observed after severe, life-threatening illnesses such as cancer (Bellizzi et al., 2010; Cordova, Cunningham, Carlson, & Andrykowski, 2001; da Silva, Moreira, & Canavarro, 2011; Morris & Shakespeare-Finch, 2011; Sumalla, Pchoa, & Blanco, 2009; Zoellner & Maercker, 2006). Cordova et al. (2001) found that PTG was higher in breast cancer survivors than in age-matched healthy controls. Interestingly, PTG was not related to distress levels or to psychological well-being. Another investigation (Mols, Vingerhoets, Coebergh, & van de Poll-Franse, 2009) highlighted that long-term breast cancer survivors reported similar levels of well-being compared to healthy women but higher levels of PTG, particularly survivors at a lower tumor stage. In their review of literature on PTG, Helgeson et al. (2006) found that the nature of the traumatic event (health stressors vs. personal trauma) could be a moderator in the relationship between growth and health outcomes.

Specifically, growth resulted from moderate distress only in health-related stressors. Indeed, cancer is a progressive and ongoing threat, with an internal source of stress, whereas acute traumas have a well-established time frame for onset and termination, with an external source of stress (Ho, Chan, Yau, & Yeung, 2011; Sumalla et al., 2009). Some authors (Vail, Juhl, Arndt, Vess, Routledge, & Rutjens, 2012) have suggested that threats of impending mortality and awareness of mortality, implicitly endorsed in oncological illnesses, are more likely to lead to positive changes and growth. Calhoun and Tedeschi (1998) suggested that the ‘‘seismic nature’’ of the event, characterized by uncontrollability, irreversibility, and threatening qualities, may play a more important role in influencing growth following adversities.

These characteristics of uncontrollability, perceived threats, and irreversi- bility could also be applied to chronic stressors and daily negative events, subsumed under the rubric of allostatic load (McEwen & Stellar, 1993).

The concept of allostatic load refers to the cost of the continual adjustment of the internal milieu required by an organism to adapt to different social, environmental, and personal challenges (McEwen & Stellar, 1993). Allostatic load may thus represent the chronic nature of stress, as traditionally opposed to specific major life events. McEwen and Wingfield (2010) have further 110 C. Ruini et al. differentiated between a tolerable level of stress (a physiological state buffered by the personal and interpersonal resources of the individual that occurs within a time-limited period) and toxic stress (strong, frequent, and=or prolonged activation of the body’s stress response system in the absence of buffering factors= protection), defining the latter state as allostatic overload (AO). Recently, Fava, Guidi, Semprini, Tomba, and Sonino (2010) introduced a more compre- hensive evaluation of the phenomenon, including not only the presence of life events and physiological response but also symptomatic manifestations of distress (presence of symptoms and absenc e of well-being). Accordingly, stress is measured by evaluating the occurrence o f stressful situations in areas of major importance to the patient, which result in significant changes in the patient’s living conditions, socia landfamilycircle,andwork,aswellassubtleand longstanding life situations such as those occurring at work. In both cases, the situation is experienced by the individual as taxing or exceeding his or her coping skills. As a result, major life even ts and chronic stress can both constitute a source of allostatic overload, according to their impact on an individual’s life.

To the best of our knowledge, there are no available data on possible positive psychological changes (i.e., benefit finding and growth) associated with chronic stress and allostatic overload. The main aim of this study is to evaluate the relationship between PTG and allostatic overload considering the nature of stressful experiences (cancer illness vs. major life events). Consistent with a biopsychosocial model of disease (Engel, 1983) and with the clinimetric definition of allostatic overload (Fava et al., 2010), our hypothesis is that the cumulative impact of adversities (allostatic load) could hamper posttraumatic growth. Accordingly, when dealing with chronic stressors or cumulative adversities in life that exceed personal resources (i.e., allostatic overload), individuals may gradually lose their capacity to find growth in stressful situations. On the other hand, the presence of life adversities and stressors not accompanied by the clinical response of allostatic overload may be associated with greater levels of PTG. On the basis of the existing literature (Ho et al., 2011; Sumalla et al., 2009; Trzebin ´ ski & Zie ba, 2013), we expected that these mechanisms might be particularly important for individuals facing chronic life-threatening illnesses such as cancer (Bigatti, Steiner, & Miller, 2012; da Silva et al., 2011; Morris & Shakespeare-Finch, 2011; Watson, Homewood, & Haviland, 2012).

Hence, we compared a sample of women reporting a diagnosis of breast cancer with matched healthy controls reporting other major stressful events. METHODS Participants The sample was recruited as part of a larger research project with the aim of assessing PTG, psychosocial distress, and t heir relation to positive psychological PTG and Allostatic Overload 111 domains such as gratitude and psychological well-being (Ruini & Vescovelli, 2013; Ruini, Vescovelli, & Albieri, 2013). Participants were recruited during mammography screening in a cancer unit of a hospital in northern Italy whose ethical commission provided prior approval to the research protocol. Eighty women with a prior di agnosisofbreastcancerand76other healthy women were approached. Twenty-three percent of them declined to participate or did not meet the inclus ion criteria (i.e., diagnosis of breast cancer or presence of major life stressors; see below). The final sample consisted of 120 women who were voluntarily enrolled in the study and gave written consent to participate.

Breast cancer survivors ( n¼ 60; mean age ¼56.31 years, SD¼11.78) were consecutively recruited during routine follow-up examinations. The diagnosis of breast cancer had been received from 1 to 15 years earlier (mean ¼6.42 years, SD¼4.06). Seventy-six percent of the participants were married, 11.7 %separated or widowed, and 8.3 %unmarried; the majority (53.4 %) were unemployed. Breast cancer survivors were diagnosed and treated for non-invasive breast cancer ( n¼ 40, 66.7 %) and invasive breast cancer ( n¼ 20, 33.3 %). Surgery, hormone therapy, radiation therapy, and chemotherapy were used. Twenty percent of patients ( n¼ 12) had only surgery and hormone therapy; 21.6 %(n ¼ 13) had surgery, hormone therapy, and chemotherapy; 30 %(n ¼ 18) had surgery, hormone therapy, and radiotherapy; and 28.3 %(n ¼ 17) had surgery, hormone therapy, chemo- therapy, and radiotherapy. At the time of the assessment, 55 %of the breast cancer survivors ( n¼ 33) were receiving hormone therapy.

Healthy stressed women ( n¼ 60; mean age ¼56.52 years, SD¼11.68) were recruited during preventive mammography screening and were matched to breast cancer survivors based on age and sociodemographic variables. Seventy-one percent of the participants were married, 15 % separated or widowed, and 8.3 %unmarried, and the majority (62.1 %) were unemployed. The inclusion criterion was reporting a severe stressful event, other than cancer, experienced 1 to 15 years earlier (mean ¼7.88 years, SD ¼6.06).

Assessment Both groups were assessed using several questionnaires. Paykel’s Interview for Recent Life Events (IRLE; Paykel, 1997), covering 64 life events, was administered as a semistructured research interview. All breast cancer survivors and stressed women were seen by the same interviewer (a clinical psychologist). When interviewing breast cancer survivors, the focus was on the cancer experience and its related negative consequences in other life domains (work, social functioning, etc.). When interviewing healthy women, the interviewer assessed the presence of major life stressors (bereavement, prolonged unemployment, etc.) and other associated negative consequences.

112 C. Ruini et al. Detailed questioning was carried out by the clinical psychologist in order to determine the full nature and circumstances of each event reported. When multiple events were reported, the interview focused on the one deemed as having the most objective negative impact (i.e., the rater made a judgment of the expected unpleasant impact and stressfulness of the event taking into account its full nature and particular circumstances). A standard Likert scale ranging from no negative impact to severe negative impact was used.

Moreover, this evaluation relied on characteristics of the event such as controllability, desirability, and irreversibility. For example, bereavement was rated differently when experienced at diverse life stages or as a conse- quence of a chronic illness rather than a sudden accident. However, in the healthy group, only women reporting stressful events judged to have a mild to severe negative impact were enrolled in the study. Finally, the rater classified events into the following categories: work, education, finance, health, bereavement, migration, courtship and cohabitation, legal issues, familial and social relationships, and marital life (Paykel, 1997).The Posttraumatic Growth Inventory (PTGI; Tedeschi & Calhoun, 1996) assesses positive changes experi enced after adversities. Breast cancer survivors were asked to rate their pos itive changes following illness. For comparative purposes, healthy stressed women were asked to rate their positive changes following the event investigated with the IRLE deemed to have the most severe negative impact. The 21-item PTGI yields a total score and five subscale scores: new possibilities (5 items), relating to others (7 items), personal strength (4 item s), spiritual change (2 items), and appreciation of life (3 items). This original five-factor structure has been recently confirmed by an Italian study (Prati & Pietrantoni, 2014). Items are rated on a 6-point Likert scale ranging from 0 (did not experience this change as a result of my crisis) to 5 (experienced this change to a very great degree as a result of my crisis). In a previous study with cancer patients and controls (Cordova et al., 2001), Cronbach’s alphas for the total score were .95 and .96, respectively. In the present study, the Cronbach’s alpha for the total score was .865. TheSymptom Questionnaire (SQ; Kellner, 1987) is a 92-item self-rating scale that yields four distress scales (anxiety, depression, somatization, and hostility-irritability) and four associated well-being scales (relaxation, contentment, physical well-being, and friendliness). Each symptom scale score may range from 0 to 17 and each well-being scale score from 0 to 6.

The SQ was previously validated in an Italian population and has been found to be a sensitive instrument to detect changes in clinical trials (Fava et al., 1983). The conventional split-half reliability of the scales in various studies was as follows: anxiety, .75 to .95 (median ¼.83); depression, .74 to .93 (median ¼.91); somatization, .57 to .84 (median ¼.78); and hostility, .78 to .95 (median ¼.89) (Kellner, 1987). In the present study, the Cronbach’s alpha for the total score was .836. PTG and Allostatic Overload 113 ThePsychological Well-Being Scale (PWB; Ryff, 1989) is a 42-item self-rating inventory that covers six areas of psychological well-being:

autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Subjects respond in a 6-point format ranging from strongly disagree to strongly agree. Responses to negatively scored items are reversed in the final scoring on the dimension assessed. The PWB scales have satisfactory test-retest reliability and are inversely related to measures of psychological distress (Kellner, 1987). In the present study, the Cronbach’s alpha for the total score was .825. The Psychosocial Index (PSI; Sonino & Fava, 1998) is a self-rating scale including 52 items; 37 of the items (1–29 and 44–51) were derived from Kellner’s Screening List for Psychosocial Problems (SLP). Items 30–37 were derived from the Wheatley Stress Profile. They were added to the list of life events included in the SLP to provide an appraisal of daily, work, and inter- personal stress. The stress rating thus attempts an integration of perceived and objective stress, life events, and daily stress. Some PSI items involve specific responses; most require a yes =no answer, while others are rated on a 0–3 Likert scale (from not at all to a great deal). In the original validation study, internal consistency coefficients were .88 for the stress subscale, .89 for psychological distress, and .90 for abnormal illness behavior (Sonino & Fava, 1998). Procedures and Statistical Analyses Descriptive analyses (frequencies) were used for classifying participants according to Paykel’s (1997) categories of reported stressful life events and their objective negative impact. Chi-square and Fvalues were calculated to analyze possible differences between groups.

Based on the criteria for the evaluation of allostatic overload defined by Fava et al. (2010) and adapted for non-psychiatric populations by Offidani and Ruini (2012), breast cancer survivors and healthy stressed women were then categorized as presenting AO if the following conditions were satisfied:

(a) scoring positive on specific Psychosocial Index items (presence of chronic stress), (b) scoring higher than the 75th percentile on at least two SQ distress scales (presence of psychiatric symptoms), (c) scoring lower than the 25th percentile on at least three PWB scales (or two if one of the scales is environmental mastery) (low psychological well-being), and (d) scoring higher than the 75th percentile on one SQ scale and contemporaneously lower than the 25th percentile on two PWB scales (presence of psychiatric symptoms combined with low psychological well-being). General linear models (GLMs) were used to calculate differences in PTG scores among AO groups. We also adjusted the models, adding covariates that were previously found to have an influence on PTG: age, time since event, marital and work status, and the event’s objective negative impact.

114 C. Ruini et al. RESULTS Life Events and Stressors Table 1 shows reported negative life events, as assessed with the IRLE (Paykel, 1997), in both healthy stressed women and breast cancer survivors.

The former mainly reported work and health problems and bereavement.

Breast cancer survivors reported work and social problems associated with their illness. No significant differences emerged between groups, but finan- cial problems were more frequently reported by breast cancer survivors than healthy women ( v 2¼3.93, p¼ .048).

Concerning objective negative impact, significant differences between the groups emerged ( v 2¼7.91, p¼ .048). Specifically, 60 %of healthy women reported a mild to moderate negative impact, and only 16.7 %described the stressful event as severe. On the contrary, in the breast cancer survivor group, the majority of women (54.2 %) reported a negative impact of their illness ranging from marked to severe; only 16.9 %considered their illness as having a mild impact. Allostatic Overload and PTG According to the clinimetric criteria for evaluating AO (Fava et al., 2010; Offidani & Ruini, 2012), 51 women out of 120 (42.5 %) were classified as presenting AO. The sample was divided into four groups according to AO status: breast cancer survivors with AO ( n¼ 31, 25.8 %), breast cancer TABLE 1 Categories of Stressors According to Paykel’s Scale of Stressful Life Events.

Events Total sample ( %)( N¼ 120) Breast cancer survivors ( %)( n¼ 60) Healthy stressed women ( %) ( n ¼ 60) v 2 Work 38.136.2 40 0.151 Education —— —— Finance 8.313.3 3.3 3.93 Health 32.231.7 32.8 0.016 Bereavement 39.236.7 41.7 0.315 Migration 7.56.7 8.3 0.120 Courtship 0.8— 1.7 0.992 Legal 1.73.3 —1.967 Family and social relationships 22.5 26.718.3 1.195 Marital problems 9.714.3 5.3 2.617 Negative impact N(%) N(%) N(%) 7.91 Mild 34 (28.6) 10 (16.9) 24 (40) Moderate 29 (24.4) 17 (28.8) 12 (20) Marked 31 (26.1) 17 (28.8) 14 (23.3) Severe 25 (21) 15 (25.4) 10 (16.7) p< .05. PTG and Allostatic Overload 115 survivors without AO (n¼ 29, 23.3 %), healthy stressed women with AO ( n ¼ 20, 16.7 %), and healthy stressed women without AO ( n¼ 40, 33.3 %).

No significant differences emerged among groups in terms of socio- demographic variables (Table 2). Descriptive statistics showed that breast cancer survivors without AO reported the highest mean levels of PTG and healthy stressed women with AO the lowest (Table 2).

Unadjusted GLMs showed that groups significantly differed on the PTG scales, [ F(15, 270.94) ¼1.877, p¼ .026] (Table 2). Most of the variance was explained by the PTG scales of personal strength, [ F(3, 98) ¼3.69, p¼ .014], and spiritual changes, [ F(3, 98) ¼3.04, p¼ .033] (Table 2). After adjusting for age, time since event, and marital and work status, the personal strength, F (3, 106) ¼3.816, p¼ .012, and spiritual changes, F(3, 106) ¼3.091, p¼ .031, scales still significantly differed among AO groups. Moreover, such differ- ences were significant even after controlling also for the objective negative impact of the event, [ F(3, 106) ¼3.512, p¼ .018], and [ F(3, 106) ¼3.049, p¼ .032], respectively. Contrast analyses revealed that the two groups without AO exhibited no significant differences on the PTG scales. However, breast cancer survivors scored significantly higher than healthy stressed women with AO on the new possibilities ( p¼ .036), personal strength ( p¼ .002), and spiritual changes ( p¼ .050) scales. DISCUSSION In this study, we examined the impact of chronic =cumulative life stress (allostatic overload) on posttraumatic growth. We asked breast cancer survivors and age-matched healthy stressed women to report positive psychological changes (PTG) following the experience of breast cancer or other personal negative events, respectively. Breast cancer survivors reported TABLE 2 Sociodemographic Characteristics and PTGI Mean Scores. Breast cancer survivors without AO (n ¼29) Breast cancer survivorswith AO(n ¼31) Healthy stressed women with AO (n ¼20) Healthy stressed women without AO (n ¼40) F=v 2 P Sociodemographic characteristics Age 53.89 9.61 58.68 13.05 56.45 11.04 56.55 12.13 0.826 .482 Time since event 6.11 3.72 6.71 4.45 7.45 6.53 8.10 5.88 0.911 .438 Marital status (% ) (married) 82.1 74.2 7072.5 1.242 .758 Work status (% ) (employed) 66.7 40 68.459 5.479 .136 PTGI scales Relations 23.84 1.68 20.43 1.63 19.21 1.97 20.09 1.49 1.386 .251 New possibilities 14.93 1.21 12.14 1.16 10.42 1.41 13.33 1.07 2.167 .097 Personal strength 15.08 0.92 12.04 0.88 10.63 1.07 13.00 0.81 3.693 .014 Spiritual changes 6.58 0.62 7.14 0.62 4.32 0.75 6.09 0.57 3.037 .033 Appreciation of life 11.00 0.75 10.61 0.72 8.47 0.87 9.91 0.66 1.831 .146 PTGI total 71.30 4.34 61.66 4.18 53.05 5.17 62.71 3.86 2.490 .064 116 C. Ruini et al. a significantly more severe objective negative impact of the event (illness) compared to healthy stressed women. Due to its chronic nature, breast cancer could more severely affect individuals’ life, encompassing problems in various life domains such as financial, work, and social (Nuray, Karanci, & Erkam, 2007). Other life stressors could be more limited and specific.According to the clinimetric criteria for evaluating AO (Fava et al., 2010; Offidani & Ruini, 2012), in the present investigation we found that 51 women out of 120 (42.5 %) presented AO. The majority ( n¼ 31) had a diagnosis of breast cancer. This prevalence is higher than the one found in patients with cardiovascular disease (11 %) (Porcelli, Laera, Mastrangelo, & Di Masi, 2012) but similar to those reported in another study involving a general population (Offidani & Ruini, 2012). These data may be interpreted as suggesting the higher emotional burden entailed by cancer and its related chronic stressors compared to other negative events. On the other hand, healthy stressed women reporting AO were comparable to ill women in terms of their symp- tomatic manifestations of stress responses. This is probably due to the fact that they also reported chains of negative events (three or more) over time.

They also reported the lowest levels in PTG dimensions. Conversely, women with breast cancer but without AO exhibited the highest levels of PTG, suggesting that cancer has a unique role in the acti- vation of transcendent aspects of human functioning such as spirituality and meaning (Ruini & Vescovelli, 2013; Vachon, 2008; Yanez et al., 2009).

This process may be facilitated by the psychological and social support that is often provided to oncological patients in the majority of health care systems. As highlighted by previous investigations (Janoff-Bulman, 1989; Tomich & Helgeson, 2004), the diagnosis of cancer may be initially traumatic but subsequently may also lead individuals to discover a new sense of personal control through reexamination of their self-identity. The potential presence of greater social support may also promote positive subjective and interpersonal changes (Brennan, 2001) that, in turn, may be protective against an excessive stressful reaction (AO). As pointed out by Helgeson et al. (2006), such positive changes are more likely to occur at a younger age and when a longer time since the traumatic event has elapsed. Our sample was indeed composed of middle-aged women with a long period of time since their diagnosis or event. Since we decided to include these and other sociodemographic variables in our analyses, our results seem to suggest an independent role played by the presence of allostatic overload in PTG levels. These results also confirm that growth may not be a function of the type of traumatic event or a function of the total amount of related distress. Rather, it is their combined effect, the subjective experience of the events and the individual resources over time that may influence growth following adversities (Linley & Joseph, 2004, 2011; Trzebin ´ ski & Zie ba, 2013). If an individual preserves low levels of psychiatric symptoms together with high PTG and Allostatic Overload 117 levels of psychological well-being (Shrira et al., 2011), his or her cognitive capacity to find growth is probably facilitated. Even though research suggests that PTG strongly refers to dimensions of psychological well-being (Durkin & Joseph, 2009; Joseph & Linley, 2008), it is not still clear if PTG occurs as a consequence of stressful events or as a result of a natural process of psychological maturation (Linley, 2003; Sumalla et al., 2009). In both cases, our findings suggest that it may be facilitated if individuals perceive stressors as tolerable and not exceeding their resources.This study is limited by the small self-selected sample, the heterogeneity of women’s clinical conditions, the types of stressful events, and the diverse time intervals since the traumatic event (1–15 years). Further, it lacks assessment of biological and metabolic data connected with stress responses (McEwen & Stellar, 1993). Moreover, the cross-sectional design of our study does not allow us to draw any conclusion about the potential reverse causality between PTG and AO, which should be addressed with future longitudinal investigations. Nonetheless, for the first time to our knowledge, posttraumatic growth has been examined in relation to both major life stressors and chronic stressors (allostatic overload). Our findings suggest that a reliable evaluation of allostatic overload may help to identify those conditions that, by exceeding individual resources, may constitute an obstacle to finding growth when facing life adversities.

Considering the positive consequences of PTG in terms of mental and physical health (Helgeson et al., 2006; Joseph & Linley, 2006; Lelorain, Bonnaud-Antignac, & Florin, 2010; Tomich & Helgeson, 2012), assessment of AO may also help target psychological treatments for severely stressed individuals or for patients with cancer or other life-threatening illnesses (Dolbier, Smith Jaggars, & Steinhardt, 2010). The important role of psycho- therapies in breast cancer survivors has been recently further supported as a buffer against distress. Hsiao et al. (2012) found that a short form of group therapy contributed to enhancing an active search for meaning in life and to maintaining stable cortisol responses to everyday life stress for breast cancer survivors. Further longitudinal research with larger samples is needed to shed new insights into the relationships between chronic stress, well-being, PTG, and their response to treatment (Ruini & Fava, 2013). REFERENCES Affleck, G., & Tennen, H. (1996). Construing benefits from adversity: Adaptational significance and dispositional underpinnings. Journal of Personality,64 , 899–922.

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Zoellner, T., & Maercker, A. (2006). Posttraumatic growth in clinical psychology —A critical review and introduction of a two component model. Clinical Psychology Review ,5, 626–653. PTG and Allostatic Overload 121 Chiara Ruiniis an assistant professor of clinical psychology at the University of Bologna. Her research interests include positive psychology, positive interventions, and their applications in clinical settings.

Emanuela Offidani is a postdoctoral fellow in the Department of Psychology at the University of Bologna. Her research interests include biological correlates of stress, psychoneuroimmunology, and psychosomatic medicine.

Francesca Vescovelli is completing an internship at the Health Psychology- Psychotherapy School, Department of Psychology, University of Bologna. Her research interests include health psychology, positive psychology, and psycho-oncology.

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