Stress, Anxiety, and Coping

Dr. Fadwa Alhalaiqa

Objective 1

• Explain how stress affects an individual

Stress

• Stress is a person–environment interaction, and nurses must realize that there are many factors to be considered in each individual’s response to stressors.

• We are aware of some stressors, but others we may not recognize as sources of stress, such as time, the foods we eat, or even the pollution we live with

Factors to be considered when trying to understand a client’s stress

• personality factors, • cognitive factors, • physical factors, • environmental factors, • cultural factors, • and coping strategies

When stress is seen as conflict

• A conflict begins when a person holds two goals at the same time. There are different sorts of conflicts that involve movement toward and away from goals:

1- An approach–avoidance conflict occurs around incompatible choices and usually constitutes an either–or situation.

2- The avoidance–avoidance conflict involves two negative goals. In this case, the tension results from simultaneous repulsion to both goals. The person in this situation must choose between “the lesser of two evils.” Vacillation occurs when a person moves back and forth between two goals that have equal intensity of push and pull.

The fight–or–flight response to stress

• involves either an aggressive response to a conflict (fight),

• or a withdrawal response (flight). • The fight–or–flight response can be

considered maladaptive due to the physiological stress on the body, which may cause or exacerbate hypertension, heart disease, or other medical conditions

Hans Selye

• Hans Selye defined stress as the rate of wear and tear on the body, and included physical, chemical, physiological, developmental, or emotional stressors.

• identified the physiologic aspects of stress, which he labeled the general adaptation syndrome

He determined three stages of reaction to stress:

• alarm reaction stage, stress stimulates the body to send messages from the hypothalamus to the glands.

• the resistance stage, the digestive system reduces function to shunt blood to areas needed for defense.

• exhaustion stage occurs when the person has responded

• negatively to anxiety and stress: body stores are depleted or the emotional components are not resolved, resulting in continual arousal of the physiologic responses and little reserve capacity

• A life change theory of stress looks at common life events, whether positive or negative, as producing stress in people’s lives. Each event is called a life change unit (LCU).

• By assessing how many LCUs have occurred, the theory suggests that it is possible to calculate an individual’s potential to experience physical stress symptoms

Holmes and Rahe life change scale• It assumes that stress occurs after a particular threshold is

reached in all individuals, and some particular events are stressors to all individuals, while others are irrelevant to some individuals.

• Furthermore, specific life events were thought to cause the same amount of stress in different individuals and everyone employed a similar amount of “adaptation” to respond to the stressor.

• The life change units in this scale can be a good starting point to help a client realize how everyday activities contribute to stress, but it does not reflect a person–environment interaction view of stress, so it gives nurses little information about the individual to help facilitate effective coping

Lazarus stress definition

As transaction: • It is a process of complex interplay among the perceived

demands of the environment and the perceived resources one has for meeting the demands.

• An individual makes a cognitive appraisal of the perceived threat.

• The person’s primary appraisal assesses the threat and the secondary appraisal evaluates coping resources and options.

• The person then applies the coping resources and then reappraises the situation.

The psychoneuroimmunology framework of stress

• is very comprehensive and is the most modern picture of the relationship between neurology, endocrine and immune systems, and exploring the role of psychosocial factors such as personality and hardiness.

• The hormone cortisol plays an important role in stress and may be responsible for much of the damage to the immune system that contributes to the development of disease.

• Some studies have found that personality types (self-healing versus disease-prone personalities) may play a role as well.

• Disease-prone personalities exhibit certain emotions, including anger, suspicion, and chronic anxiety that are physiologically linked to sympathetic nervous system responses, the release of cortisol, and the suppression of the immune response.

• We are discovering that hardiness, which is an attitudinal factor defined by a positive attitude and a feeling of confidence, may have a stress-buffering effect

Learning Outcome 2• Identify the sources of anxiety.

ANXIETY• ANXIETY IS A VAGUE FEELING of dread or apprehension; it is a

response to external or internal stimuli that can have behavioral, emotional, cognitive, and physical symptoms.

• Anxiety is distinguished from fear, which is feeling afraid or threatened by a clearly identifiable external stimulus that represents danger to the person.

• Anxiety is unavoidable in life and can serve many positive functions such as motivating the person to take action to solve a problem or to resolve a crisis.

• It is considered normal when it is appropriate to the situation and dissipates when the situation has been resolved.

Definition of anxiety • The term anxiety is often used in relation to varying feelings of

uneasiness, sometimes precipitated by a known event, and sometimes by something vague or merely anticipated.

• Anxiety is generally caused by two types of threats. The first type is threats to basic human needs, such as warmth, food, and water. This explains why anxiety and restlessness are among the common signs of impending shock (decreasing oxygenation).

• Anxiety is also related to threats to the security of the self. These threats evolve around matters that are important to human beings such as integrity, self-respect and recognition, status or prestige, approval or disapproval by significant others, guilt, and self-expectations.

• All of these threats may be actual, impending, or merely anticipated.

Levels of Anxiety

• Mild anxiety is a sensation that something is different and warrants special attention. Sensory stimulation increases and helps the person focus attention to learn, solve problems, think, act, feel, and protect himself or herself.

• Mild anxiety often motivates people to make changes or to engage in goal-directed activity.

• For example, it helps students to focus on studying for an examination.

• Moderate anxiety is the disturbing feeling that something is definitely wrong; the person becomes nervous or agitated.

• In moderate anxiety, the person can still process information, solve problems, and learn new things with assistance from others.

• He or she has difficulty concentrating independently but can be redirected to the topic.

• For example, the nurse might be giving preoperative instructions to a client who is anxious about the upcoming surgical procedure.

• severe anxiety and panic, more primitive survival skills take over, defensive responses ensue, and cognitive skills decrease significantlyhas trouble thinking and reasoning.

• Muscles tighten and vital signs increase. • The person paces; is restless, irritable, and

angry; or uses other similar emotional–psychomotor means to release tension

• Anxiety can be considered helpful or harmful, largely dependent on the degree to which it is experienced.

• Assessment:1- subjective 2- MRIs and PET scans A total body assessment would explore the

emotional, cognitive, behavioral, and physiological expressions of anxiety

Anxiety and decision masking • anxiety are associated with different types of behavior that

affect one’s ability to problem solve, make decisions, or learn new things

• When anxiety is overwhelmingly high (severe and panic level) the nurse must be conscious that independent decision making is too difficult and must intervene to protect the client from further disorganization.

• Panic levels of anxiety are associated with many severe symptoms of mental illness, including mania, disorientation, illusions, and hallucinations.

• Keeping watch over the level of stimulation in the environment is one way nurses can help reduce anxiety and prevent it from escalating

• Learning Outcome 3Describe the everyday methods people use to

cope with stress and anxiety

• Everyone has a wealth of coping strategies they rely on.

1- We use task-oriented coping skills when we feel competent and the situation is not too threatening.

2- We employ defense-oriented coping skills when we feel inadequate and the situation is extremely threatening to our sense of self.

• Task-oriented behavior is geared toward problem solving; defense-oriented behavior is protective

kinds of coping strategies• Some people turn to self-discipline and stoicism, while others express

intense feelings.• Individuals may cope by avoiding or withdrawing from a situation. • Some people will cope by seeking out someone with whom to talk things

out, but others prefer to privately think through the situation. • Physical activities, whether high-impact sports or simple gestures, allow

some people to work off stress and anxiety.• Mind/body practices are very calming for many, as is spirituality and

prayerfulness. • Symbolic substitutes, the principle of ascribing meaning beyond the

obvious one to objects, experiences, or people, reduce tension for some individuals.

• Communication between organs of the body, or somatizing, also has an effect on anxiety and stress

What do you need to cope?

• individuals need strengths and resources that they can call on.

• Antonovsky’s Sense of Coherence (SOC) is defined as a global orientation that the world is comprehensible, manageable, and meaningful.

• Antonovsky theorized that people stay healthy because they possess generalized resistance resources (GRRs).

• SOC scale was found to be a reliable, valid, and cross-culturally applicable instrument to measure how people manage stressful situations and stay well

Learning Outcome 4

Compare and contrast the common defense-oriented behaviors (defense mechanisms) people use to cope with stress and anxiety

• Defensive coping is associated with threats to the security of the self.

• Defense mechanisms lessen uncomfortable feelings of anxiety and prevent pain but often have an associated cost.

• These mechanisms are mostly unconscious and are often inflexible.

Defense mechanism

• People may engage in: repression, suppression, dissociation, identification, introjection, projection, denial, fantasy, rationalization, reaction formation, displacement, and intellectualization.

• As we grow and mature, we are able to give up primitive defenses and use defenses that are more complex.

• To some extent, defensive coping serves to distort reality and protect us from unacceptable thoughts, wishes, or feelings

Learning Outcome 5• Implement nursing intervention

strategies specific to each defense-oriented behavior listed

Nursing roles

• The nurse must address defense mechanisms within a caring and supportive relationship.

• Address repression by being supportive and protective of the client’s defenses. When appropriate, help the client examine the traumatic event or situation objectively.

• For clients manifesting dissociation, provide a safe, supportive, secure environment for clients to recall and resolve past conflicts.

• Interventions for identification and introjection include clarifying roles and expectations of the nurse and client, and helping the client formulate a self-care plan and increase self-awareness

• Nurses can deal with projection by patiently, consistently, and respectfully assisting the client in separating feelings from objective facts.

• When intervening in a client’s denial:A- it is important to discern the protective function of the

mechanism. B- Be supportive of denial if it is in the client’s best

interests. C- If denial is harmful, help the client to focus on reality. • Interventions for fantasy include helping the client to

gradually relinquish unrealistic expectations and make realistic plans

Continue ….• Help clients who rationalize by focusing on

client strengths and past successes. • Clients manifesting reaction formation need

the nurse’s respect, support, and a secure relationship in which to explore feelings.

• Address displacement by assisting the client to understand the source of the anger.

• Assist clients who use intellectualization by encouraging them to accept and explore their emotional reactions to situations

Learning Outcome 6• Discuss common medical conditions with an

onset or a course influenced by psychological and behavioral factors.

• Co-occurring psychiatric disorders, psychological symptoms, personality traits, coping styles, poor lifestyle choices, and the stress response itself can all affect the medical condition by altering its course, interfering with its treatment (outcome), or by placing the individual at higher risk

• A multicausational concept of the illness helps the nurse explore illness in a holistic way.

• The meaning and symbolic aspect of the diagram reminds the nurse to individualize an understanding of the illness by exploring it from the client’s perspective and by considering the disease within the context of the individual’s culture.

• Many conditions have psychological components.• Nurses need to be aware that treatment is not

complete unless the stress-related aspects of illness have been investigated and individuals helped to learn more effective coping strategies.

• Science has identified stress-related conditions in each body system and we are learning more about their interrelated nature all the time.

• As nurses work with individuals to increase their awareness of stress and improve health- promoting behaviors, they will find that these tasks are not always easy, nor do they always result in change.

• In the course of caring for many individuals, there will be those who gain little self awareness, cannot get past or through the conflicts that plague them and cannot or refuse to give up the coping strategies that they are using, even though they are unhelpful or unhealthful.

• Some others may have motivational difficulties that are difficult to overcome and for others the cost of delaying gratification will prevent them from adapting more useful behaviors

Thanks