"Stress and coping: Cause or consequence?" R. Fielding Department 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
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.