Basic notes Stress and coping
What do you think stress is?
Why is it important? Does it cause or worsen diseases? It has long been accepted
that stress can cause and worsen anything from allergic responses to heart disease.
There has and continues to be a great deal of research into stress using
questionnaires which we might look at in the seminars.
The word ‘stressed’ which engineers use to describe an overloaded bridge is the
same as the psychologist’s description of the overtaxed individual. It comes from the
same Latin root strictus which means stretched out or drawn tight.
In fact the
common rather than the technical usage came first.
The word stress can be a noun or a verb and the noun can refer to situations or
responses. Because this can create confusion,
Authors have differentiated between stressors (stressful stimuli) and a stress
response (the reaction to a stressor). The word stress refers to the overall process.
Ultimately, stress is an umbrella term for an increasingly wide variety of conditions,
responses, and experiences.
However, stress can be examined using particular
models, which take a relatively singular view.
The stimulus model
The first model can view stress as ‘out there’; external; a condition of the
environment. An independent variable if you like.
In this model, stress is seen as a stimulus in terms of stressors, within this model
there are two types of stressors.
A. Environmental stress
Stress here is assumed to be a condition of the environment. E.g. a noisy workplace,
difficult neighbours.
Occupational literature looks at noise, heat, light, air quality workload etc. Do you
think excess heat for example in intensive care units can have a stressful effect on
the staff who have to work under these conditions?
In this sort of model stress is an intensive level of stimulation, the level or intensity is
the distinguishing factor. This works quite well when these stressors are incredibly
extreme, but not otherwise.
It does not account for the fact that absence of
stimulation might be stressful. Also, people react differently to extremes. Some
people work well in a noisy environment. They are, perhaps able to switch off to
what is going on around them (students and teenagers often work with the radio at
full blast. This could drive someone else crazy.
Environmental factors, which are
potential stressors - heat light, smells and workload may not be experienced in the
same way by any two people. One of you might be very stressed by having to write 3
or 4 assignments at the same time, another might find it challenging rather than
stressful.
B. Life event stress
(Homes and Rahe)
This takes the view that some events are likely to be stressful for everyone e.g. death
of a close family member, going on holiday, and Christmas. However, these life
events vary in their stressfulness. Getting a divorce may alleviate the stress of living
with someone cruel. If you hate your job being made unemployed might not be so
bad for you if you loved it losing your job could be very stressful. Moving house is not
stressful if you stay at the office while the move is happening. (I've got one at home
like that). Is Christmas stressful if you are Muslim or Jewish?
A study by Israeli
sociologist Antonovsky 1979 found that over 25% of the survivors of German
concentration camps emerged without physical or emotional impairment. Obviously
these settings are the worst living conditions imaginable yet they were not uniformly
destructive. Also concentration camp and other survivors of world war two and their
children do not show serious psychological impairment. Somehow they have been
able to cope with this terrible life event. Some relationship between life events and
health seem to have been established but they have not been shown to predict the
probability of future illness. (Sabkin and Struening 1976) this is by way of a critique
of the life events scales which I will also be looking at with you after the break.
The response model
This views stress as the dependent variable if you like. It relates to the internal
factors, the reactions of the person.
Medically trained people are often familiar with this, the (physical) model known as
Selye’s General Adaptation Syndrome (GAS).
Selye used rats in his studies and found the same responses no matter what stressor
was used on the rats, cold, heat, infection, trauma, fear, loss of blood and pain etc.
He went on to study soldiers in the trenches during the war.
The initial response is an alarm reaction -flight or fight (adrenaline, nor adrenaline
and cortisol pump into the system).
Disruption in the homeostasis of the organism causes excitation of the hypothalamus.
The hypothalamus is the bridge between the brain and endocrine system.
The
pituitary is caused to discharge into general circulation the adrenocorticotrophic
hormone (known as ACTH). This has been called the ‘stress hormone' and is often
used to assess stress. As the ACTH reaches the adrenal cortex, the cortex becomes
enlarged and hyperactive, secreting corticoids, which supply a ready source of
energy for the adaptive, demands being made on the organism. This is a good thing
in the short term.
Incidentally, I was told recently that a cat plays with its prey, mouse bird to get the
stress hormones going in the circulation to make them juicier. What do you think?
In the medium or long term with continuing exposure to the stressor, there is a stage
of resistance. During the resistance stage, because of adaptation, apparently no
physical changes occur; the changes that occurred during the alarm reaction cease
and often the opposite of those occur e.g. hemodilution. The organism appears to be
well adapted to the stressor. It is however taking its toll. Resistance and adaptation
seems to be okay but better and more sophisticated measurements of e.g. stress
hormones now show it not to be very limited.
If stress is prolonged, allowed to continue unabated or additional stress is added
during the adaptive state then there is a return to the initial response and collapse.
This is a stage of exhaustion and death follows if the stressor is not terminated. In
Selye’s study, half the rats died and some of the trench soldiers suffered from shell
shock.
Selye defined stress by virtue of the organism/s response: - where there is gas there
is stress; he also believed that we are born with genetically determined and finite
adaptive resources.
Specificity
The response model may be challenged by the specificity of responses to stressors.
Different stressors along with different physical and psychological predispositions
tend to lead to different types of physical problems. There is an individual response
stereotype - hypertensives will respond with a rise in blood pressure and ulcer
patients with a change in gastric secretions (Whitehead et al 1979)
Selye viewed stress as within the individual, not the environment because he found
that any stressor would produce the same response pattern. You will see later, from
Frankenhauser’s data that this is not true.
Strain
Strain is the psychological response. Many questionnaires focus on this aspect of
stress e.g. general health questionnaire, hospital anxiety and depression
questionnaires.
These include anxiety and depression at sub-clinical levels at
irritability and sleeplessness, inability to concentrate and ‘psychosomatic’ symptoms
such as headaches.
Again here the focus is on individuals not environmental sources of stress.
The consequences can be dangerous - ignore environmental sources, so you don’t
need to do anything about them; blame the individual for ‘not being able to cope'
being over-sensitive etc.
The Interaction Model of Stress.
The third model is interactional. In this model, stress as seen as interaction between
environment and the individual’s perception of it. It suggests that the appraisal of the
event and of your resources for dealing with it are important in determining the level
of stress experienced.
The dominant stress model just now is the Cognitive Appraisal Model {see
research by - Folkman and Lazarus (1984) (Holroyd and Lazarus (1982)}.
In this model, stress depends on the individual’s appraisal of
A. How threatening an event could be. Is this a threat e.g. a life event, an exam.
(Some may see an exam as very threatening and some may see it a challenge, a
way to show what they know).
In a medical situation what do you know about what
is going to happen to you; how big a threat to you is this surgery, procedure?
One example of this has been related to the fact that most patients know little about
what to expect during major medical interventions except from e.g. casualty or other
patients accounts. It has been argued that one reason which medical procedures
induce high levels of stress is because this lack of accurate information affects the
appraisal process and leads the patient to view the impending procedure as more
threatening and frightening than it need be. The threat is greater than in reality.
And
B. Whether or not he/she is able to cope with it. This depends on experience, do
you know how to? Do you have resources?
So, the cognitive appraisal model, which operates, like this
Primary appraisal- 'Is this a threat?’
Secondary appraisal - ‘Have I some control and can I cope?’
Decreasing the threat- increasing coping strategy e.g. stress management may help
here. Boosting social support can increase self-efficacy, “of course, you can do it”.
Also, increasing information may decrease if a threat is perceived as a result of
appraisal and you can cope then the event (threat) is not stressful.
If you cannot cope and have no resources then the threat is stressful.
Coping
Coping may be seen in two parts.
Problem focussed coping and Emotion focussed coping.
1. Problem focussed coping
This is a cognitive, practical method. It looks at practical ways of dealing with, coping
with, the threat.
For example, in an exam situation, you can study hard, can make out timetables for
studying, get help, cheat, go off sick and resit it later.
If none of the above options, practical solutions is available or possible or desirable
and you fear you may not pass the exam then you can use
2. Emotion focussed coping to change or lessen the emotion.
For example,
You can tell yourself it is not important to pass the exam,
You can remind yourself that you are quite good at sitting exams,
You can moan to your friends,
Cry on someone’s understanding shoulder, become very busy doing something else.
You can use positive self-efficacy/positive thinking: - believe that you will cope
somehow.
You can also use exercise or relaxation techniques to cope.
This theory is the dominant theory. It gets round individual differences, which can be
where other models can fall down. This is in fact, the model.
However, it is very hard to research due to its variability and its complexity. Both
complex appraisals of threat and of coping have to be examined as they interact.
But, for example, life event scales which you saw last week are not terrific in their
basic state, can be modified by asking subjects to appraise the stressfulness of an
event, not just report that it occurred.
It is good for understanding someone’s stress and a good model to use when talking
to someone about their stress.
You might think of family, friends, and colleagues and see some clues - predictors as
to who might be suffering from stress.
It is important to remember. In the context of this model that two clients suffering the
same threat may experience different stress as a result.
The Frankenhauser approach
Another model, which is an Interactional model, looks at the individual consequences
of stress. This is Frankenhauser’s model.
If you remember this physiological model of reactions to stress is Selye’s. However
Frankenhauser uses this type of physiological reaction to explain stress and the
effects of stress. You will get more information from the activity affect model of stress
offprint in the library.
For Frankenhauser, unlike Selye, the pathways activated when stress is experienced
depend on the situation and are not as in Selye’s model just reactions.
For example, if you have a very busy day at work i.e. high activity then the pathways
on the left will be activated but if you are okay feeling you have some control over the
situation and feel you can cope, there will be few, if any, pathways open on the left.
If you feel that things are too busy and getting out of control and you are feeling
distress then the pathways on the right will be opened as well as the ones on the left
which are related to high activity.
Alternatively, if you have low activity but trauma for example bereavement, then there
will be low activity on the left but open pathways on the right.
If you have are busy and have high activity and low distress you have control if you
have low control then you will have high activity and high distress.
This is a good model as it includes physiology and psychology.
The model goes on to explain the outcome of stress which affects these different
pathways.
The high activity side will produce high blood pressure, high cholesterol,
This other side is different and will produce low immunity function, spots, colds and
cancer.
Coronary heart disease requires the operation of both sets of pathways.
Control
For Frankenhauser the key to alleviation of stress is related to good balance in the
cognitive assessment of the demands being made in relation to personal resources.
A good balance induces positive affects, a bad balance negative affects. Personal
control is seen as a mediator of the quality of the experience: low control invariably
inducing negative affects, high control generally inducing positive affects. However,
there are pronounced individual and sex differences in the ability to benefit from
control and it is not a universal antidote to stress.
Control, (is it internal or external) is complex.
One may act helpless and get
someone else to do it for you, in which case you still control the situation albeit
appear not to. You are, in effect, manipulating the situation.
In health you can access ‘powerful others’. Give control to the doctors.
Folkman found that decision-making by parents re what’s happening increased
stress. Would you like to take the decision to switch off ventilatory support for your
child?
In the case of tragedy’s, litigation may be pursued. This may give some measure of
control but can go on for years prolonging stress.
Consequences
There are various studies related to consequences of stress.
General
A good study to look it is the one done after the eruption of the volcano in Mount
Saint Helens, in the state of Washington State. 1980. Despite warnings beforehand
50 people died some more than 20 miles away from the explosion.
In Othello which was a town in the path of the ash 137 miles away, there was no lava
flow or deaths but the ash covered everything and the small agricultural community
was completely disrupted by this event. No one knew how to deal with the ash,
whether it might effect health and worse still, might there be more eruptions.
Psychologists found that many residents of Othello were affected by symptoms of
stress.
Hospital and emergency room visits were increased by 21%, death rate
increased 18.6 %; psychosomatic illness and mental illness more than doubled, child
abuse and divorce increased as did alcohol abuse, aggression and violence (Adams
and Adams, 1984) other nearby communities showed similar increases in stress
related disorders which were in direct relation to the distance from the explosion.
Other studies, for example those of veterans returning from Vietnam have found that
long-term stress has been found to be linked to their exposure to combat rather than
personality or behavioural characteristics.
Thirty-five percent of heavy combat
veterans fit the profile for post-traumatic stress disorder. You’ll all know a little about
that. I won’t be discussing it just now.
2. Schizophrenia.
It has been suggested that the consequences some form of stress in a genetically
vulnerable individual either cause or trigger the manifestation of schizophrenia. The
stressors, which have been held to be implicated, have been numerous. (Brown and
Birley (1968) have shown that 60% of individuals who suffered an acute episode of
schizophrenia had experienced at least one stressful life event (e.g. death in the
family) in the three weeks prior to onset, compared within 19% of a ‘normal’ British
sample. However, the role of stressful is generally held to be a triggering factor for a
specific episode of acute illness rather than a causal factor.
3. Heart disease - Type A Personality
It has also been suggested Type A personality may be related to a stressful approach
to life, one of the major the consequences of which is heart disease.
The Type A behaviour pattern was characterised as
“aggressively involved in a chronic, incessant struggle to achieve more and more in
less and less time’ (Friedman & Rosenman, 1974). At work they are likely to rake on
more tasks than necessary, without realistically assessing time and other constraints
and in leisure time, they continue to display a pervasive inability to relax, competitive
striving, and a low sense of security (Glass 1977)
Glass (1977) presented evidence from work with Type A and Type B individuals to
suggest that Type A individuals exert greater effort to control stressful events. If the
event is objectively uncontrollable then relentless striving and time urgency of type
individuals leads to frustration and ‘psychic’ exhaustion.
It is then; perhaps not
surprising that the consequences of stress on type a personality has been related to
coronary heart disease.
Evidence relating type behaviour to heart disease has been provided most
convincingly by the western collaborative group study who found that men with the
type a behaviour pattern experienced twice as much coronary heart disease than
those without this pattern. This relationship existed even when the influence of other
risk factors was taken into account.
However, the apparent strength of early evidence linking type a behaviour and
coronary heart disease was reflected in the consensus report (Review Panel, 1981)
where type a behaviour was accorded equivalent status to traditional risk factors
such as high cholesterol and hypertension.
Since then, though, there has been
increasing controversy. In non-USA studies, using non middle class class subjects,
the effect of type a personality on heart disease disappears. Research continues in
this field.
Some stress reductors (other than coping and control)
External, environmental; you can try to avoid or reduce it (turn noise heat down, get
the rota the way you feel it will work best.)
In the case of life events, don’t put yourself under extra pressure, don’t move house,
and get pregnant take on a new course of study.
There are physical ways of reducing stress e.g. relaxation and, of course, exercise
itself. It stands to reason that indulging in exercise is likely to be related to physical
fitness exercise is after all likely to develop to develop muscles including the heart
muscle and if exercise is aerobic, lowering of heart rate and blood pressure
associated with exercise are probable measures of cardiac efficiency improvement.
However, exercise doesn’t always improve physical fitness or at least improve it in
measurable ways and a number of studies suggest it improves psychological well
being, Doyne 1987 found that there was less depression even if no fitter and it does
seem to lessen or ameliorate the effects of stress, Steptoe l989, Moses et al 1989
Plante and Ropin l990.
The improvements therefore, in coronary heart disease may be due to psychological
mechanisms operating in association with exercise as well as or instead of
physiological mechanisms. The extent to which this is true is yours to evaluate.
Why exercise may have psychological effects may be related to; -
1. Bandura improved physical fitness gives people a sense of mastery, control that
from Frankenhauser’s model is important.
The ‘ I can cope' is related also to
cognitive appraisal and the effects of control.
2.
Endorphin theory (Howlett et al (984).
The stress of running etc induces
endorphin production, which has mood altering ’ opiate ‘ effects, which are short
lasting only.
3. Distraction or ‘ time out’ theory (Simons et al l985). Exercise takes your mind off
stressful situations/problems etc for the duration and gives you time out, which
reduces the physiological response and alters psychological state. Again it may only
be temporary in effect but break can be important like sleeping?
4. Exercise is often a group activity there may be group dynamics involved e.g.
social support may be involved (Berger & Owen l988).
There is evidence, therefore, of direct and indirect effects related to exercise and
stress. High blood pressure can be reduced and mood can be improved.
Social support is also considered to be important in relation to stress.
The content of social support is
1. The structure of relations - the size of the social network. Are you married or
single, divorced or individual?
The assumption is that more is better; the more relationships you have the better.
But this may be untrue more may mean more chance to be undermined, criticised
etc.
Marital relationships may be like this and they are linked to kids who are
dependants
and
not
givers.
The function provided by social supporters is
1. Practical - money, advice, practical help (this is problem focussed)
2. Emotional - distractions, relaxation, laughs, cries, cuddles, someone on you side
and self-efficacy. (This is emotion focussed)
In criticism of this lots of social support should mean good health and little social
support should mean bad health but while social undermining, mental disruption or
breakdown of relationship may cause bad health it may also be caused by bad
health.
Stress management, which I have mentioned before, is a method, which is better left
to the experts.