Stress, Anxiety, and Coping
Dr. Fadwa Alhalaiqa
Objective 1
• Explain how stress affects an individual
Stress
• Stress is a person–environment interaction,
and nurses must realize that there are many
factors to be considered in each individual’s
response to stressors.
• We are aware of some stressors, but others
we may not recognize as sources of stress,
such as time, the foods we eat, or even the
pollution we live with
Factors to be considered when trying
to understand a client’s stress
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personality factors,
cognitive factors,
physical factors,
environmental factors,
cultural factors,
and coping strategies
When stress is seen as conflict
• A conflict begins when a person holds two goals at the
same time. There are different sorts of conflicts that involve
movement toward and away from goals:
1- An approach–avoidance conflict occurs around
incompatible choices and usually constitutes an either–or
situation.
2- The avoidance–avoidance conflict involves two negative
goals. In this case, the tension results from simultaneous
repulsion to both goals. The person in this situation must
choose between “the lesser of two evils.” Vacillation occurs
when a person moves back and forth between two goals
that have equal intensity of push and pull.
The fight–or–flight response to stress
• involves either an aggressive response to a
conflict (fight),
• or a withdrawal response (flight).
• The fight–or–flight response can be
considered maladaptive due to the
physiological stress on the body, which may
cause or exacerbate hypertension, heart
disease, or other medical conditions
Hans Selye
• Hans Selye defined stress as the rate of wear
and tear on the body, and included physical,
chemical, physiological, developmental, or
emotional stressors.
• identified the physiologic aspects of stress,
which he labeled the general adaptation
syndrome
He determined three stages of
reaction to stress:
• alarm reaction stage, stress stimulates the body
to send messages from the hypothalamus to the
glands.
• the resistance stage, the digestive system reduces
function to shunt blood to areas needed for
defense.
• exhaustion stage occurs when the person has
responded
• negatively to anxiety and stress: body stores are
depleted or the emotional components are not
resolved, resulting in continual arousal of the
physiologic responses and little reserve capacity
• A life change theory of stress looks at common
life events, whether positive or negative, as
producing stress in people’s lives. Each event
is called a life change unit (LCU).
• By assessing how many LCUs have occurred,
the theory suggests that it is possible to
calculate an individual’s potential to
experience physical stress symptoms
Holmes and Rahe life change scale
• It assumes that stress occurs after a particular threshold is
reached in all individuals, and some particular events are
stressors to all individuals, while others are irrelevant to
some individuals.
• Furthermore, specific life events were thought to cause the
same amount of stress in different individuals and everyone
employed a similar amount of “adaptation” to respond to
the stressor.
• The life change units in this scale can be a good starting
point to help a client realize how everyday activities
contribute to stress, but it does not reflect a person–
environment interaction view of stress, so it gives nurses
little information about the individual to help facilitate
effective coping
Lazarus stress definition
As transaction:
• It is a process of complex interplay among the
perceived demands of the environment and the
perceived resources one has for meeting the demands.
• An individual makes a cognitive appraisal of the
perceived threat.
• The person’s primary appraisal assesses the threat and
the secondary appraisal evaluates coping resources
and options.
• The person then applies the coping resources and then
reappraises the situation.
The psychoneuroimmunology
framework of stress
• is very comprehensive and is the most modern
picture of the relationship between neurology,
endocrine and immune systems, and exploring
the role of psychosocial factors such as
personality and hardiness.
• The hormone cortisol plays an important role
in stress and may be responsible for much of
the damage to the immune system that
contributes to the development of disease.
• Some studies have found that personality types (selfhealing versus disease-prone personalities) may play a
role as well.
• Disease-prone personalities exhibit certain emotions,
including anger, suspicion, and chronic anxiety that are
physiologically linked to sympathetic nervous system
responses, the release of cortisol, and the suppression
of the immune response.
• We are discovering that hardiness, which is an
attitudinal factor defined by a positive attitude and a
feeling of confidence, may have a stress-buffering
effect
Learning Outcome 2
• Identify the sources of anxiety.
ANXIETY
• ANXIETY IS A VAGUE FEELING of dread or apprehension; it is a
response to external or internal stimuli that can have
behavioral, emotional, cognitive, and physical symptoms.
• Anxiety is distinguished from fear, which is feeling afraid or
threatened by a clearly identifiable external stimulus that
represents danger to the person.
• Anxiety is unavoidable in life and can serve many positive
functions such as motivating the person to take action to
solve a problem or to resolve a crisis.
• It is considered normal when it is appropriate to the situation
and dissipates when the situation has been resolved.
Definition of anxiety
• The term anxiety is often used in relation to varying feelings of
uneasiness, sometimes precipitated by a known event, and
sometimes by something vague or merely anticipated.
• Anxiety is generally caused by two types of threats. The first type is
threats to basic human needs, such as warmth, food, and water.
This explains why anxiety and restlessness are among the common
signs of impending shock (decreasing oxygenation).
• Anxiety is also related to threats to the security of the self. These
threats evolve around matters that are important to human beings
such as integrity, self-respect and recognition, status or prestige,
approval or disapproval by significant others, guilt, and selfexpectations.
• All of these threats may be actual, impending, or merely
anticipated.
Levels of Anxiety
• Mild anxiety is a sensation that something is
different and warrants special attention. Sensory
stimulation increases and helps the person focus
attention to learn, solve problems, think, act, feel,
and protect himself or herself.
• Mild anxiety often motivates people to make
changes or to engage in goal-directed activity.
• For example, it helps students to focus on
studying for an examination.
• Moderate anxiety is the disturbing feeling that
something is definitely wrong; the person
becomes nervous or agitated.
• In moderate anxiety, the person can still process
information, solve problems, and learn new
things with assistance from others.
• He or she has difficulty concentrating
independently but can be redirected to the topic.
• For example, the nurse might be giving
preoperative instructions to a client who is
anxious about the upcoming surgical procedure.
• severe anxiety and panic, more primitive
survival skills take over, defensive responses
ensue, and cognitive skills decrease
significantlyhas trouble thinking and
reasoning.
• Muscles tighten and vital signs increase.
• The person paces; is restless, irritable, and
angry; or uses other similar emotional–
psychomotor means to release tension
• Anxiety can be considered helpful or harmful,
largely dependent on the degree to which it is
experienced.
• Assessment:
1- subjective
2- MRIs and PET scans
A total body assessment would explore the
emotional, cognitive, behavioral, and
physiological expressions of anxiety
Anxiety and decision masking
• anxiety are associated with different types of behavior
that affect one’s ability to problem solve, make
decisions, or learn new things
• When anxiety is overwhelmingly high (severe and panic
level) the nurse must be conscious that independent
decision making is too difficult and must intervene to
protect the client from further disorganization.
• Panic levels of anxiety are associated with many severe
symptoms of mental illness, including mania,
disorientation, illusions, and hallucinations.
• Keeping watch over the level of stimulation in the
environment is one way nurses can help reduce anxiety
and prevent it from escalating
• Learning Outcome 3
Describe the everyday methods people use to
cope with stress and anxiety
• Everyone has a wealth of coping strategies they
rely on.
1- We use task-oriented coping skills when we feel
competent and the situation is not too
threatening.
2- We employ defense-oriented coping skills when
we feel inadequate and the situation is extremely
threatening to our sense of self.
• Task-oriented behavior is geared toward problem
solving; defense-oriented behavior is protective
kinds of coping strategies
• Some people turn to self-discipline and stoicism, while others
express intense feelings.
• Individuals may cope by avoiding or withdrawing from a situation.
• Some people will cope by seeking out someone with whom to talk
things out, but others prefer to privately think through the
situation.
• Physical activities, whether high-impact sports or simple gestures,
allow some people to work off stress and anxiety.
• Mind/body practices are very calming for many, as is spirituality and
prayerfulness.
• Symbolic substitutes, the principle of ascribing meaning beyond the
obvious one to objects, experiences, or people, reduce tension for
some individuals.
• Communication between organs of the body, or somatizing, also
has an effect on anxiety and stress
What do you need to cope?
• individuals need strengths and resources that they can
call on.
• Antonovsky’s Sense of Coherence (SOC) is defined as a
global orientation that the world is comprehensible,
manageable, and meaningful.
• Antonovsky theorized that people stay healthy because
they possess generalized resistance resources (GRRs).
• SOC scale was found to be a reliable, valid, and crossculturally applicable instrument to measure how
people manage stressful situations and stay well
Learning Outcome 4
Compare and contrast the common defenseoriented behaviors (defense mechanisms)
people use to cope with stress and anxiety
• Defensive coping is associated with threats to
the security of the self.
• Defense mechanisms lessen uncomfortable
feelings of anxiety and prevent pain but often
have an associated cost.
• These mechanisms are mostly unconscious
and are often inflexible.
Defense mechanism
• People may engage in: repression, suppression,
dissociation, identification, introjection,
projection, denial, fantasy, rationalization,
reaction formation, displacement, and
intellectualization.
• As we grow and mature, we are able to give up
primitive defenses and use defenses that are
more complex.
• To some extent, defensive coping serves to distort
reality and protect us from unacceptable
thoughts, wishes, or feelings
Learning Outcome 5
•
Implement nursing intervention strategies
specific to each defense-oriented behavior
listed
Nursing roles
• The nurse must address defense mechanisms within a
caring and supportive relationship.
• Address repression by being supportive and protective of
the client’s defenses. When appropriate, help the client
examine the traumatic event or situation objectively.
• For clients manifesting dissociation, provide a safe,
supportive, secure environment for clients to recall and
resolve past conflicts.
• Interventions for identification and introjection include
clarifying roles and expectations of the nurse and client,
and helping the client formulate a self-care plan and
increase self-awareness
• Nurses can deal with projection by patiently,
consistently, and respectfully assisting the client in
separating feelings from objective facts.
• When intervening in a client’s denial:
A- it is important to discern the protective function of the
mechanism.
B- Be supportive of denial if it is in the client’s best
interests.
C- If denial is harmful, help the client to focus on reality.
• Interventions for fantasy include helping the client to
gradually relinquish unrealistic expectations and make
realistic plans
Continue ….
• Help clients who rationalize by focusing on
client strengths and past successes.
• Clients manifesting reaction formation need
the nurse’s respect, support, and a secure
relationship in which to explore feelings.
• Address displacement by assisting the client to
understand the source of the anger.
• Assist clients who use intellectualization by
encouraging them to accept and explore their
emotional reactions to situations
Learning Outcome 6
• Discuss common medical conditions with an
onset or a course influenced by psychological
and behavioral factors.
• Co-occurring psychiatric disorders,
psychological symptoms, personality traits,
coping styles, poor lifestyle choices, and the
stress response itself can all affect the medical
condition by altering its course, interfering
with its treatment (outcome), or by placing
the individual at higher risk
• A multicausational concept of the illness helps
the nurse explore illness in a holistic way.
• The meaning and symbolic aspect of the
diagram reminds the nurse to individualize an
understanding of the illness by exploring it
from the client’s perspective and by
considering the disease within the context of
the individual’s culture.
• Many conditions have psychological components.
• Nurses need to be aware that treatment is not
complete unless the stress-related aspects of
illness have been investigated and individuals
helped to learn more effective coping strategies.
• Science has identified stress-related conditions in
each body system and we are learning more
about their interrelated nature all the time.
• As nurses work with individuals to increase their awareness
of stress and improve health- promoting behaviors, they
will find that these tasks are not always easy, nor do they
always result in change.
• In the course of caring for many individuals, there will be
those who gain little self awareness, cannot get past or
through the conflicts that plague them and cannot or
refuse to give up the coping strategies that they are using,
even though they are unhelpful or unhealthful.
• Some others may have motivational difficulties that are
difficult to overcome and for others the cost of delaying
gratification will prevent them from adapting more useful
behaviors