Stress Management

Stress Dr.V.Subramanian.M.B.B.S.,D. I.H Dr.K.Dhamodharan.M.Sc.,Ph. D

Three Views of Stress 1.

2.

3.

Focus on the environment: stress as a stimulus (stressors) Reaction to stress: stress as a response (distress) Relationship between person and the environment: stress as an interaction (coping)

Stressors 

Some examples?

Stressors      

War Overcrowding Deadlines Dense traffic Marital conflict Work stress

Acute vs. Chronic Stress 

Acute stress 

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Sudden, typically short-lived, threatening event (e.g., robbery, giving a speech)

Chronic stress 

Ongoing environmental demand (e.g., marital conflict, work stress, personality)

Acute Stress

Acute Stress – Rozanski 1988 

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Subjects – 39 individuals with coronary artery disease Stress tasks (0-5 minutes each):   

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Mental arithmetic Stroop-colour word conflict task Stress speech (talk about personal fault) Graded exercise on bicycle (until chest pain or exhaustion)

Acute Stress – Rozanski 1988 

Outcome – stress response 

Myocardial ischemia determined by radionuclide ventriculography (measures wall motion abnormalities in the heart)

Acute Stress – Rozanski 1988 Results 

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Cardiac wall motion abnormalities were significantly greater with stress speech than other mental stress tasks (p < .05) and was of the same order of magnitude as that with graded exercise. Wall motion abnormalities occurred with lower heart rate during stress than during exercise (64 vs. 94

Chronic Stress – Frankenhauser, 1989 

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Subjects – 30 managerial and 30 clerical workers Equal number of men and women Outcome: blood pressure, heart rate, and catecholamines measured throughout workday and non-workday.

Chronic Stress – Frankenhauser, 1989 

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No gender differences in the effect of work on BP and HR. In both men and women, BP and HR were higher on a workday than a non-workday.

Chronic Stress – Frankenhauser, 1989 Catecholamine Response 3 2.5 2 Women Men

1.5 1 0.5 0 10:00

12:00

14:00

16:00

Time of Day

18:00

20:00

Three Views of Stress 

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Focus on the environment: stress as a stimulus (stressors) Reaction to stress: stress as a response (distress) Relationship between person and the environment: stress as an interaction (coping)

Fight or Flight Response 

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Increase in Epinephrine & norepinephrine Cortisol Heart rate & blood pressure Levels & mobilization of free fatty acids, cholesterol & triglycerides Platelet adhesiveness & aggregation

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Decrease in Blood flow to the kidneys, skin and gut

Selye’s General Adaptation Syndrome (1956, 1976, 1985) Alarm Reaction Perceived •Fight or Stressor flight

Resistance •Arousal high as body tries defend and adapt.

If stress continues ….

Exhaustion •Limited physical resources; resistance to disease collapses; death

Cognitive Model of Stress Lazarus & Folkman  

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Potential stressor (external event) Primary appraisal – is this event positive, neutral or negative; and if negative, how bad? Secondary appraisal – do I have resources or skills to handle event? If No, then distress.

Cognitive Model of Stress Lazarus & Folkman 

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Primary appraisal – Is there a potential threat? Outcome – Is it irrelevant, good, or stressful? If stressful, evaluate further: 

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Harm-loss – amount of damage already caused. Threat – expectation for future harm. Challenge – opportunity to achieve growth, etc

Cognitive Model of Stress Lazarus & Folkman 

Secondary appraisal – 

Do I have the resources to deal effectively with this challenge or stressor?

Cognitive Model of Stress Lazarus & Folkman High Threat High Threat

Low High Resources Demand s High High/low Resources demands

High Stress

Low Threat

Low Low Some Resources demands stress

Low Threat

High Low Low or no Resources demands stress

Moderate Stress

Personal Factors Affecting Stress Appraisal    

Intellectual Motivational Personality Beliefs

Situational Factors Affecting Stress Appraisals       

Strong demands Imminent Life transition Timing Ambiguity – role or harm ambiguity Desirability Controllability  

Behavioural control – perform an action Cognitive control – using a mental strategy

Learned Helplessness – Seligman, Peterson, et al. 

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Dogs exposed to unavoidable shocks Following exposure, when placed in a situation where they can now jump to avoid the shock, they fail to make the escape response. Learned helplessness occurs when one perceives that one’s actions (e.g., working hard) does not lead to the expected outcome (e.g., high

Job Strain – Karasek et al., 1981 Demands High High Control Low

STRAIN

Low

Job Stress – other aspects   

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Physical environment Poor interpersonal relationships Perceived inadequate recognition or advancement Unemployment (even anticipated) Role conflict High responsibility for others

Biopsychosocial Aspect of Stress 

How stress affects health  

Via behaviour Via physiology

Behavioural Aspects     

Increased alcohol Smoking Increased caffeine Poor diet Inattention leading to carelessness

Physiological Aspects 

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Cardiovascular reactivity – increased blood pressure, platelets, lipids (cholesterol) Endocrine reactivity – increased catecholamines and corticosteroids Immune reactivity – increased hormones impairs immune function

Psychophysiological Disorders 

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Digestive system – e.g., ulcers, irritable bowel syndrome Respiratory system – e.g., asthma Cardiovascular system – e.g., hypertension, lipid disorders, heart attack, angina

Stress-Illness Relationship Preexisting Physiological physiological & psychological or psychological wear and tear vulnerability

Exposure to stress

Behavioural changes & Coping efforts

Illness

Illness precursors, symptoms Illness behaviour

Moderators of the Stress Experience

What is coping? 

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Process of managing the discrepancy between the demands of the situation and the available resources. Ongoing process of appraisal and reappraisal (not static) Can alter the stress problem OR regulate the emotional response.

Emotion-Focused Coping 

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Aimed at controlling the emotional response to the stressor. Behavioural (use of drugs, alcohol, social support, distraction) and cognitive (change the meaning of the stress). Often used when the person feels he/she can’t change the stressor (e.g., bereavement); or Doesn’t have resources to deal with the demand.

Problem-Focused Coping 

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Aimed at reducing the demands of the situation or expanding the resources for dealing with it. Often used when the person believes that the demand is changeable.

Coping responses – respond yes or no. 1. 2.

3. 4.

5.

6.

7.

Tried to see the positive side of it. Tried to step back from the situation and be more objective. Prayed for guidance or strength. Sometimes took it out on others when I felt angry and depressed. Got busy with other things to keep my mind off the problem. Read relevant material for solutions and considered several alternatives. Took some action to improve the

Problem-Focused Coping 

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Planful Problem-Solving – analyzing the situation to arrive at solutions and then taking direct action to correct the problem. Confrontive Coping – taking assertive action, often involving anger or risk taking to change the situation.

Emotion-Focused Coping 

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Seeking social support – can be either problem or emotion-focused coping. Distancing – cognitive effort to detach Escape-avoidance – wishful thinking or taking action to escape or avoid it. Self-control – attempting to modulate one’s feelings in response to the stressor. Accepting responsibility – acknowledging one’s role in the situation while trying to put things right. Positive reappraisal – create positive

Cognitive Re-structuring 

Process by which stress-provoking thoughts are replaced with more constructive one.

Gender and Coping 

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Men generally employ problem-focused coping strategies more than emotional focused strategies. Opposite for women, with women more often employing emotion-focused strategies. If men and women in same occupation, gender differences disappear, suggesting that societal sex roles influence choice of coping strategies.

Socio-economic Status (SES) and Coping 

People with higher SES tend to use problem-focused coping strategies more often (Billings & Moos, 1981).

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Why do people who have lower SES use problem-focus coping strategies less often than those with high SES?

Personality or Coping Style   

Negative affectivity Pessimism – optimism Hardiness

Life Orientation Test (Scheier & Carver) 1

2 3 4 5 6

7

8

In uncertain times, I usually expect the best. If something can go wrong for me it will. I always look on the bright side. I’m always optimistic about my future. I hardly ever expect things to go my way. Things never work out the way I want them to. I’m a believer in the idea that “every cloud has a silver lining.” I rarely count on good things happening to me.

Personality or Coping Style   

Negative affectivity Pessimism – optimism Hardiness

Social Support 

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Emotional support – expression of empathy, understanding, caring, etc. Esteem support – positive regard, encouragement, validating self-worth Tangible or instrumental – lending a helpful hand. Information support – providing information, new insights, advice. Network support – feeling of belonging

Factors Influencing Utilization or Availability of Social Support 

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Temperament – people differ in their needs for social support. Social support can be detrimental if you are the type of person who likes to handle things on your own. Previous experience with social support influences your likelihood of seeking out social support in the future.

Threats to Social Support 

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Stressful events can interfere with your ability to use social supports. People under stress may become so focused on talking about their problems that they drive their support systems away. Supports agents may react in a way that makes the problem worse. Support providers may be adversely effected by providing support.

Alxheimer’s Disease (AD) – Effect on Caregivers 

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Subsample of the Cardiovascular (CVD) Health Study, a prospective study of risk factors for CVD in the elderly. Excluded: disabled confined to wheel chair, unable to attend field centres, or undergoing cancer treatment. Caregivers defined as those whose spouse had difficulty with one activity of daily living due to physical or mental health problem. 392 caregivers and 427 non-caregivers

AD – Effect on Caregivers 

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Caregivers were asked to rate the degree of mental and physical strain associated with caregiving (3-point response format). Sample subdivided into four groups: noncaregivers; spouse disabled but not helping him/her; caregiver but no reports of strain; and caregiver with reports of strain. Followed for 4.5 years (range 3.4 – 5.5 years). Main outcome – mortality (100% follow-up

AD – Effect on Caregivers Results 

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81% of caregivers were providing care. 56% reported caregiver strain. Mortality – 9.4% in non-caregivers; 17.3% in ‘caregivers’ not providing care; 13.8% in non-strained caregivers; and 17.3% in strained caregivers.

Generally Social Support Associated with Good Effects 

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Increase survival rates in women who have breast cancer. Lower blood pressure Decrease risk of mortality

Psychological Predictors of Sudden Cardiac Death in CAMIAT J. Irvine, A. Basinski, B. Baker, S. Jandciu, M. Pickett, J. Cairns, S. Connolly, M. Gent, R. Roberts, & P. Dorian, Psychos Med 1999 Funded by Heart and Stroke Foundation of Ontario

Psychosocial Predictors of Sudden Cardiac Death in CAMIAT Measures: 

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Cook-Medley Index: measures of hostility, anger, cynicism Beck Depression Inventory Symptom Checklist-90: psychological distress Social Support: measures of social participation, network and perceived social support

Psychosocial Predictors of Sudden Cardiac Death Variable

Relative Risk 2.86

1.37 – 5.99 0.005

Hx CHF

3.86

1.89 – 7.89 0.001

Depress. – P

2.48

1.14 – 5.35 0.02

Depress. - A

0.52

0.15 – 1.76 0.29

Network Cont.

1.04

1.00 – 1.06 0.01

Social Activities

0.98

0.96 – 1.00 0.05

Previous MI

95% CI

p

Stress Management

Stress Management – teaches coping techniques 

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Reduce harmful environmental conditions Teaches techniques by which person can develop stress tolerance. Helps client maintain a positive selfimage. Help maintain emotional equilibrium. Help client maintain or develop satisfying relations with others.

Cognitive Therapy – Albert Ellis, Aaron Beck 

Assumes that stress arises or is augmented by faulty or irrational ways of thinking. 

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Catastrophizing – “It is awful if I get turned down when I ask for a date”. Overgeneralizing – “I didn’t get a good grade on this test. I can’t get anything right”. Selective abstraction – Only seeing specific details of the situation (e.g., Seeing the

Cognitive Therapy 

Often these irrational beliefs or faulty thinking errors stem from past “programming”. 

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E.g., Not receiving adequate love and nurturance as a child may lead to feelings that loved ones in the present don’t “quite love you enough”.

Hypothesis testing – client is encouraged to test out these irrational beliefs by collecting evidence for or against the belief.

Cognitive Therapy  

Errors in Information Processing Irrational Thinking Errors include:     

Emotional reasoning Overgeneralization Catastrophic thinking Mind reading Selective negative focus, etc.

Relaxation Therapy 

Aims to either reduce hyperarousal or curb emotional-physiological reactivity.    

Progressive muscular relaxation Mental imagery Meditation Autogenic training

Time Management 

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Set short-term (e.g., daily) and longterm (e.g., yearly) goals. Make daily to-do lists (prioritize each). Make a daily schedule for when and where you will carry out your to-do list items (estimate time allocated for each to-do item). Revise throughout the day as needed.