Psychology & Health

ISSN: 0887-0446 (Print) 1476-8321 (Online) Journal homepage: http://www.tandfonline.com/loi/gpsh20

Changes in positive affect and mindfulness predict

changes in cortisol response and psychiatric
symptoms: A latent change score modelling
approach

Wai Kai Hou, Sin Man Ng & Jacky Ho Yin Wan

To cite this article: Wai Kai Hou, Sin Man Ng & Jacky Ho Yin Wan (2015) Changes in positive
affect and mindfulness predict changes in cortisol response and psychiatric symptoms:
A latent change score modelling approach, Psychology & Health, 30:5, 551-567, DOI:
10.1080/08870446.2014.990389

To link to this article: http://dx.doi.org/10.1080/08870446.2014.990389

Accepted online: 21 Nov 2014.Published

online: 20 Dec 2014.

Submit your article to this journal

Article views: 198

View related articles

View Crossmark data

Citing articles: 1 View citing articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=gpsh20

Download by: [University of Nebraska, Lincoln] Date: 18 October 2015, At: 19:18
 Psychology & Health, 2015
Vol. 30, No. 5, 551–567, http://dx.doi.org/10.1080/08870446.2014.990389

Changes in positive affect and mindfulness predict changes in

cortisol response and psychiatric symptoms: A latent change score
modelling approach
Wai Kai Houa,b,c*, Sin Man Nga,b and Jacky Ho Yin Wand
a
Department of Psychological Studies, The Hong Kong Institute of Education, Hong Kong;
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

b
Laboratory of Psychobiology of Emotion and Stress (LoPES), The Hong Kong Institute of
Education, Hong Kong; cCentre for Psychosocial Health, The Hong Kong Institute of Education,
Hong Kong; dDepartment of Clinical Psychology, Queen Mary Hospital, Hong Kong
(Received 31 July 2014; accepted 18 November 2014)

Objective: This study examined whether and how changes in positive affect
and mindfulness predicted changes in cortisol secretion and psychological
distress in adaptation to examination stress.
Design: A sample of 105 college students completed a questionnaire set and
provided salivary samples before (T1), during (T2) and after (T3) an
examination period.
Results: Latent change score modelling revealed that T1–T2 and T2–T3
increases in mindfulness were associated with larger T2–T3 decrease in
area-under-the-curve ground of cortisol awakening response (CARg), whereas
T2–T3 increases in both positive affect and mindfulness were associated with
larger T2–T3 decrease in anxiety symptoms (comparative fit index = .96;
Tucker-Lewis index = .93–.95; root-mean-square error of approxima-
tion = .04–.08; standardised root-mean-square residual = .08–.10). T1–T2 and
T2–T3 increases in positive affect were not associated T2–T3 decrease in
CARg, whereas T1–T2 increases in positive affect and mindfulness were not
associated with T2–T3 decrease in anxiety symptoms.
Conclusion: The levels of post-stress recovery from anxiety symptoms could
depend on concurrent increases in positive affect and mindfulness, whereas
the levels of post-stress decline in cortisol secretion could depend on increases
in mindfulness both during and after stress. Directions for translating the
present findings into stress management programmes in college settings are
discussed.
Keywords: positive affect; mindfulness; salivary cortisol; psychiatric
symptoms; latent change score modelling

Adaptation as change processes

The conservation of resources (COR) theory argues that resource change is the central
mechanism driving adaptation (Hobfoll, 1998). Internal or psychological resources
include entities that are possessed by the self and can be mobilised on one’s own, such
as attitudes, self-perceptions, personalities and emotion processes (Diener, Oishi, &

*Corresponding author. Email: wkhou@ied.edu.hk

© 2014 Taylor & Francis

 552 W.K. Hou et al.

Lucas, 2003). External or social resources include entities that are not possessed by the
self but embedded within the physical environment or interactions with other people,
such as money, employment, emotional or practical support, social contacts and intimate
relationships (House, Landis, & Umberson, 1988). According to the COR theory, stress-
ful life events have the power of depleting people’s psychological and social resources
as well as psychological well-being; meanwhile people offset the ongoing situational
demands by mobilising these resources (Hobfoll, 1998). Prevention of the depletion of
resources and secondarily maintenance or gain of existing resources are thus the keys to
maintaining healthy functioning in adaptation to stress (Hobfoll, 1998; Hobfoll et al.,
2009). Other theoretical frameworks and empirical studies have asserted that faster
recovery from stress responses indicates successful adaptation and stress resilience
(Block & Block, 1980; Kashdan & Rottenberg, 2010; McEwen, 1998; Zautra, Hall, &
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Murray, 2010). Stress responses could be manifested into physiological reactions,

among which the hypothalamic–pituitary–adrenocortical (HPA) axis constitutes a major
part of the neuroendocrine system that regulates reactions to stress. The HPA can be op-
erationalised into secretion of glucocorticoid cortisol, which is an essential hormonal
response that mobilises energy production for coping with stress. Psychological stress is
also accompanied by negative emotions and associated behaviours, such as anxiety,
depression, anger or hostility (Kashdan & Rottenberg, 2010).
No studies to date have extended the COR theory to explain post-stress recovery
from psychological responses, not to mention recovery from physiological responses. If
changes in psychosocial resources predict adaptation outcomes and faster recovery from
stress responses indicates more adaptive functioning, then changes in psychosocial
resources could be associated with recovery from stress responses. Because psychoso-
cial resources represent a wide array of cognitions, individual differences and emotions,
a thorough examination of all possible traits deemed useful for coping is impractical.
This study aimed to investigate the associations between changes in positive affect and
mindfulness and changes in physiological and psychological stress responses during
and after stress.

Positive affect
Fredrickson’s (2001) broaden-and-build theory suggests that positive affect has the
power of undoing negative physical and psychological sequelae of stressful situations.
The current evidence suggests that positive affect could be conceptualised as a psycho-
logical resource modulating the impact of stress on both physiological and psychologi-
cal functioning. Laboratory studies of college students have demonstrated that positive
affect promoted faster recovery from cardiovascular reactions after the induction of
negative affect (Fredrickson & Levenson, 1998; Fredrickson, Mancuso, Branigan, &
Tugade, 2000). Among people with chronic pain, positive affect predicted lower levels
of negative affect both directly and indirectly by reducing the impact of elevated pain
intensity (Zautra, Johnson, & Davis, 2005). In addition, positive affect prospectively
predicted averaged cortisol secretion of employed parents with preschool child (ren)
(Hoppmann & Klumb, 2006) and middle-age working adults at three-year follow-up
(Steptoe, Wardle, & Marmot, 2005). Change in positive affect per se has also been
demonstrated to predict physiological and psychological functioning. A sample of
community adults self-administered a questionnaire and gave salivary samples six times
 Psychology & Health 553

daily on two consecutive weekdays (Smyth et al., 1998). Diurnal increase in positive
affect was associated with lower averaged cortisol secretion. Increase in maternal posi-
tive affect during pregnancy predicted longer gestation and lower risk of preterm deliv-
ery, independent of demographic characteristics, antenatal perceived stress and obstetric
risk factors (Voellmin, Entringer, Moog, Wadhwa, & Buss, 2013). More specifically, the
positive association between physical symptom distress and subsequent depressive
symptoms has been found to be stronger in the context of a loss in positive affect and
weaker in the context of a gain or maintenance in positive affect among people newly
diagnosed with cancer (Hou, Law, & Fu, 2010). What is less known is whether and
how changes in positive affect are associated with recovery from stress responses.
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Mindfulness
Mindfulness denotes a state of focus on the present moment with non-judgemental
awareness and receptiveness of mental processes and environments (Kabat-Zinn, 1994).
Dispositional mindfulness was consistently found to be associated with higher self-rated
physical health such as vitality and sleep quality (Murphy, Mermelstein, Edwards, &
Gidycz, 2012) and lower psychological distress (Brown & Ryan, 2003; Cash &
Whittingham, 2010). The stress-buffering effect of dispositional mindfulness on psychi-
atric symptoms has also been demonstrated among population-based samples of adults
(Weinstein, Brown, & Ryan, 2009). Randomised control trial has shown that mindful-
ness training was more effective than relaxation training in reducing cortisol secretion
(Tang et al., 2007). People with cancer demonstrated lower cortisol secretion and nor-
malised immune function after completing mindfulness-based stress reduction (MBSR)
training (Carlson, Speca, Faris, & Patel, 2007). A growing body of studies further
reported the effectiveness of MBSR in alleviating symptoms of anxiety and depression
(Chiesa & Serretti, 2011). In addition, increase in trait mindfulness after completing a
MBSR programme predicted higher physical functioning and lower psychological dis-
tress (Carmody, Reed, Kristeller, & Merriam, 2008).
Mindfulness has also been conceptualised to vary in accordance with situational
demands (Bishop et al., 2004), but relatively little is known about the impact of natural
changes in mindfulness on physical and psychological functioning in stress processes.
Apart from the intervention studies reviewed above, one recent study used ecological
momentary assessment method and found that regular remainders on mindfulness in
daily life predicted higher levels of calmness, suggesting that variations in state mind-
fulness could be associated with psychological functioning (Huffziger et al., 2013). In
addition, some empirical and theoretical literature proposes that associated processes of
mindfulness including non-reactivity and acceptance could interact with positive affect
and adaptive affect labelling and awareness, and then positive affect and mindfulness
together contribute to lower levels of psychiatric symptoms (Davidson et al., 2003;
Jimenez, Niles, & Park, 2010). Empirical investigation is needed on the dynamic impact
of state positive affect and mindfulness and their interactions on changes in stress-
related physiological and psychological responses over time.

The present study

This study aimed to examine the associations between changes in positive affect and
mindfulness and changes in physiological and psychological functioning in adaptation
 554 W.K. Hou et al.

to stress. This study assessed a sample of college students before (T1), during (T2) and
after (T3) an examination period. College students were studied due to two reasons.
First, despite the fact that entering college can be an exciting and fulfilling experience,
adjustment to the new academic environment and performance pressure has been clo-
sely related to psychological distress. Prevalence of anxiety and depression could be
common among 47% and 27–31% of college students, respectively (Bayram & Bilgel,
2008; Ibrahim, Kelly, Adams, & Glazebrook, 2013). Meanwhile, mounting evidence
suggested that middle adulthood is characterised by a wider range of stressful events,
the widest responsibility in the labour force, family and community, and declining phys-
ical and psychological well-being, relative to young adulthood (Blanchflower &
Oswald, 2008). These pressures make the college years’ good timing for identifying
young adults at increasing risk of poorer adjustment and enhancing their psychological
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

resilience for meeting challenges at the moment and later in the lifespan. Second, aca-
demic examination offers a real-life, naturalistic context for understanding psychological
vulnerability and resilience among young adults (Stowell, 2003). Different from the pro-
longed academic stress during extended study or examination periods, examination
stress is experienced before, during and/or after discrete examinations (Bosch, de Geus,
Ring, & Nieuw Amerongen, 2004). College students have been found to demonstrate
significantly higher cortisol secretion and perceived stress during examination period
relative to non-examination period, among which women showed higher cortisol awak-
ening response (CAR) (Weekes et al., 2006, 2008).
Latent change score (LCS) modelling (Ferrer & McArdle, 2010; McArdle, 2009)
was used to analyse whether increases/decreases in positive affect and mindfulness dur-
ing and after examination predicted the rate of recovery from physiological stress
responses, i.e. cortisol secretion and psychological responses, i.e. anxiety and depressive
symptoms, after examination. Based on the COR theory and the proposed interactions
between positive affect and mindfulness, we hypothesised the following:

Hypothesis 1: T1–T2 and T2–T3 changes in state positive affect are inversely associated
with T2–T3 changes in cortisol secretion and psychiatric symptoms. Precisely, decreases in
positive affect during and after examination are associated with lower levels of decreases
in cortisol secretion and psychiatric symptoms after examination, whereas increases/mainte-
nance of positive affect are associated with higher levels of decreases in the two outcomes.

Hypothesis 2: T1–T2 and T2–T3 changes in state mindfulness are inversely associated with
T2–T3 changes in cortisol secretion and psychiatric symptoms. Precisely, decreases in
mindfulness during and after examination are associated with lower levels of decreases in
cortisol secretion and psychiatric symptoms after examination, whereas increases/mainte-
nance of mindfulness are associated with higher levels of decreases in the two outcomes.

Hypothesis 3: Changes in positive affect and changes in state mindfulness positively inter-
act with each other and the interaction effects are associated with T2–T3 changes in corti-
sol secretion and psychiatric symptoms.

Method
Procedure
Upon obtaining the Ethics Committees’ approvals, recruitment notices were distributed
in The Hong Kong Institute of Education and The University of Hong Kong at the
 Psychology & Health 555

beginning of the first semester, 2011–2012. Inclusion criteria were 18 years of age or
older, Chinese ethnicity and Cantonese fluency. Based on participants’ self-report, fac-
tors that could impact cortisol secretion including tobacco smoking, active antihista-
mine, glucocorticoid or asthma medication, exposure to general anesthesia in the past
year and active endocrine abnormalities (e.g. due to obesity, Björntorp, 1995) and
hyper/hypocortisolism were used as exclusion criteria (Weekes et al., 2008). In addition,
students with personal or first-degree family history of DSM-IV Axis I psychiatric disor-
der(s) were not recruited because of our focus on otherwise healthy young adults. A
total of 105 students gave their written informed consent after being fully apprised of
the study. Participants were instructed to self-administer a questionnaire set and collect
salivary samples at three time points: at least one month prior to an examination period
(T1), two weeks after the start of the examination period (T2) and 15–30 days after the
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

last examination session (T3). The timing of T2 assessment was determined by referring
to the course enrolment record of each participant, whereas the timing of T3 assessment
allowed cortisol secretion to reside to normal levels after examination (Stowell, 2003).
Participants received a HK$50 supermarket coupon upon completion of an assessment.

Measures
Background variables
A standardised proforma assessed demographic information including age, sex, years of
education and average monthly household income.

Positive affect
The 10-item subscale of Chinese Affect Scale (CAS-PA) (Hamid & Cheng, 1996)
assessed frequency of positive affect. The CAS-PA is linguistically and structurally
equivalent to the Positive and Negative Affect Schedule (PANAS; Watson, Clark, &
Tellegen, 1988). Participants rated the frequency of 10 positive affective states in the
previous two weeks on a five-point scale (0 = not at all, 4 = all the time). A summation
score was used (range = 0–40). Reliability of the CAS-PA has been demonstrated in
Chinese young and middle-age adults, with Cronbach’s Alphas above .85 (Hamid &
Cheng, 1996). Positive correlations with extraversion and optimism and negative corre-
lations with psychological distress demonstrated its validity (Hamid & Cheng, 1996).
Alphas for the PA were .89, .90 and .90, respectively, for the three administrations.

Mindfulness
A Chinese version of the 15-item mindfulness attention awareness scale (MAAS;
Brown & Ryan, 2003; Lau & Hue, 2011) was used. Participants rated each item on a
six-point scale (1 = almost always, 6 = almost never) by referring to their experience in
the previous two weeks. Higher scores indicated higher levels of mindfulness
(range = 15–90). The MAAS has been demonstrated to be reliable across different pop-
ulations including Chinese (α > .70); significant correlations with self-reported emo-
tional distress, physical symptoms and self-awareness reflected its construct and clinical
validity (Brown & Ryan, 2003; Lau & Hue, 2011). In the current three administrations,
alphas were .76, .84 and .86, respectively.
 556 W.K. Hou et al.

Cortisol secretion
Salivary cortisol samples were collected using Salivettes (Sarstedt, Nümbrecht,
Germany), a device containing a small cotton swab to be placed in the mouth for 45 s.
Participants were instructed to collect seven salivary samples on a day at T2 and T3
(awakening, 30, 45 and 60 min, and 4, 9 and 14 h after waking). The number of samples
ensured reliable measures of cortisol secretion (Chida & Steptoe, 2009; Rohleder & Nater,
2009). Participants were also instructed not to eat or brush their teeth in the hour before
collecting each sample. All participants received telephone reminders for collecting the 4,
9 and 14 h samples. The actual sampling times, the time participants went to bed in the
previous night and the time of awakening were recorded to ensure data quality and com-
pliance with the instructions. Samples were stored at −20 °C before being delivered in
batches to Multigene Diagnostics Hong Kong Limited for analysis. Cortisol secretion
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

(nmol/L) was determined using a commercially available immunoassay with chemilumi-

nescent detection (IBL, Hamburg/Germany) implemented by an ELISA kit (Diagnostic
System Laboratories, Webster, TX, USA). The whole day cortisol samples (seven in total)
were calculated into area-under-the-curve ground (AUCg) to reflect total hormonal output
of the HPA axis and area-under-the-curve increase (AUCi) to reflect reactivity of the HPA
axis (Pruessner, Kirschbaum, Meinlschmid, & Hellhammer, 2003). The four samples in
the hour post awakening (CAR) were also calculated separately into AUCg and AUCi.
The AUCg and AUCi of CAR were thereafter referred to as CARg and CARi. In sum-
mary, the following indices were generated: AUCg, AUCi, CARg and CARi. Non-signifi-
cant associations were identified between the indices and the actual sampling times, the
time participants go to bed in the previous night and the time of awakening.

Psychiatric symptoms
The Chinese version of the 20-item State-Trait Anxiety Inventory (STAI; Shek, 1988)
assessed anxiety symptoms in the past two weeks on a four-point scale (1 = almost
never, 4 = almost always). Higher scores indicated higher anxiety (range = 20–80). The
Chinese STAI was found to be reliable in the previous study (α = .90; Shek, 1988). The
alphas for the T2 and T3 administrations were .91 and .90, respectively. The Chinese
version of the 21-item Beck Depression Inventory-II (BDI-II; Byrne, Stewart, & Lee,
2004) was used to assess depressive symptoms in the past two weeks on a four-point
scale (e.g. 0 = I do not feel sad, 1 = I feel sad, 2 = I am sad all the time and 3 = I am
so sad or unhappy that I can’t stand it) (range = 0–63). The Chinese BDI-II has demon-
strated high internal consistency (α > .91) among Chinese people (Byrne et al., 2004).
Alphas for the current two administrations were .89 and .91, respectively.

Perceived stress
To control for the effects of non-examination stressors on the outcome variables, the
Chinese version of the 14-item perceived stress scale (PSS; Leung, Lam, & Chan,
2010) was administered at T2 and T3. Participants reported their subjective stress in the
past two weeks on a five-point scale (0 = never, 4 = always). Higher scores indicated
higher perceived stress (range = 0–56). The scale was found to be reliable (α = .85) and
valid among Chinese adults (Leung et al., 2010). The alpha for the Chinese PSS at T2
and T3 were .83 and .76, respectively.
 Psychology & Health 557

Analytic plan
Correlations were used to identify demographic confounding variables. Logarithmic
transformation was applied to reduce skewness of the AUCg, CARg, AUCi and CARi
data (Alink, Cicchetti, Kim, & Rogosch, 2012). A LCS model was conducted for each
of the six outcomes, i.e. T2–T3 changes in the scores/data on STAI, BDI-II, AUCg,
AUCi, CARg and CARi as latent variables, with estimates of T1–T2 and T2–T3
changes in the scores on CAS-PA and MAAS. Using LCS modelling, measurement
issues pertinent to nonlinear distribution of measured scores and reliability of direct cal-
culation of change scores were minimised (King et al., 2006). To address Hypothesis 1
and Hypothesis 2, we modelled simultaneously the associations of T1–T2 and T2–T3
changes in CAS-PA and MAAS scores with T2–T3 change in an outcome. To address
Hypothesis 3, the indicators of the latent variables on changes in CAS-PA and MAAS
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

scores were centred and the products of these centred indicators were tested as latent
interaction terms predicting the outcomes in the models (Marsh, Wen, & Hau, 2004).
To control for the effect of T2 and T3 PSS scores on the outcome variables, the scores
were modelled as an exogenous variable to the outcome variable at respective time
points in all models. Based on modification indices (MI) and expected parameter
change statistics (EPC), correlations between error covariances were added to the mod-
els (Fan, Thompson, & Wang, 1999). To maximise model fit and obtain parsimonious,
theoretically justifiable models, non-significant paths were dropped according to the
results of chi-square difference tests between the models (Kline, 2011; Little, 2013).
The comparative fit index (CFI), Tucker-Lewis index (TLI), root-mean-square error of
approximation (RMSEA) and standardised root-mean-square residual (SRMR) were
used to evaluate data-model fit (Fan et al., 1999). A model was accepted if fit indi-
ces > .90, RMSEA < .08 and SRMR < .08 (Browne & Cudeck, 1993). All models were
constructed using Mplus 6.1 (Muthén & Muthén, 2010).

Results
The participants ranged in age between 19 and 24 years (M = 21.00, SD = 1.16); 58
(55%) were females. Eighteen participants (17%) have received 14 years of education, 56
(53%) have received 15 years, 21 (20%) have received 16 years and 10 (10%) have
received 17 years. Eight participants (8%) reported a monthly household income <HK
$10,000, 34 (32%) reported $10,001–$20,000, 25 (24%) reported $20,001–$30,000, 13
(12%) reported $30,001–$40,000 and 25 (24%) reported >$40,000 (US$1 ≈ HK$7.80).
The examination period of the participants lasted for 16–30 days and there were on aver-
age five examinations within the period. The time lapses between T1 and T2 and between
T2 and T3 were 45–55 days and 22–45 days, respectively. Adherence to the instructed
timings of the cortisol collection was assessed by asking the participants verbally and
examining the time indicated on the Salivettes. All participants reported having adhered
to the instruction and indicated the same timings as the instructed ones on the Salivettes.
Chi-square tests did not reveal significant differences in demographic characteristics
and the study variables between respondents and dropouts (T2: n = 17; T3: n = 26).
Multiple imputation was used in order to maximise unbiased parameter estimates and
standard errors in the small sample size and consider auxiliary variables in the models
when handling missing data (Collins, Schafer, & Kam, 2001; Graham, 2009; Graham &
 558 W.K. Hou et al.

Schafer, 1999). Each missing value became a set of plausible values that represent the
uncertainty about the right value to impute (Rubin, 2004). Trends of time were included
as an additional condition and allowed to vary across participants to ensure maximal
heterogeneity of the imputed data. Descriptive statistics of the study variables are sum-
marised in Table 1. Based on the MI and EPC, error covariances were added and non-
significant paths between changes in CAS-PA scores and changes in MAAS scores
were removed. Years of education were included in the model as an exogenous variable
because of their correlations with T3 AUCg (r = −.20, p = .04). The fit indices of all
tested models are summarised in Table 2. The models with T2–T3 change in CARg/
STAI scores as the outcome demonstrated data-model fit: χ2 (17–23) = 27.70–28.61,
p = .04–.23; CFI = .96; TLI = .93–.95; RMSEA = .04–.08; SRMR = .08–.10, and signif-
icant paths between the predictors and the outcome. The p value of chi-square was sig-
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

nificant in the model with STAI. However, several factors such as correlation strength
and sampling randomness could affect chi-square in addition to sample size (Kline,
2011). Also, the hypothesis of zero deviation from the data in chi-square goodness-of-
fit test could be a high restriction that has little direct value on SEM (Steiger, 2007).
Therefore, model fit indices other than chi-square were used to evaluate the models.
T2–T3 change in CARg was inversely associated with T1–T2 change (β = −.26,
p = .04) and T2–T3 change (β = −.32, p = .03) in MAAS scores, but not with T1–T2
and T2–T3 changes in CAS-PA scores (β = .003, p = .98; β = −.01, p = .94) (Figure 1).
Estimated means of the LCS demonstrated significant T1–T2 and T2–T3 increases in
MAAS scores (T1–T2: M = .79, p <.001; T2–T3: M = 16.74, p < .001), and significant
T2–T3 decrease in CARg (M = −.18; p < .001). T2–T3 change in STAI scores was
inversely associated with T2–T3 changes in CAS-PA scores (β = −.37, p < .001) and
MAAS scores (β = −.40, p = .01), but not with T1–T2 changes in CAS-PA scores
(β = −.05, p = .44) and MAAS scores (β = −.11, p = .24) (Figure 2). Estimated means of
the change scores indicated significant T2–T3 increases in CAS-PA scores (M = 19.18,

Table 1. Means and standard deviations of the study variables (N = 105).

T1 T2 T3
Range M SD M SD M SD
CAS-PA 0–40 22.54 5.80 20.06 5.33 23.13 5.26
MAAS 15–90 57.36 7.50 58.15 7.92 58.39 8.18
AUCg (nmol/L) – – – 2741.38 1127.46 3133.82 1557.67
AUCi (nmol/L) – – – −2739.57 4083.46 −1469.64 2587.27
CARg (nmol/L) – – – 448.88 250.56 415.12 255.74
CARi (nmol/L) – – – 27.27 224.03 61.01 192.47
STAI 20–80 – – 53.58 9.09 47.47 8.29
BDI-II 0–63 – – 11.29 7.17 8.33 6.98
PSS 0–56 – – 30.54 5.83 28.63 4.72
Note: T1 = Time 1; T2 = Time 2; T3 = Time 3; CAS-PA = Positive Affect subscale of the Chinese Affect
Scale; MAAS = Mindfulness Attention Awareness Scale; AUCg = Area under the curve with respect to ground
of cortisol; AUCi = Area under the curve with respect to increase of cortisol; CARg = Area under the curve
with respect to ground of cortisol awakening response; CARi = Area under the curve with respect to increase
of cortisol awakening response; nmol/L = nanomole per litre; STAI = State version of State-Trait Anxiety
Inventory; BDI-II = Beck Depression Inventory-II; and PSS = Perceived Stress Scale.
 Psychology & Health 559

Table 2. Fit indices for the tested models.

T2–T3 change χ2 (df) p CFI TLI RMSEA SRMR

a
AUCg 37.27(30) .17 .95 .94 .05 .08
AUCi 34.65(22) .04 .88 .84 .07 .09
CARg 27.70(23) .23 .96 .95 .04 .08
CARia 33.84(22) .05 .89 .85 .07 .09
STAI 28.61(17) .04 .96 .93 .08 .10
BDI-II 67.41(30) <.001 .79 .75 .11 .12
Notes: T2–T3 change = change between Time 2 and Time 3. χ2 (df) = Chi-square value (degree of freedom);
CFI = Comparative Fit Index; TLI = Tucker-Lewis Index; RMSEA = root-mean-square error of approximation;
SRMR = standardised root-mean-square residual; AUCg = Area under the curve with respect to ground of cor-
tisol; AUCi = Area under the curve with respect to increase of cortisol; CARg = Area under the curve with
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

respect to ground of cortisol awakening response; CARi = Area under the curve with respect to increase of
cortisol awakening response; STAI = State version of State-Trait Anxiety Inventory; and BDI-II = Beck
Depression Inventory-II.
a
No significant paths between the predictors and the outcome.

Figure 1. Standardised estimates of the LCS model with positive affect, mindfulness and
area-under-the-curve of cortisol with respects to ground of cortisol awakening response.
Notes: T1–T2 = change between Time 1 and Time 2; T2–T3 = change between Time 2 and Time
3. To enhance the readability of the figures, only the study variables are shown. The full figures
with standardised regression coefficients between the study variables and covariates and the error
covariances are available from the corresponding author. *p < .05; **p < .01; ***p < .001.

p < .001) and MAAS scores (M = 18.17, p < .001), and non-significant T2–T3 decrease
in STAI scores (M = −41.08, p = .09). All latent interaction terms of changes in
CAS-PA and changes in MAAS scores were not significantly associated with the out-
come in both models.
 560 W.K. Hou et al.
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Figure 2. Standardised estimates of the LCS model with positive affect, mindfulness and anxiety
symptoms.
Notes: T1–T2 = change between Time 1 and Time 2; T2–T3 = change between Time 2 and Time
3. To enhance the readability of the figures, only the study variables are shown. The full figures
with standardised regression coefficients between the study variables and covariates and the error
covariances are available from the corresponding author. *p < .05; **p < .01; ***p < .001.

Discussion
The present findings partially supported the study hypotheses. Controlling for the effects
of years of education and perceived stress at T2 and T3, LCS modelling revealed that
T1–T2 and T2–T3 increases in mindfulness were inversely associated with T2–T3 slope
of the total hormonal output/basal activity of CARg, such that the larger the increases
in mindfulness during and after examination, the larger the decrease in CARg after
examination. T2–T3 increases in positive affect and mindfulness were inversely associ-
ated with T2–T3 slope of anxiety symptoms, such that the larger the increases in posi-
tive affect and mindfulness after examination, the larger the decrease in anxiety
symptoms after examination. Contrary to the proposed link between positive affect and
mindfulness (Davidson et al., 2003; Jimenez et al., 2010), no significant associations
were identified between change in positive affect and change in mindfulness in our
models, suggesting positive affect and mindfulness might be independent of psychologi-
cal resources that facilitate faster recovery from physiological and/or psychological
stress responses (Shapiro, Brown, & Biegel, 2007).
This study contributed to the current theoretical literature by taking into account the
timing of changes in positive affect and mindfulness in evaluating recovery from stress-
related cortisol secretion and psychiatric symptoms. The association between psychoso-
cial resources and psychological outcomes in stress adaptation is well established.
Numerous studies have shown the negative impact of resource loss on psychological
functioning in stress adaptation (Hobfoll, 2011). Reciprocal facilitation between
resource loss and psychological distress, also known as loss spirals, has also been
 Psychology & Health 561

documented among individuals facing traumatic stress (Heath, Hall, Russ, Canetti, &
Hobfoll, 2012). A growing body of studies further identified gain spirals between effi-
cacy beliefs and positive affect and work engagement in adaptation to job-related
demands (Salanova, Llorens, & Schaufeli, 2011). Existing findings suggested that
resource gain/loss occurs in the midst of stressful encounters and contributes to adaptive
psychological outcomes during the encounters. Our LCS modelling results showed that
recovery from physiological stress response, namely HPA activation, was associated
with T1–T2 and T2–T3 changes in mindfulness but not positive affect. Also, recovery
from psychological stress response (i.e. psychiatric symptoms) might depend on the
timing of resource change, as our findings revealed that the effects of changes in posi-
tive affect and mindfulness were only apparent between T2 and T3. Taken together, the
effects of changes in positive affect were only apparent at T2–T3, while the effects of
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

changes in mindfulness were apparent at T1–T2 as well as T2–T3.

Regarding positive affect, we found that T2–T3 increase in positive affect was asso-
ciated with larger T2–T3 decrease in anxiety symptoms, consistent with existing evi-
dence on the impact of change in positive affect as a coping resource in stress (Hou
et al., 2010; Voellmin et al., 2013). However, we did not identify significant association
of T1–T2 increase in positive affect with T2–T3 recovery from cortisol secretion or
anxiety symptoms. Less-adaptive coping strategies such as avoidance and behavioural
disengagement (i.e. inaction towards the demand) have been found to be common strat-
egies to cope with stress among college students (Ben-Zur, 2009). Giving the positive
associations of these strategies with momentary positive affect and psychological dis-
tress (Dyson & Renk, 2006), the predictive utility of T1–T2 increase in positive affect
could have been diluted.
This study extended the current understanding on the physiological health benefit of
mindfulness in coping among college students. It is well documented that mindfulness
as a trait or a regular practice contributed to lower cortisol secretion and cardiac reactiv-
ity and higher self-rated physiological functioning among both clinical and non-clinical
populations (Carlson et al., 2007; Murphy et al., 2012; Tang et al., 2007). Currently, lit-
tle is known about the extent to which everyday mindfulness confers better health out-
comes in stress adaptation. This study specified the inverse association between
increase in state mindfulness and decrease in CARg in a real-life stressor. CARg indi-
cates preparedness of our physiological system to cope with stress (Clow, Hucklebridge,
Stalder, Evans, & Thorn, 2010). Higher CARg benefits mobilisation of resources and
coping efforts during stress but not in non-stress conditions. Our findings suggested that
mindfulness changes during stress, and enhancement of mindfulness during coping and
recovery could predict flexible downregulation of HPA activation during recovery. If
this is the case, then timely enhancement of mindfulness could represent an adaptive
coping strategy that predicts faster recovery from HPA activation after stress.
Our study also demonstrated the time-specific impact of state mindfulness on psy-
chological functioning in adaptation. Trait mindfulness has been associated with lower
depressive symptoms and social anxiety and higher satisfaction with life (Brown &
Ryan, 2003; Rasmussen & Pidgeon, 2011). Mindfulness in this study referred to a natu-
ral mindful state but not coping strategy in coping with examination stress. Higher
mindfulness could indicate heightened attention towards examination, resembling a
monitoring coping style (i.e. monitoring vs. blunting; Miller, 1987). Monitoring benefits
coping with demands are perceived as more controllable (Miller, 1987). The inverse
 562 W.K. Hou et al.

association between increase in mindfulness and decrease in anxiety symptoms after

examination could be because of higher perceived controllability of the examination
among the present sample.

Limitations
A number of limitations warrant cautions. First, the present findings were based on data
collected from a small convenient sample of Chinese college students. Generalisability
of the findings to other college populations with different background characteristics
was limited. Second, due to voluntariness of participation, the data could be collected
solely from students who were interested in the study and willing/able to respond at all
time points. The sampling method and sample attrition could reduce the chance of mak-
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

ing unbiased and correct inferences on the present findings. Third, the sample size was
small and could result in unstable models. Currently, there are different suggested ratios
of sample size and free parameters (e.g. as low as 5:1, Bentler & Chou, 1987) and min-
imum sample sizes for SEM (ranging from 100 to 200; Ding, Velicer, & Harlow,
1995). Future studies could investigate whether the present findings are replicable
among larger samples. Fourth, salivary samples were collected only on a single day,
respectively, at T2 and T3. Also, due to resource limitation, we did not assess cortisol
at T1; therefore, we could not control for baseline levels of cortisol in the models, limit-
ing interpretability of the findings. Future prospective studies could collect samples on
multiple days at all time points to ensure data quality and reliability and include base-
line cortisol levels in statistical analyses.

Conclusion
Notwithstanding these limitations, this study reported one of the first empirical investi-
gations on the timing of the association between changes in psychological resources
and changes in psychobiological outcomes in a stress process. Results of the LCS mod-
elling contributed to the theoretical literature on the dynamics of psychological
resources with cortisol response and psychiatric symptoms as adaptation outcomes.
Future studies could explore the associations of changes in specific aspects of positive
affect and mindfulness with changes in physiological and psychological stress
responses. For example, higher positive emotional style, i.e. aggregated scores on daily
positive affect reported over a week (Bostock, Hamer, Wawrzyniak, Mitchell, &
Steptoe, 2011) and mindfulness-related self-compassion, i.e. mindful acceptance of
one’s present moment experience coupled with the desire for oneself to be happy and
free from suffering (Neff & Dahm, in press) have been associated with reduced levels
of cortisol secretion and psychological distress. In addition, our findings informed
design and implementation of well-being and resilience interventions among college
students. Well-being intervention integrated with mindfulness training could be offered
to students at increasing risk of maladjustment after coping with academic or career-
related demands. The comprehensive intervention could be composed of sessions that
foster positive evaluation on one’s self and significant others for enhancing positive
affect (Fava & Tomba, 2009) and meditation practice that up-regulates everyday
mindfulness (Murphy et al., 2012).
 Psychology & Health 563

Acknowledgement
The authors wish to thank Prof Stevan E. Hobfoll, Chair and Professor, Department of Behavioral
Sciences, Rush University Medical Center, for his valuable feedback regarding this article.

References

Alink, L. R., Cicchetti, D., Kim, J., & Rogosch, F. A. (2012). Longitudinal associations among
child maltreatment, social functioning, and cortisol regulation. Developmental Psychology, 48,
224–236. doi:10.1037/a0024892
Bayram, N., & Bilgel, N. (2008). The prevalence and socio-demographic correlations of
depression, anxiety and stress among a group of university students. Social Psychiatry and
Psychiatric Epidemiology, 43, 667–672. doi:10.1007/s00127-008-0345-x
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Bentler, P. M., & Chou, C. P. (1987). Practical issues in structural modeling. Sociological
Methods and Research, 16, 78–117. doi:10.1177/0049124187016001004
Ben-Zur, H. (2009). Coping styles and affect. International Journal of Stress Management, 16,
87–101. doi:10.1037/a0015731
Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., … Devins, G.
(2004). Mindfulness: A proposed operational definition. Clinical Psychology: Science and
Practice, 11, 230–241. doi:10.1093/clipsy.bph077
Björntorp, P. (1995). Endocrine abnormalities of obesity. Metabolism: Clinical and Experimental,
44, 21–23. doi:10.1016/0026-0495(95)90315-1
Blanchflower, D. G., & Oswald, A. J. (2008). Is well-being U-shaped over the life cycle? Social
Science and Medicine, 66, 1733–1749. doi:10.1016/j.socscimed.2008.01.030
Block, J. H., & Block, J. (1980). The role of ego-control and ego-resiliency in the organization of
behavior. In W. A. Collins (Ed.), The Minnesota symposia on child psychology (Vol. 13, pp.
39–101). Hillsdale, NJ: Erlbaum.
Bosch, J. A., de Geus, E. E., Ring, C., & Nieuw Amerongen, A. V. (2004). Academic examina-
tions and immunity: Academic stress or examination stress? Psychosomatic Medicine, 66,
625–627. doi:10.1097/01.psy.0000133254.46947.ac
Bostock, S., Hamer, M., Wawrzyniak, A. J., Mitchell, E. S., & Steptoe, A. (2011). Positive emo-
tional style and subjective, cardiovascular and cortisol responses to acute laboratory stress.
Psychoneuroendocrinology, 36, 1175–1183. doi:10.1016/j.psyneuen.2011.02.009
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in
psychological well-being. Journal of Personality and Social Psychology, 84, 822–848.
doi:10.1037/0022-3514.84.4.822
Browne, M. W., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen
& J. S. Long (Eds.), Testing structural equation models (pp. 136–162). Newbury Park, CT:
Sage.
Byrne, B. M., Stewart, S. M., & Lee, P. H. (2004). Validating the Beck Depression Inventory-II
for Hong Kong community adolescents. International Journal of Testing, 4, 199–216.
doi:10.1207/s15327574ijt0403_1
Carlson, L. E., Speca, M., Faris, P., & Patel, K. D. (2007). One year pre-post intervention follow-
up of psychological, immune, endocrine and blood pressure outcomes of mindfulness-based
stress reduction (MBSR) in breast and prostate cancer outpatients. Brain, Behavior, and
Immunity, 21, 1038–1049. doi:10.1016/j.bbi.2007.04.002
Carmody, J., Reed, G., Kristeller, J., & Merriam, P. (2008). Mindfulness, spirituality, and health-
related symptoms. Journal of Psychosomatic Research, 64, 393–403. doi:10.1016/j.jpsych-
ores.2007.06.015
 564 W.K. Hou et al.

Cash, M., & Whittingham, K. (2010). What facets of mindfulness contribute to psychological
well-being and depressive, anxious, and stress-related symptomatology? Mindfulness, 1,
177–182. doi:10.1007/s12671-010-0023-4
Chida, Y., & Steptoe, A. (2009). Cortisol awakening response and psychosocial factors: A
systematic review and meta-analysis. Biological Psychology, 80, 265–278. doi:10.1016/j.bio-
psycho.2008.10.004
Chiesa, A., & Serretti, A. (2011). Mindfulness based cognitive therapy for psychiatric disorders:
A systematic review and meta-analysis. Psychiatry Research, 187, 441–453. doi:10.1016/
j.psychres.2010.08.011
Clow, A., Hucklebridge, F., Stalder, T., Evans, P., & Thorn, L. (2010). The cortisol awakening
response: More than a measure of HPA axis function. Neuroscience and Biobehavioral
Reviews, 35, 97–103. doi:10.1016/j.neubiorev.2009.12.011
Collins, L. M., Schafer, J. L., & Kam, C. M. (2001). A comparison of inclusive and restrictive
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

strategies in modern missing data procedures. Psychological Methods, 6, 330–351.

doi:10.1037/1082-989X.6.4.330
Diener, E., Oishi, S., & Lucas, R. E. (2003). Personality, culture, and subjective wellbeing: Emo-
tional and cognitive evaluations of life. Annual Review of Psychology, 54, 403–425.
doi:10.1146/annurev.psych.54.101601.145056
Davidson, R. J., Kabat-Zinn, J., Schumacher, J., Rosenkranz, M., Muller, D., Santorelli, S. F., …
Sheridan, J. F. (2003). Alterations in brain and immune function produced by mindfulness
meditation. Psychosomatic Medicine, 65, 564–570. doi:10.1097/01.PSY.0000077505.
67574.E3
Ding, L., Velicer, W. F., & Harlow, L. L. (1995). Effects of estimation methods, number of
indicators per factor, and improper solutions on structural equation modeling fit indices.
Structural Equation Modeling, 2, 119–143. doi:10.1080/10705519509540000
Dyson, R., & Renk, K. (2006). Freshmen adaptation to university life: Depressive symptoms,
stress, and coping. Journal of Clinical Psychology, 62, 1231–1244. doi:10.1002/jclp.20295
Fan, X., Thompson, B., & Wang, L. (1999). Effects of sample size, estimation methods, and
model specification on structural equation modeling fit indexes. Structural Equation
Modeling, 6, 56–83. doi:10.1080/10705519909540119
Fava, G. A., & Tomba, E. (2009). Increasing psychological well-being and resilience by
psychotherapeutic methods. Journal of Personality, 77, 1903–1934. doi:10.1111/j.1467-
6494.2009.00604.x
Ferrer, E., & McArdle, J. J. (2010). Longitudinal modeling of developmental changes in psycho-
logical research. Current Directions in Psychological Science, 19, 149–154. doi:10.1177/
0963721410370300
Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-
and-build theory of positive emotions. American Psychologist, 56, 218–226. doi:10.1037/
0003-066X.56.3.218
Fredrickson, B. L., & Levenson, R. W. (1998). Positive emotions speed recovery from the cardio-
vascular sequelae of negative emotions. Cognition and Emotion, 12, 191–220. doi:10.1080/
026999398379718
Fredrickson, B. L., Mancuso, R. A., Branigan, C., & Tugade, M. M. (2000). The undoing effect
of positive emotions. Motivation and Emotion, 24, 237–258. doi:10.1023/A:1010796329158
Graham, J. W. (2009). Missing data analysis: Making it work in the real world. Annual Review of
Psychology, 60, 549–576. doi:10.1146/annurev.psych.58.110405.085530
Graham, J. W., & Schafer, J. L. (1999). On the performance of multiple imputation for multivari-
ate data with small sample size. In R. Hoyle (Ed.), Statistical strategies for small sample
research (pp. 1–29). Thousand Oaks, CA: Sage.
 Psychology & Health 565

Hamid, P. N., & Cheng, S. T. (1996). The development and validation of an index of emotional
disposition and mood State: The Chinese affect scale. Educational and Psychological
Measurement, 56, 995–1014. doi:10.1177/0013164496056006006
Heath, N. M., Hall, B. J., Russ, E. U., Canetti, D., & Hobfoll, S. E. (2012). Reciprocal
relationships between resource loss and psychological distress following exposure to political
violence: An empirical investigation of COR theory’s loss spirals. Anxiety, Stress and Coping,
25, 679–695. doi:10.1080/10615806.2011.628988
Hobfoll, S. E. (1998). Stress, culture, and community: The psychology and philosophy of stress.
New York, NY: Plenum.
Hobfoll, S. E. (2011). Conservation of resources theory: Its implication for stress, health, and resil-
ience. In S. Folkman (Ed.), The Oxford handbook of stress, health, and coping (pp. 127–147).
New York, NY: Oxford University Press.
Hobfoll, S. E., Palmieri, P. A., Johnson, R. J., Canetti-Nisim, D., Hall, B. J., & Galea, S. (2009).
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Trajectories of resilience, resistance, and distress during ongoing terrorism: The case of Jews
and Arabs in Israel. Journal of Consulting and Clinical Psychology, 77, 138–148.
doi:10.1002/jts.20409
Hoppmann, C. A., & Klumb, P. L. (2006). Daily goal pursuits predict cortisol secretion and mood
states in employed parents with preschool children. Psychosomatic Medicine, 68, 887–894.
doi:10.1097/01.psy.0000238232.46870.f1
Hou, W. K., Law, C. C., & Fu, Y. T. (2010). Does change in positive affect mediate and/or mod-
erate the impact of symptom distress on psychological adjustment after cancer diagnosis? A
prospective analysis. Psychology & Health, 25, 417–431. doi:10.1080/08870440802559375
House, J. S., Landis, K. R., & Umberson, D. (1988). Social relationships and health. Science,
241, 540–545. doi:10.1126/science.3399889
Huffziger, S., Ebner-Priemer, U., Eisenbach, C., Koudela, S., Reinhard, I., Zamoscik, V., …
Kuehner, C. (2013). Induced ruminative and mindful attention in everyday life: An
experimental ambulatory assessment study. Journal of Behavior Therapy and Experimental
Psychiatry, 44, 322–328. doi:10.1016/j.jbtep.2013.01.00
Ibrahim, A. K., Kelly, S. J., Adams, C. E., & Glazebrook, C. (2013). A systematic review of
studies of depression prevalence in university students. Journal of Psychiatric Research, 47,
391–400. doi:10.1016/j.jpsychires.2012.11.015
Jimenez, S. S., Niles, B. L., & Park, C. L. (2010). A mindfulness model of affect regulation and
depressive symptoms: Positive emotions, mood regulation expectancies, and self-acceptance
as regulatory mechanisms. Personality and Individual Differences, 49, 645–650. doi:10.1016/
j.paid.2010.05.041
Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness meditation in everyday life.
New York, NY: Hyperion.
Kashdan, T. B., & Rottenberg, J. (2010). Psychological flexibility as a fundamental aspect of
health. Clinical Psychology Review, 30, 865–878. doi:10.1016/j.cpr.2010.03.001
King, L. A., King, D. W., McArdle, J. J., Saxe, G. N., Doron-LaMarca, S., & Orazem, R. J.
(2006). Latent difference score approach to longitudinal trauma research. Journal of
Traumatic Stress, 19, 771–785. doi:10.1002/jts.20188
Kline, R. B. (2011). Principles and practice of structural equation modeling. New York, NY:
Guilford Press.
Lau, N., & Hue, M. (2011). Preliminary outcomes of a mindfulness-based programme for Hong
Kong adolescents in schools: Well-being, stress and depressive symptoms. International
Journal of Children’s Spirituality, 16, 315–330. doi:10.1080/1364436X.2011.639747
Leung, D. Y. P., Lam, T. H., & Chan, S. S. (2010). Three versions of perceived stress scale:
Validation in a sample of Chinese cardiac patients who smoke. BMC Public Health, 10, 513.
doi:10.1186/1471-2458-10-513
Little, T. D. (2013). Longitudinal structural equation modeling. New York, NY: Guilford Press.
 566 W.K. Hou et al.

Marsh, H. W., Wen, Z., & Hau, K. (2004). Structural equation models of latent interactions:
Evaluation of alternative estimation strategies and indicator construction. Psychological
Methods, 9, 275–300. doi:10.1037/1082-989X.9.3.275
McArdle, J. J. (2009). Latent variable modeling of differences and changes with longitudinal data.
Annual Review of Psychology, 60, 577–605. doi:10.1146/annurev.psych.60.110707.163612
McEwen, B. S. (1998). Stress, adaptation, and disease: Allostasis and allostatic load. Annals of
the New York Academy of Sciences, 840, 33–44. doi:10.1111/j.1749-6632.1998.tb09546.x
Miller, S. M. (1987). Monitoring and blunting: Validation of a questionnaire to assess styles of
information seeking under threat. Journal of Personality and Social Psychology, 52, 345–353.
doi:10.1037/0022-3514.52.2.345
Murphy, M. J., Mermelstein, L. C., Edwards, K. M., & Gidycz, C. A. (2012). The benefits of dis-
positional mindfulness in physical health: A longitudinal study of female college students.
Journal of American College Health, 60, 341–348. doi:10.1080/07448481.2011.629260
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Muthén, L. K., & Muthén, B. O. (2010). Mplus user’s guide (6th ed.). Los Angeles, CA: Author.
Neff, K. D., & Dahm, K. A. (in press). Self-compassion: What it is, what it does, and how it
relates to mindfulness. In M. Robinson, B. Meier, & B. Ostafin (Eds.), Mindfulness and self-
regulation. New York, NY: Springer.
Pruessner, J. C., Kirschbaum, C., Meinlschmid, G., & Hellhammer, D. H. (2003). Two formulas
for computation of the area under the curve represent measures of total hormone concentra-
tion vs. time-dependent change. Psychoneuroendocrinology, 28, 916–931. doi:10.1016/S0306-
4530(02)00108-7
Rasmussen, M. K., & Pidgeon, A. M. (2011). The direct and indirect benefits of dispositional
mindfulness on self-esteem and social anxiety. Anxiety, Stress, and Coping, 24, 227–233.
doi:10.1080/10615806.2010.515681
Rohleder, N., & Nater, U. M. (2009). Determinants of salivary α-amylase in humans and method-
ological considerations. Psychoneuroendocrinology, 34, 469–485. doi:10.1016/j.psyneu-
en.2008.12.004
Rubin, D. B. (2004). Multiple imputation for nonresponse in surveys. Hoboken, NJ: Wiley-
Interscience.
Salanova, M., Llorens, S., & Schaufeli, W. B. (2011). “Yes, I can, I feel good, and I just do it!”
on gain cycles and spirals of efficacy beliefs, affect, and engagement. Applied Psychology,
60, 255–285. doi:10.1111/j.1464-0597.2010.00435.x
Shapiro, S. L., Brown, K., & Biegel, G. (2007). Teaching self-care to caregivers: Effects of mind-
fulness-based stress reduction on the mental health of therapists in training. Training and
Education in Professional Psychology, 1, 105–115. doi:10.1037/1931-3918.1.2.105
Shek, D. T. (1988). Reliability and factorial structure of the Chinese version of the State-Trait
Anxiety Inventory. Journal of Psychopathology and Behavioral Assessment, 10, 303–317.
doi:10.1007/BF00960624
Smyth, J., Ockenfels, M. C., Porter, L., Kirschbaum, C., Hellhammer, D. H., & Stone, A. A.
(1998). Stressors and mood measured on a momentary basis are associated with salivary corti-
sol secretion. Psychoneuroendocrinology, 23, 353–370. doi:10.1016/S0306-4530(98)00008-0
Steiger, J. H. (2007). Understanding the limitations of global fit assessment in structural equation
modeling. Personality and Individual Differences, 42, 893–898. doi:10.1016/j.paid.2006.
09.017
Steptoe, A., Wardle, J., & Marmot, M. (2005). Positive affect and health-related neuroendocrine,
cardiovascular, and inflammatory processes. Proceedings of the National Academy of
Sciences, 102, 6508–6512. doi:10.1073/pnas.0409174102
Stowell, J. R. (2003). Use and abuse of academic examinations in stress research. Psychosomatic
Medicine, 65, 1055–1057. doi:10.1097/01.PSY.0000097349.84109.1F
 Psychology & Health 567

Tang, Y. Y., Ma, Y., Wang, J., Fan, Y., Feng, S., Lu, Q., … Posner, M. I. (2007). Short-term med-
itation training improves attention and self-regulation. Proceedings of the National Academy
of Sciences, 104, 17152–17156. doi:10.1073/pnas.0707678104
Voellmin, A., Entringer, S., Moog, N., Wadhwa, P. D., & Buss, C. (2013). Maternal positive
affect over the course of pregnancy is associated with the length of gestation and reduced risk
of preterm delivery. Journal of Psychosomatic Research, 75, 336–340. doi:10.1016/j.jpsych-
ores.2013.06.031
Watson, D., Clark, L. A., & Tellegen, A. (1988). Development and validation of brief measures
of positive and negative affect: The PANAS scales. Journal of Personality and Social
Psychology, 54, 1063–1070. doi:10.1037/0022-3514.54.6.1063
Weekes, N. Y., Lewis, R. S., Goto, S. G., Garrison-Jakel, J., Patel, F., & Lupien, S. J. (2008).
The effect of an environmental stressor on gender differences on the awakening cortisol
response. Psychoneuroendocrinology, 33, 766–772. doi:10.1016/j.psyneuen.2008.03.003
Downloaded by [University of Nebraska, Lincoln] at 19:18 18 October 2015

Weekes, N. Y., Lewis, R. S., Patel, F., Garrison-Jakel, J., Berger, D. E., & Lupien, S. J. (2006).
Examination stress as an ecological inducer of cortisol and psychological responses to stress
in undergraduate students. Stress, 9, 199–206. doi:10.1080/10253890601029751
Weinstein, N., Brown, K. W., & Ryan, R. M. (2009). A multi-method examination of the effects
of mindfulness on stress attribution, coping, and emotional well-being. Journal of Research in
Personality, 43, 374–385. doi:10.1016/j.jrp.2008.12.008
Zautra, A. J., Hall, J. S., & Murray, K. E. (2010). A new definition of health for people and com-
munities. In J. W. Reich & A. J. Zautra (Eds.), Handbook of adult resilience (pp. 3–29). New
York, NY: Guilford Press.
Zautra, A. J., Johnson, L. M., & Davis, M. C. (2005). Positive affect as a source of resilience for
women in chronic pain. Journal of Consulting and Clinical Psychology, 73, 212–220.
doi:10.1037/0022-006X.73.2.212