STRESS AND COPING. What is stress? Stress as a stimulus Stress as a response Interactional model of stress Stress and susceptibility to physical illness.

STRESS AND COPING

STRESS AND COPING

What is stress? Stress as a stimulus Stress as a response Interactional model of stress Stress and susceptibility to physical illness Summary

What is stress?

Stress is thought to be a principal cause of psychological distress and physical illness.

But what do we mean by the term ‘stress’?– Stimulus model: ‘When you are under a lot

of pressure’, or ‘when things are getting on top of you’.

– These models derive, to some extent, from the engineering approach to the elasticity of materials.

– Stress refers to the load applied to an object or structure, setting up a force, known as strain, which can result in damage once the elastic limit is exceeded.

– Applied to human beings, it is assumed that individuals have a certain tolerance to stress but will become ill when the stress is too great.

OBJECT

Strain

What is stress?

Response model: Concentrates on the physical and psychological feeling of ‘being stressed’ or ‘completely stressed out’ with symptoms such as anxiety, poor concentration, insomnia, bodily tension and fatigue.

These have provided the impetus for the introduction of stress management programmes that focus on controlling the psychophysiology of stress using relaxation and breathing exercises, yoga, meditation, aerobics and other forms of physical exercise.

What is stress?

Interactional model: ‘When you think you can’t cope’ or ‘when you have too much strain put on you and you don’t have the resources to deal with it’.

Stress occurs when there is an imbalance between the perceived demands placed on the individual and the ability to meet those demands, often described as coping resources.

These models have led to the study of coping and to the development of techniques aimed at helping individuals to overcome stress by increasing the effectiveness of their coping methods such as in stress management workshops and stress innoculation training.

What is stress?

Not everyone agrees that the development of general theories of stress is a viable scientific objective.

Stress can be seen as an umbrella term that has been applied to so many quite different phenomena as to become virtually meaningless from a scientific point of view (Brown, 1996).

But if the concept of stress concept is too vague, why has it come to play such a significant role in popular discourse and media presentations?

Perhaps this can be answered by analysing stress as a social construct.

Stress as a social construct

Stress is often used as a device for legitimating behaviour that might otherwise be seen as the result of anxiety, neurosis or personal inadequacy.

‘I can’t take the exam today… I am too anxious…’

‘I need to take some time-off work… I’m too tired…’

‘Let’s give each other some space… I am not coping well with the pressure…’

Stress as a social construct

Doctor: Do you smoke?Person A: NoDoctor: Do you drink a lot of alcohol?Person A: NoDoctor: Do you eat too much fatty foods?Person A: NoDoctor: Do you have a history of high blood pressure?Person A: NoDoctor: Do you avoid exercise? Person A: NoDoctor: Have you been experiencing a lot of stress lately?Person A: YesDoctor: Well that explains it!!!

Stress often has the function of explaining the otherwise inexplicable, whether this be psychological or physical symptoms or actual illness.

Consider this scenario:

Person A has a consultation with the doctor after suffering a heart attack. The doctor is expected to provide an explanation why the heart attack occurred… (see dialogue)

Is the explanation a valid one or merely a convenient pseudoexplanation?

Clearly the role of stress in the aetiology of physical illness needs to be investigated just as carefully as any other proposed causal agent.

STRESS AS A STIMULUS

Holmes and Rahe (1967) conducted some influential pioneering research into the types of life events that people rate as being most stressful.

– They began by choosing 43 probably stressful life events– Then they asked 400 US adults to rate the relative amount

of readjustment that they judged would be required by each of the 43 events.

– They used these results to construct a social readjustment rating scale (SRRS) that assigns points values to different kinds of stress and which has subsequently been used in research on the relationship between stress and physical illness.

Stressful life events and daily hassles scales

LIFE EVENTS

1. Death of spouse2. Divorce3. Marital separation4. Jail term5. Death of close family member6. Personal injury or illness7. Marriage8. Fired at work9. Marital reconciliation10. Retirement

11. SOURCE: Holmes & Rahe (1967)

DAILY HASSLES

1. Not enough time2. Too many things to do3. Troubling thoughts about future4. Too many interruptions5. Misplacing or losing things6. Health of a family member7. Social obligations8. Concerns about standards9. Concerns about getting ahead10. Too many responsibilities

11. SOURCE: Chamberlain & Zika (1990)

Criticisms of the SRRS (Schroeder & Costa, 1984)

The criticisms of SRRS focus on the choice of items for inclusion in the scale:– Highly arbitrary– Vague– Ambiguous– Insensitive to individual differences – Likely to assess the individual’s level of neuroticism

rather than experienced life event stress

Alternative to SRRS

Recent researchers investigating stress-illness links have shown a trend away from the use of standardized checklists in favour of the structured interview techniques.

Originally developed to study the social origins of depression in women (Harris, 1997), the

Life events and difficulties schedule (LEDS)

is now being used to assess, classify and rate the severity of each stressful event, making allowance for individual circumstances.

STRESS AS A RESPONSE

Response models concentrate on the psychophysiology of stress.

Hans Selye’s general adaptation syndrome (GAS) proposes that the body undergoes three stages of defense reactions when it is exposed to a noxious stimulus:

AlarmResistanceExhaustion

Criticisms of the GAS (Mason, 1971)

The body’s reaction to different types of stress is not uniform at all.

The common physiological reactions found are caused by the emotional reaction of the animal to the stressful event rather than to a direct physiological effect.

In many studies of the effects of stress, laboratory animals have been exposed to some highly unpleasant conditions.

It seems likely that the researchers have been effectively studying the physiology of FEAR

Stress as a response

The GAS spans a similar historical period as the tradition of psychosomatic medicine (see Chapter 12).

The proponents of psychosomatic medicine emphasized the effects of stress and anxiety on the cardiovascular, gastro-enteritic and respiratory systems.

At present the two most active areas of investigation into responses to stress are:

– Psychoneuroimmunology (PNI) - the study of the effects of stress on the immune system

– Post-traumatic stress disorder (PTSD) - the study of the long-term effects of extreme or traumatic stress

Psychoneuroimmunology (PNI)

The immune system is implicated not only in the body’s defences against all infectious diseases but also in autoimmune diseases.

If psychological factors can be shown to have a significant role as causes of upregulation and downregulation of the immune system, then it is possible that psychological interventions could play an important role in the treatment of a very wide range of diseases.

Critical analysis of research into stress, emotion and human immune function emphasize that the immune system is a very complicated one involving a range of different types of cell with distinct functions.

Criticisms of PNI

The immune system is volatile with changes constantly taking place in one or more of its parts - one measure may indicate heightened immunity while another may indicate reduced immunity.

The preponderance of different kinds of immune cells varies considerably among healthy individuals and in the same healthy individual from day to day.

The demonstration of a statistically significant effect of stress on one or more parameters of the immune system does not necessarily entail that that these changes have clinical significance as regards disease outcomes (O’Leary, 1990) .

Criticisms of PNI

Research on stress and immunity can be broadly divided into:

– Acute stress (short-term effects) Examples: Sleep deprivation, taking examinations, exposure to the

objects of phobias, loud noises, electric shocks and attempting to solve difficult or impossible problems

– Chronic stress (longer term effects) Examples: Bereavement, unemployment, marital conflict, separation

and divorce, and caring for relatives suffering from Alzheimer’s disease.

No study has investigated the effects of any one kind of stress on all aspects of immune function and it is therefore necessary to piece together findings from different studies in order to obtain a general picture.

For future studies

A number of methodological difficulties need to be overcome before we can safely conclude that stress has direct effects on the immune system with disease consequences:

– We need to distinguish between direct effects of stress and other physiological pathways that may be activated by stressful experiences.

– It is necessary to rule out indirect effects that may be obtained when stress provokes health hazardous behaviour

– Where significant effects of stress on immune function have been adequately demonstrated, it is also necessary to show that these effects have clinical significance as regards disease outcomes.

Post-traumatic stress disorder (PTSD)

The term ‘PTSD’ was introduced by researchers studying psychological symptoms reported by soldiers returning to the USA from the Vietnam War.

It was first accepted as a diagnostic label by the American Psychiatric Association in 1980.

Symptoms include:

Insomnia, nightmares, flashbacks, problems of memory and concentration, acting or feeling as if the event is recurring and a greatly increased sensitivity to new stressful events (Baum and Spencer, 1997)

Criticisms of PTSD

Our understanding of PTSD is complicated by the existence of large individual differences.

There are also large individual differences in the types of symptoms encountered and their severity.

It is unclear whether reactions to different kinds of traumatic stress are basically the same or whether they depend on the particular type of stress involved.

While there has been at least one recent attempt to develop a theoretical model of PTSD (Brewin et al., 1996), others question its usefulness as a clinical diagnosis.

Young (1995) argues that PTSD is not, a psychiatric condition that has been vividly described throughout human history, but a cultural phenomenon of the modern era.

Criticisms of PTSD

The diagnosis of PTSD now has an important legal advantage for people seeking financial compensation for distress suffered while performing functions that might be thought to be part of their job (Summerfield, 2001) .

Although, it can be argued that PTSD involves a level of distress that transcends ordinary human misery and unhappiness. The diagnosis has the positive function of taking away blame from the sufferer who experiences guilt, shame and failure, so that the symptoms can be experienced as a normal response to an abnormal event rather than a pathological condition (Mezey and Robbins, 2001).

The current approach to the treatment of PTSD usually involves a combination of pharmacological treatment and cognitive behaviour therapy.

INTERACTIONAL MODELS OF STRESS

Interactional models focus on the imbalance between perceived demands placed on the individual and her/his coping resources.

The most influential of these models was developed by Lazarus and Folkman (1984)– Stress occurs when there is a mismatch between

perceived threat and perceived ability to cope.

INTERACTIONAL MODELS OF STRESS

A consequence of the emergence of this model of stress has been the development of checklists designed to assess the individual’s predominant coping strategies. An example is

THE COPE QUESTIONNAIRE

The COPE Questionnaire (Carver et al., 1989)

In the COPE scale, you are asked how you respond when confronting difficult or stressful events in your life.

To each item you use the following rating system:

– I usually don’t do this at all.– I usually do this a little bit.– I usually do this a medium amount.– I usually do this a lot.

The 14 COPE subscales are as follows-

Active coping: I take additional action to get rid of the problem.Planning: I try to come up with a strategy about what to do.Suppression of competing activities: I put aside other activities in order to concentrate on this.Restraint coping: I force myself to wait until the right time to do something.Seeking social support for emotional reasons: I ask people who have had similar experience what they did.Seeking social support for instrumental reasons: I talk to someone about how I feel.Positive reinterpretation and growth: I look for something food in what is happening.Acceptance: I learn to live with it.Turning to religion: I seek God’s help.Focus on and venting of emotions: I get upset and let my emotions out.Denial: I refuse to believe that it has happened.Behavioural disengagement: I give up the attempt to get what I want.Mental disengagement: I turn to work or other substitute activities to take my mind off things.Alcohol-drug disengagement: I drink alcohol, or take drugs, in order to think about it less.

Criticisms of coping scales (Somerfield, 1997; Aldwin and Park, 2004)

It adopts a ‘blunderbuss’ approach to the complex mechanisms involved in coping with different types of stress

It fails to take account of the fact that individuals may vary greatly in the way they cope with different stressful situations.

It relies too much on introspective judgments unsupported by other types of evidence.

DOES STRESS MAKE US MORE SUSCEPTIBLE TO PHYSICAL ILLNESS?

The popular belief that stress is a major cause of physical illness is not convincingly supported by existing research findings…

… but, neither is the opposite belief that stress plays only an insignificant role…

It is extremely difficult to carry out well-controlled research in this area. Most of what has been done is open to a range of possible interpretations.

DOES STRESS MAKE US MORE SUSCEPTIBLE TO PHYSICAL ILLNESS?

For example, it has been shown that people who are experiencing stress are more likely than others to indulge in health hazardous behaviour such as heavy smoking and drinking, drug taking, poor diet, inadequate sleep and lack of exercise.

Stress may possibly act only indirectly as a cause of illness insofar as it influences health behaviour.

Theoretical models of the relationship between stress and disease are also difficult to test because they involve complex interactions between stress, social support and personality variables.

DOES STRESS MAKE US MORE SUSCEPTIBLE TO PHYSICAL ILLNESS?

Coronary heart disease– There is conflicting evidence as to whether stress

does or does not contribute to risk of coronary heart disease.

Cancer– There is no convincing evidence for a significant role

of stress in the aetiology and prognosis for cancer.

DOES STRESS MAKE US MORE SUSCEPTIBLE TO PHYSICAL ILLNESS?

Infectious diseases– Viral challenge studies have established that stress

increases susceptibility to some infectious diseases, especially colds and flu.

– It has not yet been established whether this association is the direct result of effects on the immune system or indirectly caused by changes in health behaviour.

DOES STRESS MAKE US MORE SUSCEPTIBLE TO PHYSICAL ILLNESS?

– There is some recent evidence that high stress and low social support is associated with faster disease progression from HIV to AIDS.

– It remains to be determined whether interventions based on these findings can alter the clinical course for HIV infection.

Summary

There are three general approaches in conceptualizing stress: 1) the stimulus model; 2) the response model; and 3) the interactional model.

Stress can also be analysed as a social construct. Investigations into physiological reactions to stress have

identified many different types of reaction. Physiological reactions vary considerably from individual to

individual and according to the nature of the stressor. Interactional models of stress are intrinsically attractive

because they take account of individual differences in reactions to stress and methods of coping.

They have the disadvantage that they depend very much on the reliability of subjective assessments.

Summary (continued)

Empirical studies of the relationship between stress and disease have frequently been unsatisfactory.

Theoretical models of the relationship between stress and disease are difficult to test because they involve complex interactions between stress, social support and personality variables.

There is conflicting evidence as to whether stress does or does not contribute to risk of coronary heart disease and prognosis for cancer.

Viral challenge studies have established that stress does increase susceptibility to some infectious diseases, especially colds and flu.

There is some recent evidence that high stress and low social support is associated with faster disease progression from HIV to AIDS.