"Stress and coping: Cause or consequence?" R. Fielding Department of Community Medicine, HKU.

Objectives: distinguish between the different models conceptualizing stress.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 –unpredictabilityunpredictability Physiological: –cvs, immunological, dermatological, hormonal, GI, GU changes

Arousal-performance curve

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…Staff –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.