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 WashingtonState. 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.