Stress

STRESS
Dr. Jayesh Patidar
www.drjayeshpatidar.blogspot.com

Introduction
 “Hans selye” repeatedly posited the existence
of general life stressors of importance for
many, if not all, disease. Examples of his
general stressors were heat, cold and hunger.
 “Walter B. Cannon”, whose work on emotions
and physiological reactivity antedated Selye’s
studies, produced evidence concerning the
specificity of stresses on body systems. He
illustrated that the sound of a barking dog was
a specific stress that caused a cat to cease
digestion for almost one hour.
30/04/2015 www.drjayeshpatidar.blogspot.com 2

 “James Henry” summarized different
stress response patterns that depended
on subject’s differing perception of life
stressors.
 Perceptions of recent stress seen as
overwhelming, leading to behaviors of
submission & defeat, resulted in marked
elevations in serum cortisol & prolactin
concentrations, with no change in serum
catecholamines.

 Although stressors, or stress –producing
factors, vary such as physical stressors of
heat and cold and psychological stressors
of failure, success and a new challenge they
elicit essentially the same biological stress
response, stress is neither a synonym for
distress, anxiety and tension, not something
to be avoided at all costs. The absence of
all stress is according to selye, death.

 According to selye’, damaging stressors (
e.g. Anxiety, frustration, insecurity,
aimlessness) may result in various
physical and emotional disorders, such as
migraine headache,, peptic ulcer,
myocardial infarction (heart attack),
hypertension, suicide, mental illness and
hopeless unhappiness. Stress is
associated with manifestations of physical
illness (e.g. Myocardial infarction), mental
disorders (e.g. Post – traumatic stress
disorder) and social disruption (eg.
Divorce). It can also interfere with the best
treatment and rehabilitation efforts.

Definitions
 “Relationship between the person and the
environment that is appraised as exceeding the
person’s resources and endangering the person’s
well – being.”
 According to Hans Selye “Stress as the nonspecific
response of the body to any demand made upon it.”
 Richard Lazarus’ definition of stress focuses on the
relationship between the person and the
environment is taxing or beyond his or her
resources and harmful to his or her well – being.
Therefore, how the person appraises the situation
determines whether it is perceived as stressful.”

 “Stress is considered to the process of adjusting
to circumstances that disrupt, or threaten to
disrupt, a person’s equilibrium.”
(Lazavus and Forlmen, 1984)
 Stress is also the appraisal, or perception, of a
stressor.
 “Appraisal is how people interpret the impact of
the stressor on themselves, of what is happening
and what they can do about it.”
(Lazarus 1999)
 “Stress is a general term that links environmental
demands and the person’s capacity to meet those
demands.”
(Kasl 1992)

Types of stress
According to “selye” there are two types –
 Distress or damaging stress.
 Eustress or stress that protects health.
Eustress is motivating energy, such as
happiness, hopefulness and purposeful
movement.

According to Lazarus, (1999) there are several types
of stress –
 Work stress,
 Family stress,
 Chronic stress,
 Acute stress,
 Daily hassles,
 Trauma,
 Crisis.
“Work and family stress interact, family being the
background for work stress, and work the
background for family stress.”

Lazarus suggests a spillover of stress
between work and home. The individual
with family responsibility and a full time
outside the home may experience chronic
stress.
 Chronic stress occurs in stable conditions
and from stressful roles. Chronic stress is
living with a ling – term illness.
 Acute stress is provoked by time – limited
events that are threatening for a relatively
brief period.

Stress Responses
 Physiological Responses
 Emotional responses.

Physiological responses
 Physiological changes are automatic and not
under control.
 Their intensity will depend on the appraised
risk of the situation.
 Both the immune system and the sympathetic
nervous system are implicated in the stress
response.
 The locus cells in the brain initiated the stress
response by responding to the appraisal with
the neither release of nor –epinephrine.

 It stimulates the sympathetic nervous system
responds by discharging almost as a
complete unit, causing excitatory effects in
some organs and inhibitory effects in others.
 This “mass discharge” activates large portions
of the system and is called a sympathetic
alarm reaction or the “fight or flight” response.
Sympathetic Responses: -
 Increased arterial pressure.
 Increased blood flow to active muscle
concurrent with decreased blood flow to
organs that are not needed for rapid motor
activity, such as the gastrointestinal tract and
kidneys.

 Increased rater of cellular metabolism through –
out the body.
 Increased blood glucose concentration.
 Increased glycolysis in the liver and in muscle.
 Increased muscle strength.
 Increased mental activity.
 Increased rate of blood coagulation.
 One of the structure that is stimulated during the
sympathetic nervous system discharge is the
adrenal gland through activation of the
hypothalamic – pituitary – adrenal (HPA) axis.
 Not all appraisals provoked a severe “fight or
flight” response.

 Chronically unfavorable person – environment
relationships also elicit both sympathetic and
immune system responses.
 Academic examinations, job strain, care giving
for a family member with dementia, marital
conflict, and daily hassles elevate white blood
cell counts and lower these for T, B, and NK
cells.
 Negative moods (chromic hostility,
depression, and anxiety) also adversely affect
the immune system.

 If the stress is long term, the immune
alteration continues. (Hayes, 1995; Herbert &
Cohen, 1993)
 Social isolation also has a negative effect on
immune functioning, especially in the elderly,
the poor, and African Americans (House etal.,
1988).
 The biological responses to stress
compromise a person’s health status.
 The responses of the neuro hormonal and
immune systems can precipitate more severe
stress responses.

Emotional response
 After cognitive appraisal of a person
experiences specific emotions while
physiologic changes are occurring.
 Lazarus defines emotions as organized
psychological reactions.
 The emotion of the person experiences
depends on the significance of the person –
environment event to his or her personal well –
being.
 If the emotion is intense, a disturbance in
intellectual functions occurs.

Emotions are developed through a process:
 Anticipation,
 Provocation,
 Unfolding, and
 Outcome
According to Lazarus, emotions are categorized
as: -
 Negative emotions: -These occur when there
is a threat to delay in, or thwarting of a goal or
a conflict between goals: anger, fright, anxiety,
guilt, shame, sadness, envy, jealousy and
disgust.

 Positive emotions: - These occur when there is
movement toward or attainment of a goal: happiness,
pride, relief and love.
 Borderline emotions: - These are somewhat
ambiguous: hope, compassion, empathy, sympathy,
and contentment,
 Non emotions: - Connote emotional reactions but are
too ambiguous to fit into any of the preceding
categories: confidence, awe, confusion, and
excitement.
Therefore, the stress response is an automatic and
sometimes intense bio - psychological reaction in
response to an appraised unfavorable person –
environment situation. The physiologic responses
involve the environment situation.

Theories of stress
 Hans Selye’s theory.
 Aldwin’s immunological responses.
 Neuro pharmacologic Theories.
 Walter Canon ’s homeostasis mechanism.
 “Harold Wolff” and “Stewart Wolf” theory.

Hans Selye’s theory
 In the 1930s, 1940s,and 1950s Hans Selye
enlarged on cannon’s fight – or – flight
hypothesis to describe the general adaptation
syndrome ( GAS), a three – stage reaction to
stress.
 The GAS describes how the body responds to
stressors through the –
 Alarm reaction,
 Resistance stage, and
 Exhaustion stage.

 The GAS is an immediate physiological
response of the body to stress and involves
several body systems, especially the
autonomic nervous system and the endocrine
system. When a physical demand is made on
the body, such as an injury, the GAS is
initiated by the pituitary gland. The pituitary
gland is closely linked to the hypothalamus.
That secretes endorphins.
 Endorphins are hormones that act on the mind
like morphine and opiates, producing a sense
of well – being and reducing pain.

Alarm reaction: -
 During the alarm reaction rising hormone
levels result in increased blood glucose
levels, epinephrine and nor epinephrine
amounts, heart rate, blood flow to muscles,
oxygen intake, and mental alertness.
 In addition, the pupils of the eyes dilate to
produce a greater visual field. This change
in body systems prepares an individual for
fight or flight and may last from 1 minute to
many hours. If the stressor poses an
extreme threat to life or remains for a long
time, the person progress to the second
stage, resistance.

Resistance stage: -
 During the resistance stage the body stabilizes
and responds in an opposite manner to the
alarm reaction.
 Hormone levels, heart rate, blood pressure
and cardiac output return to normal and the
body repairs any damage that may have
occurred.
 If the stressor remains, and there is no
adaptation the person enters the third stage,
exhaustion.

Exhaustion stage: -
 This occurs when the body no longer the
effects of the stressor and when the energy
necessary to maintain adaptation is depleted.
 The physiological response is intensified, but
the person’s energy level is compromised, and
adaptation to the stressor diminishes.
 The body is unable to defend itself against the
impact of the event, physiological regulation
diminishes, and if the stress continues, death
may result.

Selye (1991) noted that a prolonged state of
stress can cause disease. Stress can make
people ill as a result of –
 Increased levels of powerful hormones that
change our bodily processes;
 Coping choices that are unhealthy such as not
getting enough rest or a proper diet or use of
tobacco, alcohol, other substance, or caffeine:
and
 Neglect of warning signs of illness or failure to
adhere to prescribed medicines or treatments.

Aldwin’s immunological responses theory
 Physiological responses to stress also
include immunological responses.
 The immune system differentiates between
self and oneself, so that under normal
conditions one’s own cells are not treated as
threats, In the way that bacteria, viruses,
parasites, or toxins are treated.
 Typically the immune system recognizes
bacteria, for example, as a threat and attacks
them.

 An antigen on the surface of the bacteria cells
identifies the bacteria as invaders. After being
exposed to a particular antigen, the immune system
remembers how to respond to that antigen and is
prepared to respond with antibodies when the same
antigen appears at a later time.
 A virus might cerate an antigen that is very similar to
a naturally occurring protein and the immune system
would attack it as if it were a threat.
 Problems occur when the immune system
misinterprets antigens and makes a too vigorous
response, leading to an autoimmune illness.
 The mechanism through which stress affects the
immune system is unclear.

Neuro pharmacologic Theories
 Acute stressors lead to dysfunction in the
hypothalamic – pituitary – adrenal (HPA)
axis.
 In contrast to chronic stress disorders, acute
stress in both animals and humans results in
the release of stress hormones.
 These corticosteroids aid the body’s
physiological and perhaps psychological
response to stress.

Canon describes “that an individual gas a
homeostasis mechanism. Homoeostasis is
defined as the maintenance of a normal
steady state in the body fluid and electrolyte
balance body temperature control and
nervous system control are examples of
homeostatic mechanism equilibrium.”
Canon explained Flight Fight alert of the body
to stress. Disease is viewed as a fight to
maintain the haemostatic balance of the body
tissues.

 The stress theory has contributed towards in
understanding the nature and causes of
diseases.
 The work of Walter Canon, Harold Wolff,
Hand Gelye and R.S. Lazarus is significant in
this theory.
 It describes that certain stimulus perceived
as threatening cause reactions which have
adverse emotional, behavioral and
physiological reactions.

“Harold Wolff” and “Stewart Wolf” theory.
 The systemic research of the internists “Harold
Wolff” and “Stewart Wolf” has served as a model
for scientific investigations.
 One of wolff’s fundamental premises was that disease
is a failure or inability to adapt to life stress.
 Wolff’s thirty heralded the concept that the way in
which a person is able to cope with a stressful event
is a critical factor in determining the magnitude of
subsequent physiological effects. Events are depend
to be stressful only if the person perceives that the
stress threatens life, well – being or emotional
security.

 Wolff and wolf also observed that the physiological
states of the gastrointestinal tract appear to
correlate with specific emotional states (hyper
function with hostility and hypo function with
sadness).
 They regarded such reaction as relatively
nonspecific, believing that the patient’s reaction is
determined by the general life situation and
perceptual appraisal of the stressful event.
 Wolff also emphasized that the capacity to adapt to
a threatening even determines the nature and the
severity of psycho physiological response patterns.
Familial discord, emotional deprivation, foal
frustration, object loss, separation, and
unemployment were emphasized.

ASSESSING HUMAN RESPONSES TO STRESS
 Stress responses vary from one person to another.
 Some people have primarily somatic responses, such
as headaches, dermatitis, flushing, or stomach pains.
 Some experience fear and apprehension or withdraw
from social situations.
 The nurse must consider many aspects during
nursing assessment they are:
 The situation
 The biological responses
 The emotions &
 The coping responses.
 From the assessment data, the nurse can determine
any illnesses, the intensity of the stress response, and
effectiveness of coping strategies.30/04/2015 www.drjayeshpatidar.blogspot.com 34

 Biological Assessment
 Careful health history, focusing on past and
present illness in the assessment.
 An illness or a recent trauma may be either a
result of or a contributing factor to stress.
 If a psychiatric disorder is present, psychiatric
symptom may spontaneously reappear.
 Nurses should also pay special attention to
disorders of the neuro endocrine system,
such as hypothyroidism because these
illnesses can affect the person’s ability to
deal with stress.

 Review of systems
 Physiological responses to stress result from
the activation of the sympathetic nervous
system and the immune system.
 Biological data are useful for analyzing the
person – environment situation and the
person’s stress reactions, coping responses
and adaptation.
 Physical functioning
 Physical functioning usually changes during a
stress response.

 Sleep is disturbed.
 Appetite either increases or decreases,
 Body weight fluctuates &
 Sexual activity changes
 Body language expresses muscle tnsion, which
conveys a state of anxiety may not usually present.
Because exercise is an important strategy in stress
reduction.
 The nurse should assess the amount of physical
activity, tolerance for exercise, and usual exercise
patterns.
 Determining the details of the person’s exercise
pattern can help on formulating reasonable
interventions.

 Pharmacological Assessment
 In assessing a person’s coping strategies, the
nurse needs to ask about the use of alcohol,
tobacco, marijuana, and any other addictive
substances. Many people begin or increase
the frequency of using these substances as a
way of coping with stress.
 Knowing detail about the person’s use of
these substances (number of times a day or
week, amount, circumstances, side effects)
helps in determining the role these
substances play in overall stress reduction or
management.

 The nurse should carefully assess the use of
any drugs to manage stress symptoms.
 If someone is using medication as a primary
coping strategy, he or she may need further
evaluation and referral to a mental health
specialty.
 If the person is being treated for a psychiatric
symptoms are reappearing.

 Psychological Assessment
 Psychological Assessment focuses on the person’s
emotion and their severity and his or her coping
strategies. The nurse can then understand how
vulnerable the person is to stress.
 Using therapeutic communication techniques, the
nurse assess a person’s emotional state in a nurse
patient interview.
 Emotions have different behavioral manifestations
(tears for sadness, tenseness for anxiety), these
responses can be indicators of specific emotions.
 Identifying the person’s emotions can be helpful in
assessing the intensity of the stress being
experienced.

 Emotions often thought of as negative (anger, fright,
anxiety, guilt, shame, sadness, envy, jealousy, and
disgust) are usually associated with an inability to
cope and severe stress.
 After identifying the person’s emotions, the nurse
determines how the person reacts initially to them.
Ex: - Dose the person who is angry responds by
carrying out the innate urge to attack someone
whom the person blames for the situation? Or doer
that person respond by thinking through the
situation and overriding the initial innate urge to act?
 The nurse should consider a nursing diagnosis of
ineffective coping. For the person who can resist the
innate urge to act and has developed coping skills,
the focus of the assessment becomes determining
their effectiveness.

 Social Assessment
 The ability to make healthy lifestyle changes
is strongly influenced by the person’s health
beliefs and family support system.
 Even the expression of stress is related to
social factors, particularly cultural
expectations and values.
 The assessment should include discovering
the person’s social network, social support,
and underlying socio cultural attitudes and
beliefs that relate to the current stress.

 Recent life changes: - Assessment should
include use of the life change event questionnaire
to determine the number and importance of life
changes that the patient has experienced within
the past year.
 If several recent life changes have occurred, the
person – environment relationship has changed.
 Social Network and Social Support
 The nurse should determine the significance of the
unemployment, if a person is unemployed, and its
effects on the person’s social network.
 For children and adolescents, nurses should note
any recent changes in their attendance at school.

 The nurse should elicit
 Size and extent of the network, both relatives and non
relatives, professional and nonprofessional, and how
long known.
 Function that the network server (e.g. Intimacy, social
integration nurturance, reassurance of worth, guidance
and advice, access to new contacts)
 Degree of reciprocity between the patient and other
network members, that is, which provides support to
the patient and who the patient supports.
 Degree of interconnect ness, that is, how many of the
network member know one another and are in contact.
The nurse should assess both the supportive and non –
supportive relationships within the patient’s
environment.30/04/2015 www.drjayeshpatidar.blogspot.com 44

 Malone social Network inventory (MSNI)
 It is a scale that assess a person’s social
relationships by using an open – ended
interview format.
 The patient can use this inventory to assess
the helpfulness of those who mist and least
affect his or her life and to determine those
who are members of the patient’s formal &
informal groups (eg. work, clubs, and religious
organizations).

 The MSNI elicits the some information
o Who is in the network?
o The relationship (e.g. Spouse, child, minister)
o A brief description of what each relationship
provides.
o The degree of helpfulness.
o The expected degree of helpfulness (Malone,
1988)

 On the inventory, the patient responds
o Highest as to how helpful each person in the
environment. Next the patient responds to
how helpful they should be a variation in
scores between how helpful the person is
and how helpful he or she should be gives a
dissonance score.
o The discrepancy between the reality of the
relationship & what the person would like the
relationship to be the higher the score, the
higher the dissonance.

Post traumatic stress disorder
Definition: - “An area of stress and psycho physiological
response that is critically influenced by a person’s
perceptions of stress, psychological defenses, and
coping capabilities is that of posttraumatic stress
disorder (PTSD).”
History: -
 PTSD is a modern term, which first appeared in the
diagnostic and statistical manual of mental disorders
(DSM III) the disorder was described in the English
medical literature more than 100 year ago.
 Modern recognition of PTSD came from observations
made by combat medical officers in both world wars,
from studies of disaster victims, and through the
experiences of psychiatrists and psychologist.30/04/2015 www.drjayeshpatidar.blogspot.com 48

 Criteria for the diagnosis in the fourth edition
of DMS (DSM – IV) differentiate the acute
(duration of symptoms of less than three
months) from the chronic forms (symptoms
lasting three month or more)
 The disorder also can be noted to be of
delayed onset (symptoms beginning at least
six months after the stressful event).
 Persons suffering from acute PTSD show
classic symptoms of the disorder over the
first days to weeks following their trauma.

 Their perceptions of the event are generally
accurate and their uses of psychological
defenses are transitory.
 Those who develop the chronic disorder
evidence distorted perceptions of the
traumatic event, and their uses of
psychological defenses are often excessive
and persistent.
 Delayed onset PTSD shows much the same
pattern as the chronic type, with even more
emphasis on defense mechanisms, such as
denial, repression, and projection.

Acute stress disorder
 This diagnosis in DSM – IV refers to persons
who show PTSD symptoms in the days
following their exposure to a traumatic event
but recover with one month.
 The phenomenon might be referred to as
normal stress and recovery.
 One month might be rather brief as a defining
period, in that time the majority of disturbing
symptoms will be seen to be in clear
remission with an acute stress disorder.

Stress

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