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STRESS AND COPING Stress is generally known as pattern of disruptive physiological and psychological reaction to events that threaten the ability to cope. It has become an important topic because it is clear that the pattern of disease, especially cardiovascular disease, and other diseases such as gastrointestinal and respiratory diseases cannot be explained simply by physiological factors alone. However, because stress involves some complicated process and mechanisms, as well as divers external and internal variables, it is considered as a multidimensional concept. Conceptualizing stress as a unitary concept has been abandoned and some authors called for using terms like adversity and adverse live events, in addition to stress and life event stress. All these terms is meant to emphasize the multidimensionality of the term. Within a biopsychosocial model of health, it has been suggested that the complex interaction of a person’s biology, psychological state, and social environment determine whether they become ill or not. There are many approaches to the study of stress. One of these is the attempt to identify the events in our life that cause stress. The second one is to analyze the personal factors that shape our response to those events. And still a third approach is to trace the physiological consequences of stress. The following is a summary of three main theoretical approaches to the understanding of stress. So, Researchers have conceptualized stress in three Ways. In one approach, stress is seen as a stimulus, and studies focus on the impact of stressors. Another approach treats stress as a response and examines the strains that the stressors produce. The third approach views stress as a process that involves continuous interaction and adjustmentor transaction- between the person and the environment. These viewpoints have led to the definition of stress as the condition that results when a person/environment transactions leads the individual to perceive a discrepancy between the demands of the situation and the resources of the person’s biological, psychological, and social systems. (A)The Response-Based Model of Stress: (1)This model emphasizes the common physiological consequences of stressful situation. It is represented in the well-known theory of Hans Selye. It is similar to the “Fight or Flight” response, which occurs in situation that perceived as very threatening. The response is a physiological one in which arousal of the sympathetic nervous system results in many physiological and somatic changes and finally disruption of homeostasis. (2)Selye developed this idea into a theoretical model of stress called the General Adaptation Syndrome theory. He defined stress as (a non-specific response and demand made upon the body). He proposed that different types of stimuli would result in similar physiological responses. (3)The GAS theory has three phases, which is based on the hypothesis that the body has normal level of resistance to stress. (a) Phase (I): Initial alarm resulting in a slight reduction in the resistance to stress, (The Shock stage). Then reverts to the normal level in the (Counter-shock Stage,).
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(b)
Phase (II): RESISTANCE remains high until the final stage of exhaustion, where resistance rapidly drops.
(c)
Phase (III): which starts with exhaustion and described as Collapse, where disease occurs.
So, according to this model, stressors produce strain in the person’s biological, psychological, and social systems. Emergency situations evoke a physiological fight-orflight reaction, by which the organism prepares to attack the threat or flee. When stress is strong and prolonged, the physiological reaction goes through three stages: the alarm reaction, the stage of resistance, and the stage of exhaustion. This series of reactions is called the general adaptation syndrome. According to Selye, continuous high levels of stress can make the person vulnerable to diseases of adaptation, including ulcers and high blood pressure. Psychosocial factors influence the physiological reaction to stress. Critics of the GAS theory say that the theory fails to account for individual differences in the development of stress-related illness and, further, it underestimate the multidimensional nature of stress. (B)The Stimulus-Based Model of Stress: (1)Holmes and Rahes advanced this theory. It proposed that life changes (LIFE EVENTS) or (STRESSORS), either positive or negative, are stressors that tax the adaptation capacity of an individual, causing physiological and psychological strains that lead to health problems. (2)They developed the Social Readjustment Rating Scale (SRRS). They hypothesized that people with higher scores in the SRRS, -that is major life changes-are more likely to experience physical or mental illness. (3) There is some supporting evidence to this, but the correlation is fairly low. Moreover, this theory was criticized as ignoring the cognitive aspects of the effects of stress. In other words, it does not account for the individual appraisal of the meaning of various life events. (C) The Transactional Model of Stress: (l) Lazarus& Folkman_(1 98Q) proposed the third approach. They criticized the first and the second models mentioned above as treating people as machines. They believe that people have the capacity to think, evaluate, and then react. Thinking can make stress either better or worse. (2)Lazarus developed an interaction theory, which emphasize the role_of cognition. This theory proposed that people engage in TWO-STAGE PROCESS of appraisal: (1)
A Primary Appraisal Process: Determine whether the event represents a threat to the individual. This results in three outcomes: (a) Events regarded as irrelevant. (b) Events regarded as positive to well being. (c) Events regarded as negative to well being. This negative appraisal leads to:
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(II) A Secondary Appraisal Process: Here the individuals assess their COPING RESOURCES. These resources include environmental factors, social support or help, knowledge and skills to reduce this threat. (3)Coping with potential threat also d depends on COPING STYLE. The outcome of appraisals of the situations and the available resources is the coping response or COPING STRATEGY. (4)COPING STRATEGIES: Some psychologists differentiate between Emotion-Focused and Problem Focused strategies. In the former type, the objective is to reduce the feeling of distress and anxiety, for example denying the existence of a disease. In the second type of coping strategy, problem-focused, the individual concentrate on the problem and actively seeks solutions to deal with the situation. (5)Other distinctions between types of coping strategy include active versus passive strategy, and approaching versus avoidance coping strategy. (6) When coping outcomes are positive such as accepting the death of a relative or passing an exam, a psychological adjustment or adaptation takes place. However, unsuccessful coping leads anxiety and depression. Maladjustment or maladaptation is more frequently associated situation when Primary or Secondary Appraisals fail to identify an appropriate course of action. These may include: a)
Uncertainty: “I don’t know what is going on” Primary Appraisal.
b)
Unpredictability: “I don’t know what is going to happen “Primary Appraisal~.
c)
Uncontrollability: “I don’t Know what to do about it” Secondary Appraisal. OR “There is nothing that I can do” Secondary Appraisal“. OR There is nothing anyone can do” Secondary Appraisal.
Stress, Biopsychosocial Factors, and Illness Researchers have identified several psychosocial factors that modify the impact of stress on the individual. One of these factors is social support—the perceived comfort, caring, esteem, or help a person receives from other people or groups. There are five basic types of support: emotional, esteem, tangible or instrumental, informational, and network. Whether people receive social support or not, depends on characteristics of the recipients and providers of support and on the composition and structure of the social network. Social support appears to reduce the stress people experience and generally enhance their health. The greater the degree of support people have, the lower their mortality rates and likelihood of becoming ill. Another psychosocial modifier of stress is the sense of personal control people has over the events in their lives. Personal control includes beliefs about one’s locus of control— that is, whether control is internal or external to the person—and self-efficacy. People acquire a sense of personal control from their successes and failures and through the process of social learning. Individuals who experience prolonged, high levels of stress and have a weak sense of personal control tend to feel helpless. The cognitive process of attribution seems to be important in the development of learned helplessness. A strong sense of personal control tends to benefit people’s health and
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help them adjust to a serious illness if it occurs. Hardiness is another psychosocial modifier of stress. Hardy individuals have a strong sense of control, commitment, and challenge; they tend to remain healthier when under stress than individuals who are less hardy. The effects of hardiness, social support, and exercise appear to add to each other in protecting people from illness. One other psychosocial modifier of stress is people’ s tendency toward either the Type A or the Type B behavior patterns. The Type A behavior pattern consists of three characteristics: competitive achievement orientation, time urgency, and anger or hostility. Compared with Type Bs, Type A individuals respond more quickly and strongly to stressors both in their overt behaviors and in their physiological reactivity. The Type A pattern—particularly the anger/hostility component—is associated with the development of coronary heart disease (CHD). Both biological and psychosocial factors affect the development of the Type A and B behavior patterns. Negative affectivity Negative affectivity is a pervasive negative mood marked by anxiety, depression and hostility. High negative affectivity is associated with greater distress, more drinking, more likely to be depressed, poorer health, greater reports of physical symptoms, and they are more likely to commit suicide Pessimism – optimism Pessimism-optimism –pessimists more likely to attribute negative events in their lives to internal (something wrong with me), stable (never going to change), and global (effects all aspects of my life) qualities. Pessimists generally associated with poorer health and premature mortality. Optimists on the other hand have better health, engage in more effective coping strategies, and are more likely to engage in self-management health care practices. Stress affects health in two ways. First, stress can affect health-related behaviors, such as alcohol and cigarette use. Second, it produces changes in the body’s physical systems, as when the endocrine system releases catecholamines and corticosteroids, which can cause damage to the heart and blood vessels and impair immune system functioning. The physiological effects of intense stress can even lead to sudden death. Psychoneuroimmunology is a new field of study that focuses on how psychosocial processes and the nervous, endocrine, and immune systems are interrelated. Stress also plays a role in many psychophysiological disorders, such as ulcers, asthma, chronic headache, rheumatoid arthritis, and several skin disorders. In addition, stress is implicated in the development of hypertension, CHD, and cancer. STRESS, ILLNESS, AND COPING Coping is the process by which people try to manage the real or perceived discrepancy between the demands and resources they appraise in stressful situations. We cope with stress through transactions with the environment that do not necessarily lead to solutions to the problems causing the stress. As we said in page 3 above, coping serves two types of functions. The function of emotion-
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focused coping is to regulate the person’s emotional response to stress. This regulation occurs through the person’s behavior, such as using alcohol or seeking social support, and through cognitive strategies, such as denying unpleasant facts. People tend to rely on emotion-focused coping when they believe they cannot change the stressful conditions. The function of problem-focused coping is to reduce the demands of the stressor or expand the resources to deal with it, such as by learning new skills. People tend to use problem-focused coping when they believe they can change the situation. Adults report using more problem-focused than emotion-focused coping approaches when they experience stress. People use a wide variety of methods in coping with stress. These methods include direct action, seeking information, turning to others, resigned acceptance, emotional discharge, and intrapsychic processes. The strategies within intrapsychic processes include cognitive redefinition and the defense mechanisms of denial, intellectualization, and suppression. Some of these methods tend to increase the attention the person gives to the problem, and other methods promote avoidance of the problem. There is no one best method of coping and no method is uniformly applied or effective with all stressors. People tend to use a combination of methods in coping with a stressful situation. Although coping changes across the life span, the exact nature of these changes is unclear. Young children’ s coping is limited by their cognitive abilities, which improve throughout childhood. During adulthood, a shift in coping function occurs as people approach old age—they rely less on problem-focused and more on emotion-focused coping. Elderly people seem to regard stressors as less changeable than middle-aged individuals do. People can reduce the potential for stress in their lives and others’ lives in several ways. First, they can increase the social support they give and receive by joining social, religious, and special interest groups. Second, they can improve their own and others’ sense of personal control and hardiness by giving and taking responsibility. Also, they can reduce frustration and waste less time by organizing their world better, such as through time management. And, by exercising and keeping fit, they can reduce the experience of stress and the impact it has on their health. Lastly, they can prepare for stressful events, such as a medical procedure, by improving their behavioral, cognitive, and informational control. Sometimes the coping skills individuals have learned are not adequate for dealing with a stressor that is very strong, novel, or unrelenting. A variety o stress management techniques is available to help people who are having trouble coping effectively. One technique is pharmacological, that is, using prescribed drugs, such as beta-blockers. Behavioral and cognitive methods include progressive muscle relaxation, systematic desensitization, biofeedback, modeling, and cognitive/behavioral approaches. Rational emotive therapy (RET) attempts to modify stress- producing, irrational thought patterns through process of cognitive restructuring. Stress-inoculation training is designed to teach people skills to alleviate stress and achieve personal goals. Stress-inoculation training is an example of multimodal therapy in it uses a variety of techniques that are designed reduce specific components of the person’s problems. Beneficial effects have been found for all of the behavioral and cognitive stress management methods, particularly relaxation. Meditation and hypnosis have shown promise for reducing stress, too. Stress management techniques can reduce coronary risk modifying Type A behavior and by treating hypertension.
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(D)
COPING WITH MEDICAL PROCEDURES:
(1)Medical procedures including investigation or treatment may create potential threat or stressful experience. Even minor procedure, such as having chest X-Ray, can cause anxiety because of the Uncertainty involved. (2)Causes of anxiety prior to surgery include various types of worries that are related to lack of information, uncertainty, and unpredictability. (3)Several programs have been suggested to prepare the patient psychologically for surgery. Many different methods have been suggested. These are based on Behavioral Therapy and Cognitive Therapy that describes specific strategies for the reduction of anxiety. (4)Methods used in this situation include providing the patient with procedural, sensory, and behavioral information. Relaxation training, Modeling, and teaching other CognitiveBehavioral Coping Response, such as positive self-talk modeling, assertion have also been applied successfully. Finally, it should be recalled that the concept of stress is no longer valid as unitary concept. It is multidimensional in the sense that it involves several interrelated factors. In addition to what we have mentioned earlier, interpersonal factor, such as Social Support, influences the way stress affects health. Interapersonal factors, such as Attribution Style, Locus of Control, Type A behavior Pattern, also mediate the experience of stress and affect our coping and health. Prepared by Dr. Mohamed Salah Khalil Assistant professor /consultant of Clinical Psychology