Stress

STRESS

Dr. Jayesh Patidar

www.drjayeshpatidar.blogspot.com

Introduction

“Hans selye” repeatedly posited the existence

of general life stressors of importance for

many, if not all, disease. Examples of his

general stressors were heat, cold and hunger.

“Walter B. Cannon”, whose work on emotions

and physiological reactivity antedated Selye’s

studies, produced evidence concerning the

specificity of stresses on body systems. He

illustrated that the sound of a barking dog was

a specific stress that caused a cat to cease

digestion for almost one hour.

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“James Henry” summarized different

stress response patterns that depended

on subject’s differing perception of life

stressors.

Perceptions of recent stress seen as

overwhelming, leading to behaviors of

submission & defeat, resulted in marked

elevations in serum cortisol & prolactin

concentrations, with no change in serum

catecholamines.


Although stressors, or stress –producing

factors, vary such as physical stressors of

heat and cold and psychological stressors

of failure, success and a new challenge they

elicit essentially the same biological stress

response, stress is neither a synonym for

distress, anxiety and tension, not something

to be avoided at all costs. The absence of

all stress is according to selye, death.


According to selye’, damaging stressors ( e.g. Anxiety, frustration, insecurity, aimlessness) may result in various physical and emotional disorders, such as migraine headache,, peptic ulcer, myocardial infarction (heart attack), hypertension, suicide, mental illness and hopeless unhappiness. Stress is associated with manifestations of physical illness (e.g. Myocardial infarction), mental disorders (e.g. Post – traumatic stress disorder) and social disruption (eg. Divorce). It can also interfere with the best treatment and rehabilitation efforts.


Definitions

“Relationship between the person and the

environment that is appraised as exceeding the

person’s resources and endangering the person’s

well – being.”

According to Hans Selye “Stress as the nonspecific

response of the body to any demand made upon it.”

Richard Lazarus’ definition of stress focuses on the

relationship between the person and the

environment is taxing or beyond his or her

resources and harmful to his or her well – being.

Therefore, how the person appraises the situation

determines whether it is perceived as stressful.”


“Stress is considered to the process of adjusting

to circumstances that disrupt, or threaten to

disrupt, a person’s equilibrium.”

(Lazavus and Forlmen, 1984)

Stress is also the appraisal, or perception, of a

stressor.

“Appraisal is how people interpret the impact of

the stressor on themselves, of what is happening

and what they can do about it.”

(Lazarus 1999)

“Stress is a general term that links environmental

demands and the person’s capacity to meet those

demands.”

(Kasl 1992) 30/04/2015 www.drjayeshpatidar.blogspot.com 7

Types of stress

According to “selye” there are two types –

Distress or damaging stress.

Eustress or stress that protects health.

Eustress is motivating energy, such as

happiness, hopefulness and purposeful

movement.


According to Lazarus, (1999) there are several types

of stress –

Work stress,

Family stress,

Chronic stress,

Acute stress,

Daily hassles,

Trauma,

Crisis.

“Work and family stress interact, family being the

background for work stress, and work the

background for family stress.”


Lazarus suggests a spillover of stress

between work and home. The individual

with family responsibility and a full time

outside the home may experience chronic

stress.

Chronic stress occurs in stable conditions

and from stressful roles. Chronic stress is

living with a ling – term illness.

Acute stress is provoked by time – limited

events that are threatening for a relatively

brief period.


Stress Responses

Physiological Responses

Emotional responses.


Physiological responses

Physiological changes are automatic and not

under control.

Their intensity will depend on the appraised

risk of the situation.

Both the immune system and the sympathetic

nervous system are implicated in the stress

response.

The locus cells in the brain initiated the stress

response by responding to the appraisal with

the neither release of nor –epinephrine.


It stimulates the sympathetic nervous system responds by discharging almost as a complete unit, causing excitatory effects in some organs and inhibitory effects in others.

This “mass discharge” activates large portions of the system and is called a sympathetic alarm reaction or the “fight or flight” response.

Sympathetic Responses: -

Increased arterial pressure.

Increased blood flow to active muscle concurrent with decreased blood flow to organs that are not needed for rapid motor activity, such as the gastrointestinal tract and kidneys.


Increased rater of cellular metabolism through – out the body.

Increased blood glucose concentration.

Increased glycolysis in the liver and in muscle.

Increased muscle strength.

Increased mental activity.

Increased rate of blood coagulation.

One of the structure that is stimulated during the sympathetic nervous system discharge is the adrenal gland through activation of the hypothalamic – pituitary – adrenal (HPA) axis.

Not all appraisals provoked a severe “fight or flight” response.


Chronically unfavorable person – environment

relationships also elicit both sympathetic and

immune system responses.

Academic examinations, job strain, care giving

for a family member with dementia, marital

conflict, and daily hassles elevate white blood

cell counts and lower these for T, B, and NK

cells.

Negative moods (chromic hostility,

depression, and anxiety) also adversely affect

the immune system.


If the stress is long term, the immune

alteration continues. (Hayes, 1995; Herbert &

Cohen, 1993)

Social isolation also has a negative effect on

immune functioning, especially in the elderly,

the poor, and African Americans (House etal.,

1988).

The biological responses to stress

compromise a person’s health status.

The responses of the neuro hormonal and

immune systems can precipitate more severe

stress responses.


Emotional response

After cognitive appraisal of a person

experiences specific emotions while

physiologic changes are occurring.

Lazarus defines emotions as organized

psychological reactions.

The emotion of the person experiences

depends on the significance of the person –

environment event to his or her personal well –

being.

If the emotion is intense, a disturbance in

intellectual functions occurs. 30/04/2015 www.drjayeshpatidar.blogspot.com 17

Emotions are developed through a process:

Anticipation,

Provocation,

Unfolding, and

Outcome

According to Lazarus, emotions are categorized

as: -

Negative emotions: -These occur when there

is a threat to delay in, or thwarting of a goal or

a conflict between goals: anger, fright, anxiety,

guilt, shame, sadness, envy, jealousy and

disgust. 30/04/2015 www.drjayeshpatidar.blogspot.com 18

Positive emotions: - These occur when there is

movement toward or attainment of a goal: happiness,

pride, relief and love.

Borderline emotions: - These are somewhat

ambiguous: hope, compassion, empathy, sympathy,

and contentment,

Non emotions: - Connote emotional reactions but are

too ambiguous to fit into any of the preceding

categories: confidence, awe, confusion, and

excitement.

Therefore, the stress response is an automatic and

sometimes intense bio - psychological reaction in

response to an appraised unfavorable person –

environment situation. The physiologic responses

involve the environment situation. 30/04/2015 www.drjayeshpatidar.blogspot.com 19

Theories of stress

Hans Selye’s theory.

Aldwin’s immunological responses.

Neuro pharmacologic Theories.

Walter Canon ’s homeostasis mechanism.

“Harold Wolff” and “Stewart Wolf” theory.


Hans Selye’s theory

In the 1930s, 1940s,and 1950s Hans Selye

enlarged on cannon’s fight – or – flight

hypothesis to describe the general adaptation

syndrome ( GAS), a three – stage reaction to

stress.

The GAS describes how the body responds to

stressors through the –

Alarm reaction,

Resistance stage, and

Exhaustion stage.


The GAS is an immediate physiological

response of the body to stress and involves

several body systems, especially the

autonomic nervous system and the endocrine

system. When a physical demand is made on

the body, such as an injury, the GAS is

initiated by the pituitary gland. The pituitary

gland is closely linked to the hypothalamus.

That secretes endorphins.

Endorphins are hormones that act on the mind

like morphine and opiates, producing a sense

of well – being and reducing pain.


Alarm reaction: -

During the alarm reaction rising hormone levels result in increased blood glucose levels, epinephrine and nor epinephrine amounts, heart rate, blood flow to muscles, oxygen intake, and mental alertness.

In addition, the pupils of the eyes dilate to produce a greater visual field. This change in body systems prepares an individual for fight or flight and may last from 1 minute to many hours. If the stressor poses an extreme threat to life or remains for a long time, the person progress to the second stage, resistance.


Resistance stage: -

During the resistance stage the body stabilizes

and responds in an opposite manner to the

alarm reaction.

Hormone levels, heart rate, blood pressure

and cardiac output return to normal and the

body repairs any damage that may have

occurred.

If the stressor remains, and there is no

adaptation the person enters the third stage,

exhaustion.


Exhaustion stage: -

This occurs when the body no longer the

effects of the stressor and when the energy

necessary to maintain adaptation is depleted.

The physiological response is intensified, but

the person’s energy level is compromised, and

adaptation to the stressor diminishes.

The body is unable to defend itself against the

impact of the event, physiological regulation

diminishes, and if the stress continues, death

may result.


Selye (1991) noted that a prolonged state of

stress can cause disease. Stress can make

people ill as a result of –

Increased levels of powerful hormones that

change our bodily processes;

Coping choices that are unhealthy such as not

getting enough rest or a proper diet or use of

tobacco, alcohol, other substance, or caffeine:

and

Neglect of warning signs of illness or failure to

adhere to prescribed medicines or treatments.


Aldwin’s immunological responses theory

Physiological responses to stress also include immunological responses.

The immune system differentiates between self and oneself, so that under normal conditions one’s own cells are not treated as threats, In the way that bacteria, viruses, parasites, or toxins are treated.

Typically the immune system recognizes bacteria, for example, as a threat and attacks them.


An antigen on the surface of the bacteria cells

identifies the bacteria as invaders. After being

exposed to a particular antigen, the immune system

remembers how to respond to that antigen and is

prepared to respond with antibodies when the same

antigen appears at a later time.

A virus might cerate an antigen that is very similar to

a naturally occurring protein and the immune system

would attack it as if it were a threat.

Problems occur when the immune system

misinterprets antigens and makes a too vigorous

response, leading to an autoimmune illness.

The mechanism through which stress affects the

immune system is unclear.


Neuro pharmacologic Theories Acute stressors lead to dysfunction in the

hypothalamic – pituitary – adrenal (HPA)

axis.

In contrast to chronic stress disorders, acute

stress in both animals and humans results in

the release of stress hormones.

These corticosteroids aid the body’s

physiological and perhaps psychological

response to stress.


Canon describes “that an individual gas a

homeostasis mechanism. Homoeostasis is

defined as the maintenance of a normal

steady state in the body fluid and electrolyte

balance body temperature control and

nervous system control are examples of

homeostatic mechanism equilibrium.”

Canon explained Flight Fight alert of the body

to stress. Disease is viewed as a fight to

maintain the haemostatic balance of the body

tissues.


The stress theory has contributed towards in

understanding the nature and causes of

diseases.

The work of Walter Canon, Harold Wolff,

Hand Gelye and R.S. Lazarus is significant in

this theory.

It describes that certain stimulus perceived

as threatening cause reactions which have

adverse emotional, behavioral and

physiological reactions.


“Harold Wolff” and “Stewart Wolf” theory.

The systemic research of the internists “Harold

Wolff” and “Stewart Wolf” has served as a model

for scientific investigations.

One of wolff’s fundamental premises was that disease

is a failure or inability to adapt to life stress.

Wolff’s thirty heralded the concept that the way in

which a person is able to cope with a stressful event

is a critical factor in determining the magnitude of

subsequent physiological effects. Events are depend

to be stressful only if the person perceives that the

stress threatens life, well – being or emotional

security.


Wolff and wolf also observed that the physiological states of the gastrointestinal tract appear to correlate with specific emotional states (hyper function with hostility and hypo function with sadness).

They regarded such reaction as relatively nonspecific, believing that the patient’s reaction is determined by the general life situation and perceptual appraisal of the stressful event.

Wolff also emphasized that the capacity to adapt to a threatening even determines the nature and the severity of psycho physiological response patterns. Familial discord, emotional deprivation, foal frustration, object loss, separation, and unemployment were emphasized.


ASSESSING HUMAN RESPONSES TO STRESS

Stress responses vary from one person to another.

Some people have primarily somatic responses, such as headaches, dermatitis, flushing, or stomach pains.

Some experience fear and apprehension or withdraw from social situations.

The nurse must consider many aspects during nursing assessment they are:

The situation

The biological responses

The emotions &

The coping responses.

From the assessment data, the nurse can determine any illnesses, the intensity of the stress response, and effectiveness of coping strategies.


Biological Assessment

Careful health history, focusing on past and

present illness in the assessment.

An illness or a recent trauma may be either a

result of or a contributing factor to stress.

If a psychiatric disorder is present, psychiatric

symptom may spontaneously reappear.

Nurses should also pay special attention to

disorders of the neuro endocrine system,

such as hypothyroidism because these

illnesses can affect the person’s ability to

deal with stress.


Review of systems

Physiological responses to stress result from

the activation of the sympathetic nervous

system and the immune system.

Biological data are useful for analyzing the

person – environment situation and the

person’s stress reactions, coping responses

and adaptation.

Physical functioning

Physical functioning usually changes during a

stress response.


Sleep is disturbed.

Appetite either increases or decreases,

Body weight fluctuates &

Sexual activity changes

Body language expresses muscle tnsion, which

conveys a state of anxiety may not usually present.

Because exercise is an important strategy in stress

reduction.

The nurse should assess the amount of physical

activity, tolerance for exercise, and usual exercise

patterns.

Determining the details of the person’s exercise

pattern can help on formulating reasonable

interventions.


Pharmacological Assessment

In assessing a person’s coping strategies, the

nurse needs to ask about the use of alcohol,

tobacco, marijuana, and any other addictive

substances. Many people begin or increase

the frequency of using these substances as a

way of coping with stress.

Knowing detail about the person’s use of

these substances (number of times a day or

week, amount, circumstances, side effects)

helps in determining the role these

substances play in overall stress reduction or

management. 30/04/2015 www.drjayeshpatidar.blogspot.com 38

The nurse should carefully assess the use of

any drugs to manage stress symptoms.

If someone is using medication as a primary

coping strategy, he or she may need further

evaluation and referral to a mental health

specialty.

If the person is being treated for a psychiatric

symptoms are reappearing.


Psychological Assessment

Psychological Assessment focuses on the person’s

emotion and their severity and his or her coping

strategies. The nurse can then understand how

vulnerable the person is to stress.

Using therapeutic communication techniques, the

nurse assess a person’s emotional state in a nurse

patient interview.

Emotions have different behavioral manifestations

(tears for sadness, tenseness for anxiety), these

responses can be indicators of specific emotions.

Identifying the person’s emotions can be helpful in

assessing the intensity of the stress being

experienced.


Emotions often thought of as negative (anger, fright, anxiety, guilt, shame, sadness, envy, jealousy, and disgust) are usually associated with an inability to cope and severe stress.

After identifying the person’s emotions, the nurse determines how the person reacts initially to them.

Ex: - Dose the person who is angry responds by carrying out the innate urge to attack someone whom the person blames for the situation? Or doer that person respond by thinking through the situation and overriding the initial innate urge to act?

The nurse should consider a nursing diagnosis of ineffective coping. For the person who can resist the innate urge to act and has developed coping skills, the focus of the assessment becomes determining their effectiveness.


Social Assessment

The ability to make healthy lifestyle changes

is strongly influenced by the person’s health

beliefs and family support system.

Even the expression of stress is related to

social factors, particularly cultural

expectations and values.

The assessment should include discovering

the person’s social network, social support,

and underlying socio cultural attitudes and

beliefs that relate to the current stress.


Recent life changes: - Assessment should include use of the life change event questionnaire to determine the number and importance of life changes that the patient has experienced within the past year.

If several recent life changes have occurred, the person – environment relationship has changed.

Social Network and Social Support

The nurse should determine the significance of the unemployment, if a person is unemployed, and its effects on the person’s social network.

For children and adolescents, nurses should note any recent changes in their attendance at school.


The nurse should elicit

Size and extent of the network, both relatives and non

relatives, professional and nonprofessional, and how

long known.

Function that the network server (e.g. Intimacy, social

integration nurturance, reassurance of worth, guidance

and advice, access to new contacts)

Degree of reciprocity between the patient and other

network members, that is, which provides support to

the patient and who the patient supports.

Degree of interconnect ness, that is, how many of the

network member know one another and are in contact.

The nurse should assess both the supportive and non –

supportive relationships within the patient’s

environment. 30/04/2015 www.drjayeshpatidar.blogspot.com 44

Malone social Network inventory (MSNI)

It is a scale that assess a person’s social

relationships by using an open – ended

interview format.

The patient can use this inventory to assess

the helpfulness of those who mist and least

affect his or her life and to determine those

who are members of the patient’s formal &

informal groups (eg. work, clubs, and religious

organizations).


The MSNI elicits the some information

o Who is in the network?

o The relationship (e.g. Spouse, child, minister)

o A brief description of what each relationship

provides.

o The degree of helpfulness.

o The expected degree of helpfulness (Malone,

1988)


On the inventory, the patient responds

o Highest as to how helpful each person in the

environment. Next the patient responds to

how helpful they should be a variation in

scores between how helpful the person is

and how helpful he or she should be gives a

dissonance score.

o The discrepancy between the reality of the

relationship & what the person would like the

relationship to be the higher the score, the

higher the dissonance.


Post traumatic stress disorder Definition: - “An area of stress and psycho physiological

response that is critically influenced by a person’s perceptions of stress, psychological defenses, and coping capabilities is that of posttraumatic stress disorder (PTSD).”

History: -

PTSD is a modern term, which first appeared in the diagnostic and statistical manual of mental disorders (DSM III) the disorder was described in the English medical literature more than 100 year ago.

Modern recognition of PTSD came from observations made by combat medical officers in both world wars, from studies of disaster victims, and through the experiences of psychiatrists and psychologist. 30/04/2015 www.drjayeshpatidar.blogspot.com 48

Criteria for the diagnosis in the fourth edition

of DMS (DSM – IV) differentiate the acute

(duration of symptoms of less than three

months) from the chronic forms (symptoms

lasting three month or more)

The disorder also can be noted to be of

delayed onset (symptoms beginning at least

six months after the stressful event).

Persons suffering from acute PTSD show

classic symptoms of the disorder over the

first days to weeks following their trauma.


Their perceptions of the event are generally

accurate and their uses of psychological

defenses are transitory.

Those who develop the chronic disorder

evidence distorted perceptions of the

traumatic event, and their uses of

psychological defenses are often excessive

and persistent.

Delayed onset PTSD shows much the same

pattern as the chronic type, with even more

emphasis on defense mechanisms, such as

denial, repression, and projection.


Acute stress disorder

This diagnosis in DSM – IV refers to persons

who show PTSD symptoms in the days

following their exposure to a traumatic event

but recover with one month.

The phenomenon might be referred to as

normal stress and recovery.

One month might be rather brief as a defining

period, in that time the majority of disturbing

symptoms will be seen to be in clear

remission with an acute stress disorder.







Education

Stress