"Stress and coping: Cause or consequence?"

R. FieldingDepartment of Community

Medicine, HKU.

Objectives:

• distinguish between the different models conceptualizing stress.

• demonstrate an understanding of the relationship between demands and resources in the generation of threat

• characterize those types of situations most likely to generate stress, giving a range of clinical examples.

The role of “threat”

Threat is the anticipation of harm.

Threat experience 1

Threat experience 2

• This harm can be physical, emotional, financial, social, or in any other form.

• Anticipated harm reflects some evaluation that the person has made. This evaluation is called Primary Appraisal.

Demands and resources

• Primary appraisal is the judgement of the potential mismatch between the perceived demands and perceived resources available to deal with those demands.

• If primary appraisal concludes that perceived demands exceed perceived resources, then threat of harm can cause the individual to experience the feelings sometimes referred to as “stress”.

Coping

• 2 major categories of coping :– coping to tackle demands (problem-focused)– coping to control emotional reactions (emotion-

focused).

• Coping may be effective and contribute to resolving the demands or emotions, when it is called “adaptive”.

• Coping may be effective but cause other problems, then it is said to be “maladaptive”.

Secondary Appraisal

• Secondary appraisal: The evaluation of coping effectiveness: coping appraised as.. – effective, then threat is avoided, and “stress”

symptoms not usually experienced (hassles)– marginally effective, increased or modified

coping efforts made, increased cost on resources, and/or high stress if harm great.

– ineffective, emotion-focused coping or passive withdrawal, e.g. helplessness, depression, “giving-up”.

Maladaptive coping• Sources of maladaptive coping:

– adopting harmful activities in response to demands during maturation(e.g. substance use)

– successful early coping and unwillingness to abandon coping that is no longer effective (immaturity)

– maladaptive coping patterns from parents/ peers/ society (e.g. aggression, striving to maintain control, coping over-exertion)

– maladaptive coping due to limited opportunity to learn more adaptive responses (dysfunctional social environment)

Indicators of stress• Cognitive:

– concentration/memory difficulties– disruption of cognitive performance

• Emotional:– fear/anxiety, depression, fatigue

• Behavioural: – irritability, withdrawal, vegetative disturbances– unpredictability

• Physiological:– cvs, immunological, dermatological, hormonal, GI, GU

changes

Arousal-performance curve

Determinants of stress• Which circumstances are most stressful?• Stimulus conditions:

- a stimulus’ potential for harm is great or lethal

- the stimulus impact imminent

- there is a high degree of ambiguity in significance of cues signaling stimulus impact

• Respondent conditions:

- motivational strength is low

- general beliefs about environment transactions reflect marginal perceived control

- available intellectual resources, education, etc

Stress in clinical situations

• Patients: When...– risk of harm and uncertainty are high, i.e.

demands are perceived as exceeding resources or are unknown, or;

resources are perceived as inadequate or unknown.

• Staff : When…– risk of harm (in form of error) is high, – demands exceed resources.

Effect of stress on CVS

• In situations appraised as borderline coping, cardiovascular changes are seen:

• Changes in heart-rate reactivity due to increased catecholamine production.

• Sensitization of cardiac tissue to catecholamines by corticosteroids

• Pressor changes

Summary

• Stress symptoms arise from appraised mismatch between perceived demands and perceived resources, the consequences of which indicate harm may occur (threat).

• Hassles (minor demands) are cumulative and can occupy significant coping capacity.

• Many important physiological systems can be influenced via hormonal and autonomic pathways.

• High levels of demand can disintegrate normal activity and are pathogenic.