Stress & Coping

Definition of Stress

• Stress refers to an event or demand on the individual or family that causes the individual or family to appraise the event or demand for scope and meaning and to determine whether resources for its management are exceeded and whether the event or demand is neutral (no stress), challenging, or threatening.

• It is the appraisal that determines the end result (outcome) of health, disability, or dysfunction.

• The appraisal process is central: same event can be neutral, challenging, or threatening depending on interpretation.

Scope of Stress

• No stress: Experience perceived as easily manageable; equilibrium is not disrupted.

• Challenging: Experience perceived as manageable but requires mobilization of resources; is not harmful, and equilibrium is maintained.

• Threatening: Experience perceived as taxing; exceeds existing resources; causes disruption to equilibrium; can impact health.

General Adaptation Syndrome (GAS)

Alarm Stage – “fight or flight”

• Threat message is conveyed to the hypothalamus.

• Hypothalamus communicates with the pituitary gland.

• The pituitary releases adrenocorticotropic hormone (ACTH) and activates hormones for the adrenal medulla.

• The adrenal medulla pumps adrenaline, noradrenaline, and other catecholamines into the bloodstream.

Alarm Stage – Physiological responses

• Heart rate (HR) and blood pressure (BP) rise to increase circulation of blood and oxygen.

• Airways in the lungs dilate.

• Blood flow shifts from smooth muscle of the digestive system to the skeletal muscles.

• Increases in glucose, triglycerides, and free fatty acids to be used as fuel.

• Platelet aggregation increases to aid blood clotting.

• Kidney clearance is reduced to prevent loss of water.

GAS – Other stages

• Alarm

• Resistance

• Exhaustion

Reactions to Stress

• Acute reactions include: Uneasiness, Sadness, Loss of appetite or increased appetite, Immune system suppression, Increased metabolism, Infertility, Increased energy use, Increased cardiopulmonary tone.

• Chronic reactions include: Chronic anxiety and panic attacks, Depression, Anorexia or overeating, Opportunistic infections, Type II diabetes, hypertension, Amenorrhea, impotence, anovulation, decreased sex drive, Fatigue, irritability, Angina, heart attack, stroke, and increased respiratory problems.

Biopsychosocial Model

• Psychoneuroimmunological model: Links stress, the immune system, and disease.

Categories of Stressors

• Emotional stressors

• Behavioral stressors

• Physiologic stressors

Individual Risk Factors

• Impaired cognition

• Chronic health conditions including mental health issues

• Multiple significant life changes

• Socioeconomic status (e.g., poor, homeless)

• Caregiver role

• Individual in a foreign country—especially with language/cultural barriers

Mediating Factors

• Elements that may lessen or increase the degree of stress:

  • Age

  • Sex

  • Culture

  • Life experiences

  • Spiritual/Religious beliefs

  • Social support

Social Support

• Strong social support can enhance mental and physical health and buffer distress.

• Strong correlation between lower mortality rates and intact support systems.

• High-quality social support:

  • Free from conflict and negative interactions

  • Close, confiding and reciprocal

• Low-quality social support:

  • May negatively affect coping effectiveness

Other Factors to Consider

• Culture

  • How a stressful event is appraised

  • How emotion generated by the event should be expressed

• Spirituality: helpful for many coping with stress; spiritual practices can enhance immune function and sense of well-being

Stress and Anxiety – Operational Definition

• Stress and anxiety considerations span Psychological, Physical, Environmental, Social, and Physical Condition domains.

• Relief, behavior, defense mechanisms, coping responses, spiritual/cultural supports, and social support networks are involved.

• Effective mediation leads to anxiety returning to usual coping style;

• Ineffective mediation leads to prolonged distress or illness.

Coping – Definition

• An ever-changing process involving both cognitive means and behavioral actions to manage internal or external situations perceived as difficult and/or beyond resources (Lazarus & Folkman).

• Also described as being action-oriented toward a goal of changing a situation (Ray).

Coping – Scope

• Coping mechanisms: Constructive vs Destructive.

• Continuum of coping responses: Effective/Adaptive vs Ineffective/Maladaptive.

Assessing Coping Styles

• Four categories of coping styles used as stress buffers:

  • Health-sustaining habits

  • Life satisfaction

  • Social supports

  • Response to stress

General Risk Factors: Maladaptive Coping

• Inability to accurately assess stressor

• Denial or avoidance

• Actual or perceived lack of control over the situation

• Actual or perceived lack of support

• No experience or poor past experiences in managing stressful situations

Individual Risk Factors – Maladaptive Coping

• Impaired cognition

• Limited resources

• Age

• Changes in health status

• Chronic health conditions

Coping Responses

• Primary appraisal:

  • Initial assessment of stressor to determine if it is a threat.

• Secondary appraisal:

  • Evaluation of resources to overcome, eliminate, or reduce the stressor.

Consequences of Ineffective Coping

• Potential maladaptive behaviors can lead to negative outcomes such as:

  • Alcohol abuse

  • Bullying

  • Excessive eating

  • Violence

Elements of Assessment – Coping

• Goal: Determine individual’s appraisal stage and coping strategies

• History

  • Perception of threat

  • Past coping patterns

  • Medical history

  • Social history

• Examination

  • Observation of behavior

  • Mental health assessment

Clinical Management: Primary Prevention

• Exercise

• Nutrition

• Positive relationships

• Social supports

Collaborative Care

• Education

• Developing an action plan

• Accessing resources

• Cognitive restructuring

Holistic Approaches to Stress

• Poor management of stress has been correlated with increased incidence of conditions such as heart disease, poor diabetes control, chronic pain, and significant emotional distress

Benefits of Stress Reduction

• Altering the course of medical conditions

• Decreasing need for medications

• Diminishing or eliminating unhealthy behaviors

• Increasing ability to learn, concentrate, and study

• Can stop old patterns of thinking and behaving and allow new problem-solving perspectives

Cognitive-Behavioral Approaches

• Cognitive–behavioral methods are among the most effective for reducing stress.

• Cognitive-behavioral therapy teaches new ways of responding to stress.

  • May be the most effective method of permanently relieving stress in everyday life

Relaxation Techniques

• Relaxation Exercises:

  • Teaches switching from the sympathetic (fight or flight) to parasympathetic (relaxation) state

• Meditation:

  • Training the mind for greater calm

• Guided imagery:

  • Envision calming, health-enhancing images

• Breathing exercises:

  • Abdominal breathing can modify stress and anxiety responses

Relaxation Techniques Requiring Special Training

• Therapeutic Touch:

  • Centering, scanning, and rebalancing to manipulate energy fields

• Progressive Muscle Relaxation:

  • Systematically tensing and releasing muscle groups for deep relaxation

• Biofeedback:

  • Uses instrumentation to provide physiological data (e.g., brain waves, skin temperature, blood pressure) to gain control over involuntary functions

Cognitive Approaches

• Journal Keeping:

  • Helps identify sources of daily stress

• Priority Restructuring:

  • Shifts from stress-producing events to stress-reducing activities

• Cognitive Reframing:

  • Restructuring irrational beliefs; replacing worried self-statements with positive ones

• Humor

• Mindfulness

Additional Effective Stress Reducers

• Sleep

• Exercise

• Reduction or cessation of caffeine intake

• Music (classical or soft melodies)

• Pets

• Massage