Most contemporary work into stress and stress management is influenced by the fundamental works of Seyle, 1984 and Hebb, 1955. It was Seyle’s work that led medicine to become interested in stress (Pacak & Palkovits, 2001) and it is his definition of stress as ‘the non-specific response of the body to any demand’ (Seyle 1984: 74) that has become used widely in both research and practice.

In vernacular use the term stress is usually associated with negative feelings. This is not always correct though, as a certain amount of stress is a normal part of day-to-day life. Hebb (1955) originally demonstrated this in the arousal curve (Fig 9.1), where an individual’s performance is seen to increase in proportion to the level of arousal. Once the individual’s maximum capacity for arousal is exceeded though, performance falls and adverse effects on an individual’s health begin.

Although since surpassed by more complex models, what is important about Hebb’s work is that it shows all individuals require a certain amount of stress to achieve optimal functioning. Once this point is exceeded though, an individual’s ability to function deteriorates rapidly and this is also associated with negative effects in health. This explains why people in very demanding, high-pressure jobs are at risk of developing stress-related diseases.

Hebb’s work explains the relationship between exposure to excessive stress, performance and illness; however, people who have jobs that offer little in the way of stimulation also develop stress-related diseases. This apparent contradiction to Hebb’s arousal theory was proposed by Sutherland & Cooper (1990) and latterly by Zivnuska et al (2002). While they agreed with Hebb that over-stimulation caused excessive stress, they found that stress also could be caused by under-stimulation. This led to the evolution of Hebb’s arousal curve into an inverted U which identified an optimal level of performance in the centre of excessive levels of stress characterized by under-stimulation and over-stimulation (Fig. 9.2) and shows that boredom is just as stressful as over-stimulation.

Seyle (1984) took a slightly different view on the nature of stress. He argued that stress could be positive or negative. Positive stress he named eustress (from the Greek word ‘eu’; good) and it is associated with feelings of excitement or euphoria. Conversely, negative stress was named distress (from the Latin word ‘dis’; bad). Although the body undergoes similar immediate physiological changes in both types of stress, it is the long-term effects of distress that are damaging. Seyle’s definition integrates well with the inverted U hypothesis in that individuals require a certain amount of arousal to perform optimally (whether this occurs when working or when relaxing). This occurs in eustress stimulation. If the arousal becomes too great or too little, however, then eustress is replaced by distress.

Often, whether stress is positive or negative is related to whether the individual has control of the stressor (the object triggering the stress). Stress that occurs where the individual retains control is positive and exhilarating. On the other hand, where the individual has little control of the threat then the experience is negative and damaging. This is referred to as the locus of control, a lack of which has been linked to poorer health outcomes (Schmitz et al., 2000, Coyne, 2006 and Sjöström-Strand and Fridlund, 2007). See Evolve 9.1 for more information and an exercise to develop your awareness of this.

Some individuals consistently respond to stressors in similar ways. The most common classification is that of Friedman & Rosenman (1974) who identified two personality types: type A and type B (Fig. 9.4). The type A personality is characterized by extreme competitiveness and an inability to place stressors in perspective. They routinely work against the clock, find it difficult to say ‘no’ or to delegate, and consequently find themselves with multiple commitments. Consequently, they are unable to fit all their demands into the available time and they end up juggling tasks, switching from one to another, without completing any. This is worsened by a lack of direction. Rather than taking a systematic approach to problem solving, they attempt to solve problems without first identifying the goals. They are also fiercely competitive, leading them to appear aggressive, and they react to minor irritations in the form of temper tantrums. By way of contrast, the second personality type, type B, is the antithesis to type A. They are almost unconcerned when confronted by stressors.

Type A and type B are in reality two extreme points of a scale. Most people have traits of both personality types and fit on a point somewhere along it. Significantly though, Friedman & Rosenman, and latterly Myrtek (2001), found that people with more type B characteristics were less susceptible to coronary heart disease.

It is not just the circulatory system that is affected by continued exposure to stressful events though. Figure 9.3 shows that the action of cortisol suppresses the immune response. This was demonstrated by Brosschot et al., 1998 and Segerstrom and Miller, 2004, who found that when individuals were exposed to stressors they were unable to control, their immune systems became suppressed. Similarly, Pruessner et al (1999) reported that individuals who were in situations where they experienced high distress and low self-esteem had higher serum cortisol than would be expected, which in turn suppressed their immune systems. A suppressed immune system renders the individual less able to fight off disease. Often people find that when they are tired, such as when they have been working for a long time without a holiday break, they become more susceptible to minor infections such as colds, and that once they contract an infection it takes longer than usual to recover. Indeed, the incidence of sickness in the workplace is an indicator of employee stress.

The immune system also protects the body against more sinister diseases though. Following major life events an extreme stress response is invoked and it has been observed that for around a year afterwards people have an increased susceptibility to developing cancers (Lillberg et al., 2003 and Thaker et al., 2007).

Psycho/social responses to stress vary according to the level of threat. A mild level of stimulation, where the individual remains in control (eustress), is accompanied by positive feelings. As the level of stress increases though, the pleasure changes to a feeling of being overwhelmed (distress). The ability to function effectively decreases and although individuals may be aware of what is happening, they find it difficult to engage in problem-solving thinking. Consequently, individuals find they have ever-increasing demands that they are unable to meet, which in turn perpetuates their distress.

Due to the fight or flight reaction that this invokes, individuals may become short tempered and aggressive, and often their social interactions will reflect this increased hostility where they may experience frequent arguments and become intolerant of others. In the long term, this causes their interpersonal relationships to deteriorate (Vernarec 2001), making things worse, and individuals can quickly find themselves locked into a stress cycle.

Often, in response to stressors, individuals attempt to cope by using mental defence mechanisms (Table 9.2). These were originally identified by Freud (1934), who claimed they provided a defence against conflict, and they have since been developed by many other psychologists. In the short term mental defence mechanisms are a healthy response and they buy time for the individual to adjust. As they do not alter the cause of the distress (they only alter an individual’s interpretation of it) they involve a degree of self-deception and prevent the individual from addressing the problems. Consequently, prolonged use of mental defence mechanisms is unhealthy and potentially damaging.

Post-traumatic stress disorder (PTSD) is a severe response to an extremely threatening or catastrophic event or situation (e.g. being a victim of a violent crime or witnessing a major disaster) that occurs within the 6 months of the triggering factor (World Health Organization 1992).

The main features of PTSD are:

Additionally, a number of other symptoms can occur including insomnia, headaches, ulcers and circulatory problems. Sometimes individuals blame themselves for the incident and suffer additional fear and guilt. Furthermore, to compensate individuals may abuse alcohol or other drugs, which may lead to dependence.

The most effective methods of treatment for PTSD are early supportive interventions that avoid focusing on the traumatic event. Following 1 month, however, all individuals involved in the event should be screened for PTSD. Those identified as suffering can then be offered targeted interventions, which should also include support for the sufferer’s family (NICE 2005). Chapter 12, ‘Aggression’, contains further information on managing PTSD.

When people are exposed to stressors for prolonged periods they can develop a condition called burnout. People suffering from burnout feel drained, emotionally blunt and cynical. As burnout is usually work-related; sufferers feel devalued by their employers and trivialize any achievements they make. Consequently their relationships within work deteriorate and the effects can also spill out of the workplace where they may struggle to maintain social contacts and partnerships (Leiter & Maslach, 2005).

Most employees in health and social care work with ill people for prolonged periods, often with inadequate resources or support. These are powerful sources of distress which predisposes to burnout (Schmitz et al., 2000 and Leiter and Maslach, 2005).

Burnout is aggravated by the highly competitive, insecure workplaces that are common in contemporary society, where working long hours – frequently for low pay – are seen as normal (Leiter & Maslach, 2005). This leads individuals to feel that their feelings are as a result of weakness in their character, thus compounding their problem as they are reluctant to seek help (Payne 2001).

The causes of stress (stressors) are the result of an individual’s interpretation of a phenomenon. Holmes & Rahe (1967) discovered that certain life events invoked differing amounts of stress and that their effects accumulated. Their classification of the significance of these stressors forms the Social Readjustment Rating Scale (SRRS) (Box 9.1), an instrument which is still commonly used. On this scale, according to the amount of stress invoked by a stressor, a greater weighting is ascribed to it.

To use the scale, each stressor that has occurred within the previous year is identified. By summating the rating ascribed to each it becomes possible to assess an individual’s level of stress. For clinical work, Holmes & Rahe found that a score over 300 was associated with an increased risk of developing a stress-related disease.

Even when experiencing similar stressors some individuals appear to be able to cope better than others. By using Hebb’s model of arousal (Hebb 1955) in conjunction with the SRRS (Holmes & Rahe 1967), it is possible to see why one individual may be unaffected by an incident while to another individual the effect of the same incident may be catastrophic. By using the SRRS to review life events that occurred over the previous year, it could be found that one individual had an accumulation of many stressors while the other had comparatively few. Thus exposure to the same new stressor could push the first individual into overload whereas the other had sufficient coping reserve.

The SRRS was developed over 40 years ago and has been criticized for its inability to predict the specific type of illness and for relying on retrospective data. Despite this, it remains a reliable instrument and enjoys extensive contemporary use in practice and research (Scully at al 2000). There are two major limitations of the scale, however. First, it only addresses long-term stressors and fails to take into account short-term stressors such as being late for work or sitting in a traffic jam. Short-term stressors, or ‘hassles’, invoke a severe stress response but only for a short period (Lazarus et al 1985). Being out of the individual’s control though, they invoke distress and have adverse effects on health.

The second shortcoming of the SRRS is forwarded by Le Fevre et al (2006), who argue that it is difficult to generalize individuals’ esoteric experiences of stress. Holmes & Rahe (1967) assumed that a stressor causes the same amount of stress for everyone. This is the engineering model of stress and is demonstrated in Figure 9.5 where the spider is interpreted identically by subject A and subject B.

Le Fevre et al (2006) argue this model is too simplistic, and that to gain a true understanding of the nature of stress, the stressor must be appraised from the context of the perceived threat (or excitement) that it poses; i.e. the level of stress depends on the amount of threat the individual thinks it poses. This is represented in Figure 9.6 where subjects A and B are exposed to the same stressor as before but, because of the meaning subject B attaches to the spider in that particular context, the interpretation of threat is greater for subject B than subject A.

Therefore, to understand an individual’s stress also requires measuring hassles and gaining an understanding of their interpretation of stressors (Lazarus et al., 1985, Hahn and Smith, 1999, Narayanasamy and Owens, 2001 and Le Fevre et al., 2006). Applied to clinical practice, this suggests that the use of the SRRS to measure long-term stress is useful in so much as it identifies a baseline of background stressors. From this baseline, however, the effects of day-to-day stressors and the interpretation an individual attaches to the nature of stressful experiences must also be added.

Relaxation and rest are linked strongly with stress. Sometimes relaxing is simply doing something different from work. Thus, relaxation can be active or recreational, for example walking or playing a sport (eustressful activities). At other times relaxing means reducing physical activity (such as sunbathing).

Relaxation is generally the precursor to rest. Rest is the period when the body does minimum activity; allowing restorative processes to happen and following which the individual feels refreshed or rested. Often this coincides with sleep.

Although there is a close relationship between stress and relaxation, they are not opposite ends of a scale. It depends on context and the amount of control the individual has over the situation. Sitting down and doing nothing in a quiet room at home may be relaxing; however, sitting and doing nothing in an airport because your flight has been delayed is far from restful! Similar to stress then, relaxation and rest need to be examined in context.

Sleep is associated with resting. It is a recurrent natural condition where consciousness is temporarily lost and bodily functions are partly suspended. It ends either by a natural return of consciousness or by external stimulation, for example by an alarm clock.

There are five stages in the sleep cycle (Box 9.2). Initially individuals move through stages 1 to 4. This is followed by a period of rapid eye movement (REM) sleep, a lighter level of sleep which is when dreaming occurs and is also when the individual will change position in bed. The sleep cycle then returns to stage 2 and repeats until the individual awakens. Each cycle lasts around 90 minutes in an adult, although the length of time spent at each stage alters throughout the night; during the early night the percentage spent in stages 3 and 4 is larger in comparison to REM sleep, while in the later hours of sleep the proportion of REM sleep increases.

Although individuals respond to stress in their own esoteric ways, some responses are universal. By measuring these it is possible to assess the degree of stress an individual is experiencing and to consider the ramifications on their ability to relax and rest. The first part of this section therefore begins by outlining tools to measure stress. This progresses to examine common causes of stress affecting clients, carers and care professionals and at the end of this section, strategies for managing stress are discussed.

The second part of Care Delivery Knowledge discusses how sleep may be assessed and outlines approaches to use to promote sleep.

For clarity, this section examines separately stress that occurs in clients, in their relatives and in the workplace.