Chapter 13 STRESS AND ADAPTATION
Throughout life each person is faced with situations capable of producing stress responses. There is an intricate and complex relationship between psychological and biological responses to stress and how these reactions link to physical and mental health or ill-health. The way individuals respond and adapt to stress may be quite different — what may cause a mild reaction in one person may evoke a much stronger stress response in another. Depending on the individual and the stressor, the experience of stress may be positive, negative or a mixture of both. Illness and hospitalisation can be a stressful experience for clients and families. The role of the nurse involves recognising stress and anxiety and the associated physical and psychological responses, understanding the causes and implementing holistic nursing care strategies to help clients cope with physical and emotional responses during periods of health-related stress.
I was so anxious I couldn’t stop shaking and I felt that I couldn’t get my breath. I know it was only a biopsy to them, but to me it was huge. There was one nurse who noticed how distressed I was and she showed me how to breathe in and focus on relaxing my muscles as I breathed out. She did it in time with me for quite a while, until they were ready for me. Without that I don’t know how I would have coped.
The art and science of nursing is based on the concept of holism. This concept is essential in understanding stress and its relationship to physical and mental health or ill-health. This is because stress and the way individuals adapt and cope is related to the interplay between environmental, cultural, spiritual, psychosocial and biological dimensions of each person. A basic concept of this chapter is therefore that each person is unique and the whole person a totality of body, mind and spirit.
Stress is any emotional, physical, social, economic or other factor that requires a response or change. Stress can lead to a variety of psychological responses, the most common of which is anxiety. Anxiety can be defined as a feeling of apprehension, uneasiness, uncertainty or dread. The source of the anxiety may be real and easily identified or it may be a perceived threat and the person may not be able to identify the cause. Everyone experiences anxiety. It may be experienced on four different levels: mild, moderate, severe and panic level. It can be classified as normal, acute or chronic and has the potential to affect the person at a very deep level and to a point where self-esteem can be seriously eroded (Boyd 2007; Keltner et al 2006; Varcarolis 2006).
Stress can result in psychological and physiological effects, and prolonged stress can result in physical illness. This is because the immune system responds to a person’s internal and external environments and, when exposed to excessive stress, becomes damaged, reducing the body’s ability to combat infection and disease. Prolonged stress has been linked to many physical health problems, including migraine headaches, allergies, asthma, gastric ulceration and other disorders of the digestive tract. Scientists explain the physical manifestations of prolonged stress as being related to chemical, hormonal and cellular changes (deWit 2005; Rice 2000).
A stressor is the stimulus that precipitates stress. Stressors can be classified as physical or psychological. Physical stressors include bodily trauma such as injury or surgery, blood loss, pain, infection and illness. Psychological stressors can be defined as any stimuli that the person interprets as challenging, demanding or threatening. These are usually events and circumstances that demand a change or response. Psychological stressors relate to situations that result in emotional tension; for example, interpersonal conflict such as might occur with divorce, personal loss such as the death of a loved one, and changes in family or social role such as might arise from redundancy, retirement or illness.
Stressors can also be classified as internal or external. Internal stressors arise from within the person. They include hunger, thirst, fatigue, fever and the effects of pregnancy or menopause. Internal stressors also include strong emotions such as embarrassment, shame or guilt. External stressors are those that originate outside a person and include environmental conditions such as exposure to overly high or low temperatures, overcrowding, noise and, of course, the traumatic effects of accidents or natural disasters such as fires, floods, hurricanes and earthquakes. External stressors also include issues such as peer group pressure, social isolation and the demands of study, family or work (deWit 2005; Watkins 2001).
A stressor may be perceived as positive, negative or a mixture of both. Many situations are both demanding and stressful, evoking mixed responses; a new job can be challenging and stressful but at the same time a positive and personally rewarding experience; the stress of a looming exam or competitive event can be very stressful but the stimulus also provides high levels of motivating energy that leads to positive outcomes (Varcarolis 2006; Stuart & Laraia 2004; Shives 2007).
Different people may respond to the same stressor in totally different ways. For example a footballer faced with the prospect of scoring the winning goal after the final siren has sounded may perceive this as a challenge, a chance to shine — and may well do so. Another might perceive this situation as a major threat to self-esteem — fear of performing badly may cause his body to feel like jelly, which may result in poor performance. Despite differences in individual responses to stress, there are some common themes concerning what is perceived as stressful. People generally feel anxious when they perceive a loss of or threat to their:
Illness and hospitalisation are commonly significant stressors. Nurses frequently encounter a range of stress responses when providing care to clients. In fact, anxiety is the word most commonly used by clients to describe their emotional response to illness (Shives 2007). The nature and degree of stress a client experiences is an important component of wellbeing that is evaluated by the nurse as part of ongoing holistic nursing assessment. Some people adapt to hospitalisation, many cope successfully with illness, but others need help and support. The nurse in all areas of care, and particularly in mental health care, needs to facilitate exploration of the significance of particular stressors to each individual client.
A person’s ability to adapt to, and cope with, stress depends on the combined aspects of the stressor itself and the characteristics of the person. Aspects of the stressor that influence the person’s response relate to the nature, origin, timing and number of stressors. Specifically this relates to:
The way individuals adapt to stress is related to coping mechanisms, many of which are learned during childhood and adolescence. Coping mechanisms can be constructive (adaptive) or destructive (maladaptive). Constructive coping mechanisms include the ability to be flexible in response to different situations, to take responsibility, and to be independent and assertive when needed. Destructive coping mechanisms ward off anxiety without resolving the cause of the problem, and include defence mechanisms such as denial and repression and behaviours such as being constantly submissive. Constructive lifestyle factors include a healthy diet, exercise, effective time management and illness-prevention measures such as regular medical checks, vaccinations and breast screening. Destructive lifestyle factors include smoking, excessive consumption of alcohol and other drugs, and a sedentary lifestyle. The combination of multiple influences determine a person’s ability to adapt and cope successfully with stress. Adapting to stress involves physiological and psychological responses.
Physiological adaptation to stress concerns how the central nervous system and the immune system work as an integrated whole to maintain homeostasis, a state of healthy balance within the body. Automatic mechanisms operate to monitor, maintain or restore a healthy state of equilibrium. These feedback mechanisms sense when there is an alteration or interruption to the norm and make adaptive responses. These processes occur continuously in response to the minor stresses of everyday life, keeping the body’s internal environment constant. In the case of trauma, physical illness or prolonged stress the homeostatic responses may struggle to adapt and fail to restore normal concentrations of gases, nutrients and ions, body temperature and blood pressure to within normal limits. Medical interventions such as fluid replacement, oxygen therapy and nutritional measures can assist the process but, if unsuccessful and failure of the natural homeostatic mechanisms continues, cells die and eventually death of the person occurs.
The physiological response to acute stress is known as the fight-or-flight response. It begins when people are faced with a threat or stressful situation. When the body prepares to fight or flee, a number of changes occur. The autonomic nervous system and the neuroendocrine system combine to provide the body with the capacity to deal with the stressor. Hormones needed to adapt to the stress are secreted, muscles tense, the heart beats faster, the breathing and perspiration increase, the pupils dilate and blood sugar level increases. Once the cause of the stress is removed, homeostatic mechanisms involving the parasympathetic nervous system and decreased activity in the hypothalamus and pituitary gland return the body from its state of heightened readiness to relaxed mode (Keltner et al 2006). The fight-or-flight response is vital to defend against and tolerate danger. However, continued unresolved stress results in a chronic stress condition that impacts on the body and may produce any of a wide range of diseases and disorders. Box 13.1 indicates some of the health concerns that have been linked to stress. The body responds to stress in the same way regardless of the source of the stress and whether or not the stress is real or perceived.
Box 13.1 Health concerns linked to stress
(adapted from deWit 2005)
Prolonged stress may also lower the threshold at which the body responds to threats, so that future stressors may trigger the physical stress response more easily. This can lead to a stress cycle whereby the person responds to relatively minor events with physical reactions and psychological fears beyond those congruent to the situation. Symptoms such as a rapid or pounding heart and rapid breathing start to become worrying, making the person even more anxious; this then reactivates the stress response, causing symptoms to become more severe. This can evolve into a cycle of stress, anxiety and more stress that ultimately causes increasingly severe or frequent episodes of high anxiety and, sometimes, negative thoughts and fears that can interfere with the person’s normal lifestyle, physical and mental health (Clinical Interest Box 13.1).
CLINICAL INTEREST BOX 13.1 The stressor–anxiety stress cycle
It started months ago, I don’t know why. Now it is really bad. Just the thought of driving to pick my daughter up from school causes my heart to race, I get the shakes, I feel faint, sometimes I feel sick. Sometimes my heart is pounding so hard I’m sure I’m going to collapse or even die. My doctor says that won’t happen, so I feel stupid, but I can’t help it and these symptoms have gotten worse and worse. Now I am so anxious I never go out in the car at all. I pay for a taxi to collect my daughter from school every day.
A range of anxiety disorders such as panic disorder, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) has been linked to this stress cycle. Recurrent and prolonged stress causes a range of effects on mood, cognition and behaviour in addition to physical responses. Overwhelming stress or distress can seriously interfere with mental wellbeing and can cause the person to lose contact with what is real or not real. This may manifest with a range of effects, including disorganised and/or delusional thoughts and hallucinations.
Stress is not easily measured but the nurse can assess and evaluate clients’ subjective stress by exploring their feelings. Objective indicators may be observed in a variety of physiological, psychological, cognitive and behavioural responses. Examples of some common effects are outlined in Box 13.2. and Table 13.1.
|Sadness||Confusion||Unable to sleep|
|Depression||Forgetfulness||Under- or over-eating|
|Labile mood||Inability to concentrate||Talking rapidly/loudly|
|Irritability||Decision making is difficult||Stammering|
|Quick to anger||Comprehension impaired||Inability to sit still|
|Constant pulling at hair|
|Constant pumping of leg up and down|
|Inability to control tears|
Illness and hospitalisation and frightening medical procedures may mean that clients feel they have little control. Many people adapt successfully to the reality of what is happening to them and are able to remain optimistic and cheerful. However, individuals respond differently to the experience of illness, and high levels of anxiety and frustration at being ill or feeling neglected mean that clients may respond with irritability. This may manifest as constant complaints and criticisms or even displays of anger towards people around them, including nurses. Anxiety may also result in clients becoming withdrawn. Some may become passive and dependent on others and behave in an immature way. Some clients may become introspective and self-absorbed, showing no interest in anything other than themselves and their illness. Nurses who understand these behaviours as ways of attempting to cope with stress and anxiety continue to respond with empathy and are therefore able to promote a relationship of trust with the client. An example of a nursing diagnosis for an anxious client might be, ‘Anxiety related to verbalised “fear of hospitals”, as evidenced by changes in vital signs, discomfort due to diaphoresis (sweating) and client’s inability to sit still, pacing and wringing hands’. A trusting relationship and effective communication skills (Chapter 29) facilitate the client being able to talk about and deal with fears and other feelings and ultimately to adapt more positively to their situation.
Two significant theoretical models concerning responses to stress are Selye’s stress adaptation model and Lazarus’s interactional model. An understanding of theoretical models enables the nurse to understand the mechanisms people use to adapt to stress in their lives. The ability to adapt has positive effects such as the resolution of conflicts and increased self-confidence. When people are continually unable to adapt effectively they are at risk of physical or mental ill-health and, in the worst-case scenario, death.
In 1950 Hans Selye published a now renowned work called The Stress of Life. In a later edition he defined stress as the wear and tear on the body (Selye 1976). Selye links the wear and tear on the body to chemical changes that instigate a process of adaptation.
In the 1950s Selye popularised a physiological understanding of how a person responds to stress. Selye’s version of stress adaptation is that, when faced with stress, the body responds in three distinct phases: alarm reaction, stage of resistance and stage of exhaustion. These stages involve structural and chemical changes in the body that have become known as the general adaptation syndrome (GAS).
This is the initial reaction of the body to any stressor. It is a complex set of reactions between the hypothalamus, the sympathetic nervous system and the adrenal medulla. This is the fight-or-flight response referred to earlier. It creates a heightened level of alertness and mobilises the body’s resources for immediate physical activity in readiness to tackle the threat. Bodily responses are designed to rapidly increase circulation, promote release of glucose for energy and decrease activity that is not essential to combat the threat.
If the cause for the stress is not removed, the body moves to this second stage of the GAS. The resistance stage provides the body with what it needs to continue fighting a stressor long after the effects of the alarm stage have fizzled out. Reactions in this stage involve the anterior pituitary gland and the adrenal cortex. The resistance reaction is slower to start than the alarm reaction but the effects are longer lasting. They serve in part to maintain the readiness created by the alarm stage, such as increased levels of glucose for energy; however, during this phase the body also begins the process of trying to return physical functioning closer to normal homeostasis.
If this stage of the GAS continues for a prolonged period of time without periods of relaxation and rest to counterbalance the stress response, sufferers become prone to fatigue, concentration lapses, irritability and lethargy. Significantly, continued release of excessive amounts of the steroid cortisol, stimulated during prolonged stress, leads to suppression of the immune response. Reduced immunity makes the body more susceptible to health problems ranging from the common cold and other infections to disorders such as headaches, gastritis, a range of intestinal disorders and cancer (Keltner et al 2006; Herlihy & Maebius 2002).
In this stage the body runs out of its reserve of body energy and immunity. This is the result of the inability to adapt or cope. Mental, physical and emotional resources suffer heavily. By this stage there is a significant loss of potassium ions, which interferes with the function of all body cells. Cells function less and less effectively and unless potassium depletion is reversed they will begin to die. The body experiences adrenal exhaustion, and the adrenal cortex no longer produces sufficient hormones to prevent a drop in blood glucose levels, so that eventually the body cells fail to receive adequate nutrients. The effect of a prolonged or strong resistance reaction on the body places a particularly heavy demand on the heart, blood vessels and adrenal cortex. Thus, previous health can be thought of as an indicator of a person’s capacity to adapt and cope physically with stress. The inability to adapt, and the continuation of exposure to stress, results in progressive mental and physical exhaustion, illness, collapse and ultimately cardiac failure, renal failure and death.
Selye also identified that the body adapts to physical stressors at the local level, for example, when stress occurs within a single organ or area of the body. This is termed the local adaptation syndrome (LAS). It applies, for example, when a person sustains an insect bite on the foot and the body responds to the local inflammation.
Selye (1974) defined two particular concepts of stress; distress and eustress. Distress is described as the negative outcome that drains energy and gives rise to feelings of anxiety, confusion and depression, and creates an inner sense of helplessness and hopelessness. Mental illness is closely associated with human distress. Watkins (2001) links difficulty in adapting and coping with overwhelming distress to the distress behaviours and feelings associated with poor mental health, for example, defensive or self-harming behaviour, despair, helplessness, anger, guilt and self-loathing. Eustress is described as the converse effect that gives rise to positive outcomes — motivating energy, feelings of happiness and an inner sense of peace and hope.
|Stage||Physical response||Psychosocial changes|
Noradrenaline and adrenaline are released, causing vasoconstriction, increased blood pressure and increased rate and force of cardiac contractions
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