STRESS

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STRESS Coping Module

• Developed by
• Dianna Spies Sorenson,
• PhD, RN, CNS
• Modifications provided by Suzie Bakken and Tami
  Hogie-Lorenzen

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OBJECTIVES

• Critique the definitions of stress.
• Identify the APNs role in identifying and
  treating stress disorders.
• Compare and contrast effective and ineffective
  coping strategies.
• Demonstrate the use of critical thinking skills
  and theoretical application during stress
  management.
• Identify costs related to stress.

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Definitions of Stress

• A force that strains usual coping resources
• Physiological response by the body to external or
  internal stimuli
• Change in physiologic response

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Recognizing StressWhich of These Create Stress?

• You receive a promotion at work.
• Your car has a flat tire.
• You go to a fun party that lasts till 200 a.m.
• Your dog gets sick.

• Your new bedroom set is being delivered.
• Your best friend and his wife come to stay at
  your house for a week.
• You get a bad case of hay fever.

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Prevalence

• Stress is linked to the six leading causes of
  death heart disease, cancer, lung ailments,
  accidents, cirrhosis, and suicide

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Prevalence

• 75 general population have significant stress
  in 2 wk period
• 1/2 of those experience mod- high levels of
  stress during those two weeks
• 43 adults suffer adverse stress effects
• gt 1/2 of all deaths between the ages of 1-65
  result from stressful lifestyles
• 75-90 of all doctors visits is for
  stress-related ailments complaints
• 42.6 adults have adverse health effects from
  stress

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Did you know????

• Annually, over 800 million dollars are spent on
  anti-anxiety pills.
• The US. accounts for 5 of the worlds population
  and consumes 33 of the pills.
• Tranquilizers, anti-depressants, and anti-anxiety
  medications account for 1/4 of all prescriptions
  written in the USA each year.

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Causes of Stress Stressors

• Internal (e.g.s)
• Hormonal
• Psychological/perceptual
• Infections
• Physical exertion
• External (e.g.s)
• Environmental
• Social
• Physical

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Types of Stressors

• Good
• Increased productivity
• Motivational
• Exciting
• Bad
• Altered psychological /or physiological
  functioning that interferes with normal life
• Psychological dysfunction (anxiety, panic, etc)

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Levels of Stress

• Level I
• New rules and transformations occur
• Birth of the first child
• Family Processes remain intact
• Level II
• Surpasses level I stressors
• Involve changes in relationships
• Marital conflicts/Spouse goes back to school
• Family Processes still able to return to their
  normal level of functioning.

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Levels of Stress Cont.

• Level III Stress
• Levels I and II are non-effective
• Involves changes in beliefs and/or family
  functioning
• Child using drugs
• Death of a spouse
• Professional assistance is often necessary

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Who does Stress Affect???????

• Everyone to some degree!

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Developmentally

• All stages of development have some stress
• Infancy
• Early childhood
• Middle childhood
• Late childhood
• Adolescent

• Parents of
• newborns
• infancy
• early to late childhood
• adolescent
• Adults
• Retirement
• Seniors

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Development-Early Childhood

• Tasks Profile
• Egocentrism
• Impulse ridden
• Differentiating self from environment

• Coping
• Regressive-like
• Displacement
• Denial
• Projection
• Rationalization
• Sublimation
• Attack
• Identification
• Temper Tantrums
• Play and Fantasy

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Middle Childhood - 2 New Strategies Appear

• Tasks Profile
• Differentiation
• Capability/ Industrious
• Initiative
• Self-Protective Conformative

• Coping
• Repression
• Reaction Formation
• Noncompliance
• Attention-Deficit type

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Adolescence

• Tasks Profile
• Strive for autonomy and independence
• Social and relational expansion
• Sexuality exploration
• Career decisions

• Coping
• Cognitive rationalization
• Projection
• Sexual acting out
• Alcohol drug

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Adult

• Tasks Profile
• Social Norms
• Reconciling internal conflicts
• Parenting
• Focus on others
• Financial Security

• Coping
• Avoidance
• Adherence to rules
• Internalization
• Active / passive
• Suicide
• Addictions

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Senior or Elderly

• Tasks Profile
• Acceptance of mortality
• Focus on future generations
• Reflections on personal significance
• Acceptance of Losses

• Coping
• FEAR
• Depression
• Isolation
• Suicide

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Contextual Stressors

• Family
• Employment
• Social
• Environmental

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Stress at Work

• OSHA has declared stress a hazard of the
  workplace
• 11 million Americans suffer unhealthy levels of
  stress in the workplace
• CA workers claims for mental stress rose
  200-700 in 1980s

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Stress at Work

• Over 30 of U.S. adults experience enough stress
  to impact their home or work performance
• Job related stress creates home problems, which
  adds to job stress affecting personal
  productivity (National Study)

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Stress at Work

• Stress costs American industry more than 300
  billion annually, or 7500 per worker, per year
  in terms of lost hours due to absenteeism,
  reduced productivity, and workers compensation
  benefits.
• Occupational Safety and Health Administration

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Stress at Work

• Differences in gender
• Self esteem vs. depression
• Parenting and work demands
• Dual-earning families

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Family Stress

• Real or imagined imbalance between demands placed
  on the family and the familys ability to meet
  those needs.

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Family Stress

• Demands in the family are referred to as
  stressors.
• Stressors are a life event or a transition that
  happens in the family.
• Stressors can cause changes in familys coping
  pattern.
• These can be either positive or negative

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Family Crisis

• A situation in which unusual behavior patterns
  are ineffective and new ones are called for
  immediately.
• Provides families with dangers and opportunities.

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Will Crisis Occur?

• Is there a stressor present?
• What is the familys perception of the event?
• What are the familys resources for dealing with
  the event?

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Coping skills for Families

• Do things as a family.
• Build self esteem in each other and themselves.
• Develop social support within the community.
• They can enjoy the lifestyle they have chosen and
  endure the hardships of that lifestyle.

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When to get Help.

• You feel depressed most of the time.
• You show violence toward your family.
• You discipline your children too harshly.
• You see marital problems as a solution to your
  current stressors.
• You constantly feel down about yourself or your
  family members.

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When to get help cont.

• You use alcohol more than usual, start drinking
  in the AM, and/or get mean while you are
  drinking.
• You feel guilty and believe you are not a good
  parent or spouse.
• You feel out of control

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The Cost of Stress

• Stress is expensive
• Health care cost account for approximately 12 of
  the gross domestic product - growing yearly!
• Stress cost more than 300 billion annually or
  7500.00 per worker per year
• absenteeism
• reduced productivity
• workers compensation benefits

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INDIRECT COSTS OF STRESS

• IT HAS BEEN ESTIMATED THAT 50 TO 85 OF ALL
  ILLNESSES ARE STRESS AIDED OR STRESS INDUCED
• McCANCE HUETHER 1998

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Nations Direct and Indirect Costs Totaled

• Mental illness..148 billion
• Cancer...104 billion
• Respiratory disease....99 billion
• Coronary heart disease..43 billion

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COST OF STRESS TO THE SYSTEM

• HEALTH CARE SYSTEMS
• INSURANCE PREMIUMS
• BUSINESS
• EMPLOYEE ILLNESS

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Personal Costs of Stress

• Health
• Family
• Relationships

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THE STRESS TAX

• HOW MUCH ARE YOU PAYING?

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DETERMINE YOUR STRESS TAX

• Have you paid YOUR stress tax?

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US Public Health Goals

• Reducing stress was a major health promotion goal
  for 2000
• How are we doing???
• Healthy People 2010

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COMPONENTS OF STRESS (Smith, 1993)

• . Varying Dimensions
• Cognitive Appraisal
• Physiological Responses
• Behavioral Responses
• Personality Variables

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THEORETICAL APPLICATION

• Physiological/ Biobehavioral Model
• ABC-X Model
• Perturbation
• Roller Coaster Model
• Stress and Coping Model -McCubbin
• Transactional Model of Coping

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STRESS THEORY - Origins

• Hans Selye (1907 1982)
• Endocrinologist
• University of Prague
• Fellowship to Johns Hopkins University(1930)

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Theory cont.

• Director Institute of Experimental Medicine
• Univ. of Montreal (1932) Retired (1976)
• Established International Institute of Stress
• Wrote 30 books 1500 journal articles
• 1976 Stress without Distress
• Einstein of Medicine
• Research general syndrome of being sick
• Most research conducted with lab rats
• Developed the General Adaptation Syndrome (GAS)

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GENERAL ADAPTATION SYNDROME

• Concepts
• Response to stress individual
• Persons have Adaptive Energy
• Predictable physiological response to stress

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GENERAL ADAPTATION SYNDROME

• 3 STAGES
• Alarm
• Resistance
• Exhaustion

Alarm
Resistance
Exhaustion
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Physiologic Phases of the General Stress Response

• Alarm release of catecholamines Fight or
  Flight Response
• Cortisol/Hormone release
• ResistanceDecreased inflammatory response, blood
  sugar increases, defenses wearing out
• Exhaustionillness

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STRESS

• ADAPTIVE lt---------gtDESTRUCTIVE
• DEPENDS ON THE INTENSITY TYPES AND DURATION OF
  THE STRESSOR
• With appropriate adaptation (coping), the cycle
  may end with the alarm or resistance phases or
  progress to the exhaustion phase

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STRESS

• ADAPTIVE lt---------gtDESTRUCTIVE
• DEPENDS ON THE INTENSITY TYPES AND DURATION OF
  THE STRESSOR
• With appropriate adaptation (coping), the cycle
  may end with the alarm or resistance phases or
  progress to the exhaustion phase

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Acute vs. Chronic Stress

• Acute Stress
• Effects
• Anxiety/ panic
• Attention deficit
• Loss of sequential/ executive functioning
• Odor
• Physical overdrive

• Chronic Stress Effects
• Heath
• Memory
• Immunity
• Menstruation
• Fertility
• Sexuality
• System failure

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Morbidity/Mortality

• Stress is linked to the six leading causes of
  death heart disease, cancer, lung ailments,
  accidents, cirrhosis, and suicide

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PATHOPHYSIOLOGY

• General Adaptation Syndrome Chemical or physical
  disturbance in the cells or tissue produced by a
  change either in the environment that requires a
  response to control it

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Components of Physiologic Stress

• The exogenous or endogenous stressor to initiate
  the disturbance
• Chemical or physical disturbance produced by the
  stressor
• The bodys counteracting (adaptation) response to
  the disturbance

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Psychoneuroimmunologic Regulation

• Consciousness (psycho)
• Brain and CNS (neuro)
• Bodys defense (immunology)

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AUTONOMIC NERVOUS SYSTEM

• Norepinepherine smooth muscle constrictor, lt
  gastric activation
• Epinepherine gt heart rate, cardiac
  contractility, hyperglycemia
• Cortisol gt protein synthesis,lt inflammatory
  reaction

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CARDIOVASCULAR

• Hypertension - 50 million Americans ages 6
• Coronary artery disease 1 in 4.6 deaths
• Stroke 3rd leading cause of death
• Disturbance of heart rhythm

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MUSCLES

• Tension headaches occur in 60 of the population,
  can occur 15 days of the month
• Muscle contraction/ cluster headache
• Stiff joints

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CONNECTIVE TISSUES

• Rheumatoid arthritisaffects 1-2 of the
  population
• Inflammatory diseases
• Bowel diseases
• Ankylosing Spondylitis of the joints
• Muscleviral/bacterial/paracytic myositis
• Skincontact dermatitis/seborrheic dermatitis

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PULMONARY SYSTEM

• Asthma
• Hay fever

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IMMUNE SYSTEM

• Immunosupression
• Autoimmune disease systemic lupus
• Diabetes
• Thyroid disorder
• Anemia

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GASTROINTESTINAL

• Ulcers
• Irritable bowel syndrome
• Diarrhea-malabsorption/ dehydration
• Nausea/vomiting
• Ulcerative colitis
• Diverticulitis
• Crohns Disease

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GENITOURINARY

• Diuresis fluid and electrolyte imbalance
• Impotence
• Frigidity
• Ammenorrhea

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ENDOCRINE

• Diabetes
• Acne
• Neurodermatitis

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CENTRAL NERVOUS SYSTEM

• Fatigue Lethargy
• Type A behavior
• Overeating
• Depression
• Insomnia

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ABC-X Model

• Developed by Hill in 1949
• Post war period
• A, B, and C factors cause or determine the X or
  the amount of stress or crisis in the family.
• Loss of job, decreased funds, no insurance leads
  to couple separation.
• If X continues, it leads to stress pile-up.

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Perturbation Theory

• Derived from range science
• Effect of grazing practices on plant growth and
  survival

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Perturbation Theory- Primary Components

• Direct Grazing Factors
• Timing between grazings
• Length of grazing
• Severity plant shaft root damage
• Contextual Factors
• Rain fall
• Winter severity
• Other range management effects

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Perturbation Theory Outcomes

• Stress stimulates growth
• Stress can be maintained
• Stress can damage or destroy
• Effects can be immediate or latent

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Perturbation Theory

• Stimulate growth effects
• Monitor responsiveness
• Provide counterbalances to any given stressor
• Monitor long-term effects

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Roller Coaster Model

• Developed by Koos
• Predictable family functioning-Pre-trauma
  phase-Acute coping phase-Period of
  disorganization-Recovery phase-use of coping
  strategies.

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COGNITIVE TRANSACTIONAL THEORY OF STRESS

• Unidirectional influence between
• stimulus
• change
• individual

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TRANSACTIONAL THEORY

• Studied human responses not animals
• Focus on behavior related to social psychology
• Concepts

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TRANSACTIONAL THEORY (cont.)

• Individuals perception and appraisal determines
  stress
• Individual response to perception and appraisal
• Two Stages
• Primary Appraisal
• Secondary Appraisal

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COPING

• Efforts to master conditions of threat
• Response to stress
• Effected by complex interactions
• Mediation behavior between stress, anxiety

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COPING

• Selye
• responsiveness of the body to deal with perceived
  stressors
• Lazarus
• Refers to conditions, concepts, processes to
  mitigate or eliminate stressors
• Subset of emotions
• Judgment that demands or exceeds resources

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COGNITIVE APPRAISALS

• CRUCIAL COMPONENT

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LOCUS OF CONTROL

• INTERNAL
• EXTERNAL
• SELF-EFFICACY

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ASSESSMENT Identifying Stress

• Self-identification
• Physical findings
• Tools used

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ASSESSMENT

• PRIMARY
• SECONDARY
• TERTIARY
• ASSESSMENT SCALES
• Holmes Rahe dated
• Schedule of Recent Experiences
• Life Change Unit
• Life Event Schedule

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INTERVENTIONS

• Poll the class

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Interventions for Stress

• First step is identification
• What triggers your stress?
• Why does this cause stress for you?
• Why do some people function better in stressful
  situations than others?
• Can we control or avoid the stressor?
• Does the stressor really exist?

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Interventions (Survival Strategies)

• Appropriate
• Avoid stress
• Change the situation
• Change the way you THINK about the situation
• Make necessary life changes
• Seek help
• Seek support
• Share emotions with those close to you
• Crying
• Distraction

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Interventions Remedial actions

• Change your thinking
• Reframing
• Positive thinking
• Change your behavior
• Be assertive
• Get organized
• Use diversion and distraction

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Interventions Cont.

• Change your lifestyle
• Diet
• Exercise
• Drink Water
• Pet Therapy
• Nature Walks
• Hydrotherapy
• Music Therapy

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Appropriate Options

• Activity
• Stretching
• Exercise
• Nutrition
• Well balanced diet
• Avoid foods high in fat, sugar, and sodium
• Humor
• Mind Body Connection Activity
• Meditation
• Prayer
• Adequate sleep

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Appropriate Options

• Learn to say NO
• Think positive
• Practice good time management
• Keep things in perspective

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Ineffective Coping

• Inappropriate
• Avoid stress
• Alcohol
• Tobacco
• Drugs
• Procrastination
• Nail biting
• Toe tapping
• Focusing on only negatives in your life

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Ineffective Coping

• Ineffective
• Withdrawing
• Crying
• Distraction
• Excess eating
• Excess sex

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BARRIERS TO INTERVENTION
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Myths related to Stress

• Stress is the same for everybody
• Stress is always bad for you
• Stress is everywhere, so you cant do anything
  about it
• No symptoms, no stress
• Only major symptoms of stress require attention

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OUTCOMES

• EVALUATION OF GOALS
• MEASUREMENT OF BEHAVIOR CHANGE
• INTEGRATED COPING RESPONSE MODEL psychological
  and physiologic measures

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CONCLUSION

• Case Studies

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CASE STUDY QUESTIONS

• What stressors is this family dealing with?
• What can you as an APN do to help this family?
• Frame an empathetic response that you would tell
  the family.
• Apply a theory to this scenario
• List some possible coping strategies.

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Any Questions?