STRESS MANAGEMENT

INTRODUCTION
Everyone is under stress. It is a normal part of everyday life. As
long as we keep that stress within reasonable limits, there is no problem. But when
we allow it to exceed its reasonable limits, trouble begins.

Stress is, and will continue to be a part of our nursing life regardless of
our area of clinical practice. Living & working in a high tech, low touch
environment may cause us to feel apprehensive.

MEANING

The term stress is derived from the Latin word stringere which means to
draw tight. Claude Bernard [1867] was one of the first physiologist who recognized
the potential consequences of stress for an organism. He proposed that changes in the
internal and external disrupt the functioning of an organism and that is essential for
an organism to adapt to a stressor to survive

BASIC CONCEPTS OF STRESS AND ADAPTATION

STRESS:

Stress is a relationship between a person and the environment that the person
perceives as taxing or dangerous(Lazarus &Folkman 1984)

It is an unpleasant psychological and physiological state caused due to some

internal and or external demands that go beyond our capacity.

Stress is a disruptive condition that occurs in response to adverse influences from the
internal or external environments.

Stress is a state produced by a change in the environment that is perceived as

challenging, threatening, or damaging to the persons dynamic balance or equilibrium

CLASSIFICATION

Stress can be mainly divided into 4 types.

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 Good stress [Eustress] : This type helps us to improve our performance . This
occurs before going to a life situation like examinations .People tend to get sweaty
and their heart beat increases. So they keep on memorizing or practicing what they
have to say in their mind. This makes them succeed in what they are doing.
Bad stress [Chronic stress] : This type occurs in situations that cause
continuous physical and emotional stress reactions and the body never gets a chance
to get relaxed. This causes tension in the muscles.
Survival stress : When you are afraid that someone or something may hurt
you, your body naturally burst of energy so that you will be able to survive the
dangerous situation or escape it all together.
Internal stress: This is the type of people make themselves stressed . This is
when we worry about things we cant control or put our self in that situation we
know we will cause stress.

STRESSOR:

Any factor that causes a person experience stress is a stressor .

[Ivancevich & Matteson]

Stressors are mainly two types Internal and external

Internal stressor: Physical ailments such as infection or inflammation , or

psychological problems such as worrying about something. Eg: fever, pregnancy,
menopause, etc.
External stressor: Physical conditions such as heat or cold, stressful
psychological environments like working conditions and abusive relationships. Eg:
change in family and social role, changes in environment.

ADAPTATION

The change that take place as a result of the response to a stressor is adaptation. It
is to some degree, an ongoing process as a person strives to maintain balance in
internal and external environment. All hormone levels can be altered by stress.
Extreme levels of stress damage human tissue and may interfere with adaptive
responses. If adaptive behaviours are effective, energy is freed and may be directed

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towards healing. If adaptive behaviours fail or are ineffective, the tension is
increased, as is the demand for energy. So the original stress of illness looms larger.

HOMEOSTASIS:

W.B Cannon in 1939 introduced the concept- Homeostasis. To maintain

health, the bodys internal environment must remain in a balanced state. Various
physiologic mechanisms within the body responds to internal changes to maintain
relative constancy in the internal environment, which is called Homeostasis. A
healthy individual maintains homeostasis if personal physiological needs are met,
even though these needs may change with time. It is maintained by physiological
mechanisms controlling body functions.

CRISIS:

When stress overwhelms , a persons existing coping mechanism

disequilibrium occurs and thus causes a crisis. Crisis can be viewed as an integral
component of everyday life situation. A crisis may influence peoples lives in
different ways. Intervention at a crisis is extremely important to prevent mental
illness, because long- standing problems make the person totally incapable of
handling the situation.

STATISTICS OF STRESS:

o 75% of the general population experiences at least "some stress" every two weeks
(National Health Interview Survey).
o Half of those experience moderate or high levels of stress during the same two-
week period.
o Millions of Americans suffer from unhealthy levels of stress at work. (A study
several years ago estimated the number to be 11 million--given events since that
time, this number has certainly more than tripled--studies in Sweden, Canada, and
other Westernized countries show similar trends.
o Tranquilizers, antidepressants, and anti-anxiety medications account for one fourth
of all prescriptions written in the U.S. each year.

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o The U.S. Public Health Service has made reducing stress by the year 2000 one of
its major health promotion goals.
o Over 50% of US population visit a clinical psychologist atleast once in 2 years.
o Approximately 1 in 52 people in USA is suffering from PTSD.
o Bangalore, the IT city is the suicide capital. Till june 2008, 1070 cases of suicide
has been reported in Bangalore alone.
o India accounts for 10% of world suicide rates.

SOURCES OF STRESS

The sourses of stress plays a vital role in stress and adaptation.

Environmental : Noise, pollution, traffic, crowding, weather, etc.

Physiological: Illness ,injuries, hormonal fluctuations, sleep disturbances,
nutrition, etc
Social: Financial problems, work demands social events, losing a loved one,
etc.
Thoughts: Negative self talk, perfectionism, etc.
Any kind of change : Fear of the new, feeling of insecurity, fear of rejection,
fear of conflict, fear of taking a risk, etc.
Individual personalities: Low self esteem, feeling of over responsibility, fear
of loss of control, fear of error, failure, mistakes & chronic guilt, anger, hostility
depression, etc.
Inter personal issues: Poor maintenance of relationship, lack of healthy
communication, disapproval, over dependency, struggle for power, etc.
System [family, job, school, club, organization issues] :
Lack of leadership, Un co-operative atmosphere, Competitive atmosphere, Autocratic
leadership, Lack of team work, Confused communication, etc.

MODELS OF STRESS:

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 A stress model predicts stressors for an individual and responses to
stress. By understanding how stressors and individual interacts, the nurse can use the
stress model to help the client to avoid unhealthy, non productive responses to
stressors.

The psychosomatic model is based on the premise that stressors affecting the
client in one dimension can have pathological effect in other dimensions. For
example, stressors in emotional dimension are manifested in physiological ways. A
person must control the responses to a stressor. Many kinds of stressors cannot be
avoided, but a persons responses to stressor can be controlled.

Adaptation model: The adaptation model of stress proposes that four factors
determine whether a situation is stressful [Mechanic, 1978].
The first factor is the ability of a person to cope with stress. This ability usually
depends on previous experience with similar stressors, support systems, and overall
perception of the stressor.
The second factor involves the practices and norms of the persons peer group. Peer
groups set standards about what can and cannot be voiced as concerns.
The third factor is the means that the social environment provides an individual to
adapt to a stressor. Eg: counselor, community health worker.
The fourth factor is the nature of the process that determines where and how an
individual can use resources in the social environment to deal with stress. If the
resources are difficult to access, the client may delay seeking help and stress may
increase.
The adaptation model is based on the understanding that, when people feel
unprepared to cope with a stressful situation, they are uncomfortable and experience
anxiety and often increased stress. By understanding this, the nurse can anticipate
stresses their clients may experience. With appropriate interventions, nurses can help
clients and their families to reduce the effects of stress in all human dimensions.
Social environmental model :This model is concerned with the effects of a
persons work role on health. This model focuses on 6 variables that determine how a
persons work role interacts with health. The model explains how personality,
external and internal environments, individual responses to stressors , and
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interpersonal relationships influence responses to the stresses of work and affect
physical and mental health. When assessing clients level of wellness, nurses should
identify actual and potential stressors in work environments to help the client modify
or adapt to them.
PROCESS MODEL: This model is concerned with how a person chooses
among alternative responses to stress, with the overall goal of changing the stress
situation and thus reducing stress. This model describes a stress situation as a four
stage, closed- cycle set of processes. In the first stage, the person encounters the
stress situation and either perceives it as stress or does not. If the person perceives
stress, the second stage, he then decides how to respond to the stressor. In the third
stage, the person acts in some way and finally in the fourth stage, assesses the
situation again to determine whether it has changed and whether stress is reduced. If
the level of stress remains high, the person moves through the process again &
attempts new responses to stress. The process model of stress is useful in
understanding stress situations within the organizations, and it helps nurses caring for
clients with disabilities or chronic illnesses .This model helps the nurse to teach
clients with chronic diseases and their families to adapt to changes in functioning
and life style.

NORMAL RESPONSES TO STRESS

Physiological response

Local adaptation syndrome [LAS] :

It is a localized response of the body to stress. It involves only a

specific body part [tissue or organ] instead of the whole body. The stress
precipitating the LAS may be traumatic or pathologic. LAS includes 2 main
responses that influence nursing care are the reflex pain response and inflammatory
response. Reflex pain response is a response of the CNS to pain. The reflex depends
on an intact, functioning neurologic reflex arc and involves both sensory and motor
neurons. Inflammatory response is a local response to injury or infection. It serves to
localize and prevent the spread of infection and promote wound healing.

General adaptation syndrome [GAS] :

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 It is a biochemical model of stress developed by Hans Selye [1976].
The GAS describes the bodys general response to stress, a concept essential in all
areas of nursing care. Three stages in the GAS are

1. Alarm reaction : When a person perceives a specific stressor, various defense

mechanisms are activated. Autonomic nervous system initiates the fightor-flight
response , preparing the body to either fight off the stressor or run away from it.
Hormone levels rise to prepare the body to react. This phase of alarm reaction, called
the shock phase, is characterized by an increase in energy levels, oxygen intake,
cardiac out- put, BP, and mental alertness.
2. Resistance reaction: After perception of threat, the body attempts to adapt to
the stressor. Vital signs, hormone levels, and energy production returns to normal. If
the stress can be managed or confined to a smaller area [LAS], the body regains
homeostasis. If the damage to the body is too great, the adaptive mechanisms fail.
3. Exhaustion : When the distress is continued and adaptive mechanisms fail, the
body may either rest & mobilize its defense to return to normal or reach total
exhaustion & death.

Psychological response:- Everyone frequently encounters physical, psychological

,& social changes in the internal and external environments. A persons perception of
these changes may be conscious or unconscious . Person tries to establish balance
between stressors and the environment. Adaptation to stress also depends on age,
developmental level, past experience, support systems & coping mechanisms.
Adaptive responses include the mind- body interactions anxiety and coping / defense
mechanisms.

Mind-Body interaction: Human reacts to threats of danger as if

they were physiologic threats. A person perceives the threat on an emotional level,
and the body prepares itself either to resist the danger or to run away from it. [ fight
or flight response]. With prolonged stress, some may develop chronic diarrhea, others
may develop headaches. Such illness are real and are called psychosomatic disorder,
because the physiologic alterations are thought to be at least partially caused by
psychological influences. Another component of mind-body interaction is the effect

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of life changes on a person. Researchers have found that the number of changes a
person has in his or her life ,[both positive and negative ] is correlated with illness.
Because life changes is an environment in a persons life that requires energy for
adaptation.

Anxiety: The most common human responses to stress is anxiety.

Anxiety is a vague, uneasy feeling of discomfort or dread accompanied by an
autonomic response; the source is often nonspecific or unknown to the individual.
Anxiety is the emotional response to stress. According to NANDA[ 2003], Anxiety is
an altering signal that warns of impending danger and enables the individual to take
measures to deal with threat.
Anxiety is mainly 3 types :
a) Mild anxiety: This type present in day today living. It increases
alertness and perceptual fields & motivates learning and growth. This type is
manifested as restlessness and increased questioning.

b) Moderate anxiety: It narrows a persons perceptual fields so that

the focus is on immediate concerns with inattention to other communication and
details. It is manifested with increased respiration pulse, increased muscle tension
etc.
c) Severe anxiety: Creates a very narrow focus on specific detail,
causing all behavior to be geared toward getting relief. It is manifested as difficult
verbal communication, increased motor activity, fearful facial expression, headache,
nausea, dizziness, tachycardia, and hyperventilation.
d) Panic: It causes person to lose control and experience dread and
terror. It is manifested by increased physical activity, loss of personal thought, etc.
Coping mechanisms: Anxiety often is managed without conscious
thought by coping mechanisms, which are learned behaviours from family, past
experiences and socio cultural influences and expectations. Eg: crying, laughing,
sleeping, smoking, drinking ,etc.
Defense mechanisms: These are unconscious reactions to
stressors. These mechanisms protects ones self-esteem and are useful in moderate to

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mild anxiety. In extremes, they distort reality and create problems with relationships.
Some of the defense mechanisms are:
Compensation Attempts to overcome perceived weakness by
emphasizing a more desirable trait.
Denial Refuses to acknowledge the presence of a condition ie
disturbing.
Rationalization- Behaviour justification.
Repression Voluntary exclusion of an anxiety producing situation
from conscious awareness.
Regression- Returning to early behavior.
Undoing- An act or communication used to negate a previous act
or communication.
Projection- Blaming someone else for how they are feeling.

PHYSIOLOGIC RESPONSE TO STRESS

An understanding of the physiological changes associated with stress provides

the foundation for the assessment of the client experiencing stress
and the implications for health outcomes. The physiologic response to a stressor
is a protective and adaptive mechanism to maintain the homeostatic balance the
body. Stressors or demands may be physical, psychologic or social. The body
will respond physiologically to both actual or symbolic stressors. The complex
processes by which an event is perceived as a stressor and by which the body
responds is not fully understood. However, there are three interrelated systems,
viz. nervous system, endocrine system, immune system.

Nervous System

Neural and hormonal actions to maintain homeostatic balance are integrated by

the hypothalamus. Hypothalamus is located in the center of
the brain, surrounded by the limbic system and the cerebral hemispheres. It
integrates autonomic nervous system mechanism,that maintains the chemical
constancy of the internal environment of the body. Hypothalamus participates
in both emotional and physiologic response to stressors.
This control is Significant because most stressors precipitate an emotional
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reaction. In addition to the hypothalamus, other parts of the CNS
including cerebral cortex, limbic system and reticular formations are involved in
the neural control of emotions and the physiologic responses to stress. The
function of these structures are closly interrelated.
Cerebral Cortex

After an external event has occurred, afferent input is sent to the cerebral cortex
via sensory impulses from the peripheral nervous system including the eyes and
ears. In stress response, afferent impulses are carried from sensory organs
(eyes, ear, nose, skin) and internal sensors (baroreceptors, chemoreceptors) to
nerve centers to the brain. Afferent impulses that travel to the cortex
from the periphery via the spinal cord (spinophthalmic pathway) also activate
the reticular formation in the area of the brain stem. The reticular formation then
relays input to the thalamus and from the thalamus to the cerebral cortex. The
cerebral hemispheres are concerned with cognitive functions, through processes,
learning and memory (The limbic system has connection with the both cerebral
hemispheres and the brain stem). The network of neurons which is involved with
arousal and consciousness is called reticular activating system (RAS). The RAS
functions to maintain wakefulness and alertness. The somatic,
auditory and visual associative areas and the cerebral cortex receive input from
the peripheral sensory fibers and then interpret it. The prefrontal area serves to
reduce the speed of the associative functions so that the person has time to
evaluate the information in light of the past experiences and future consequences
and to plan a course of action. All these functions are involved in the perception
of a stressor.

Limbic System

The limbic system, which lies in the inner mid- portion of the brain, near the
base includes the septum, cingulate gyrus, amygdala, hippo- campus, and
anterior muscle of the thalamus. The function of the limbic system is thought to
be involved with emotions and behaviors. When these structures are stimulated,
emotions, feelings, and behaviors can occur that ensure survival and self-
preservation such as feeding, sociability and sexuality (drinking, eating,

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temperature control, reproduction defense and aggression).
The cerebral cortex and limbic system instruct to serve the experiential and
executive functions of emotions. Endorphins are found in this system and
around, reduce the perception of painful stimuli.

Reticular Formation

Reticular formation is also located in between the lower end of the brain stem
and the thalamus. It contains the RAS, which sends impulses contributing to the
limbic system and to the cerebral cortex and thalamus. In addition to receiving
input from the periphery, the RAS also receives impulses from the
hypothalamus, when the RAS stimulates it increases its output of impulses
leading to wakefulness. Both physiologic stress, usually increase the degree of
wakefulness.

Hypothalamus

Hypothalamus lies just above the pituitary gland. It has many functions as given
below.
1.Coordinates impulse
Autonomic nervous system
Body temperature regulation
Food intake
Water balance
Urine formation
Cardiovascular function.
2.Secretes releasing factors - regulation of anterior and posterior pituitary
hormone.
3.Affects behavior
Emotion and alertness.
The hypothalamus receives information regarding traumatic stimuli via the
spinophthalmic pathway, pressure-sensitive input from the

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baroreceptors via brain stem, and emotional stimuli via limbic system. Because
the hypothalamus secretes peptide hormones and factors that
regulate the release of hormones by the anterior pituitary, it is central to the
connection between the nervous and endocrine system responding to stress. In
addition, the hypothalamus regulates the function of both sympathetic and
parasympathetic branches of the autonomic nervous system.

Endocrine system

Once the hypothalamus is activated in response to stress, the endocrine system

becomes involved. The sympathetic nervous system stimulates the adrenal
medulla to release the hormones. Epinephrines and the sympathetic nervous
system including adrenal-medulla, is referred to as sympathoadrenal response.
These hormones prepare the body for the "fight or flight" response. This
response is activated by physical stressors such as hypovolemia and hypoxia,
and
emotional status, particularly anger, excitement and fear.
The hypothalamus released corticotrophin- releasing hormones (CRH) which
stimulates the anterior pituitary to release propiomelanocortin (POMC). Both
adrenocorticotrophic hormones (ACTH) and endorphins are derived from
POMC. ACTH, in turn, stimulates adrenal cortex to synthesize and secretes
glucocorticoids, and to a lesser degree aldosterone and androgen.
Glucocorticoids in particular, cortisol, are essential for the stress response.
Cortisol produces a
number of physiologic effects that include increasing the glucose level, potentia
tory action of catecholamines on blood vessels and inhibiting inflammatory
response. Aldosterone acts to increase sodium reabsorption in the kidney tubu -
les, and as a result increases ECF. During stress, neural stimulation of the
posterior pituitary results in the secretion of ADH which also promotes water
reabsorption by the distal and collecting tubules of the kidney.
Stimulation of both the adrenal medulla and cortex results in an increased blood
glucose level. This elevation provides the additional fuel for the increase d
metabolism needed for fighting or fleeing. The increased cardiac output, due to
increased (HR and ECF) increased blood glucose level, and increased metabolic
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rate make the physical response possible. In addition, dilatation of the skeletal
muscle blood vessels and the brain provide quick movement and increased
alertness.
Immune System

Negative stressors lead to alterations in immune functions in humans through

processes involving the hypothalamic-pituitary-adrenal axis and the autonomic
nervous system that affects immune function. In turn, immune system also
affects endocrine and CNS responses. Both corticostreroids and catecholamines
are known to suppress immune function. Interleukin-l (which is released by
activated macrophages), on type of cytokine, may directly stimulate the release
of ACTH and thus initiate the stress response. Glucocorticoids depress the
immune system; when these are present in high concentrations, there is a
reduction in the inflammatory response to injury or infection. The steps of
inflammation process are inhibited, lymphocytes are destroyed
in lymphoid tissues and antibody production is decreased. As a result, the ability
of the persons to resist infections is reduced.

EFFECTS OF STRESS
Individual response to stress - The stressful personality type:
Friedmann & Roseman [1974] classified individuals into 2 groups
according to personality charecteristics.

Type A group : Personalized by extreme competitiveness and

inability to place stress in perspective. They are unable to delegate and find it
difficult to refuse additional work. Consequently, they have insufficient time to
complete tasks and instead of problem solving and prioritizing ,they juggle them,
switching in an undirected manner from one task to another without completing any.
This personalities appear aggressive, reacting to minor irritations with temper
tantrums.

Type B group : This group remains totally relaxed, & almost

unconcerned when confronted by stressor.

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 Most people exhibit traits from both personality types and are situated
on a point along this scale somewhere between the two extremes. But the correlation
between health and personality types are still existing.
Friedman & Roseman found that people who were less susceptible to
heart diseases had a greater number of type B characteristics than type A.

Post Traumatic Stress Disorder : [PTSD]

It is a condition that occurs within 6 months of exposture to a
triggering event & is defined as a delayed and /or protracted response to a stressful
situation [either short or long lasting] of an exceptionally threatening nature which is
likely to cause pervasive distress in almost anyone. The trigger is therefore any major
psychological event outside the range of usual day-today experience.
A 2004 study found that 18% of troops of US soldiers returned after
Iraq war developed PTSD.

Eg: Natural disasters [earthquake,floods,etc.]

Manmade disasters [industrial accidents , major air accidents,etc]

Intentional manmade disasters[rape victim, torture, assault, witnessing
Violent deaths, etc]

Five major features are:

1. Flash backs: Individuals relieve the experience during nightmares.

Additionally, when awake they may experience a type of dj-vu and feel that the
situation is about to recur.
2. Emotional numbing: Individuals repress the distressing experience
& the feeling they associated with it.This leads to emotional blunting and detachment
from others.
3. Hypervigilence: Individuals are very restless, as if on a constant
look out for danger. They also react in an exaggerated way to unexpected events.
4. Avoidance: Avoids anything reminiscent of the triggering event.
5. Confusion, anxiety & depression : Individuals become confused,
anxious or depressed and suicidal attempts may occur. Additionally, many

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individuals blame themselves for the incident & the resulting guilt augments their
symptoms. Associated symptoms are : insomnia, headache peptic ulcer drug abuse,
etc.

Management:

Early counseling
Exposure therapy, cognitive therapy
Anxiety management
Hypnotherapy

Stress and basic human needs :

Basic human needs, are common to all people. Stress, too, is common
to all people. Both the attainment of these needs and the adaptation to stress require
energy and motivate behaviours. As a person strives to meet basic human needs at
each level, stress can be either a stimulus or a barrier.
How a person meets basic human needs and responds to stress is unique
to the individual depending on his or her sociocultural background, priorities & past
experiences. In all people, the failure to meet needs results in an imbalance in
homeostatic mechanisms and, eventually illness.

Effects of stress on basic human needs

Physiologic Change in appetite, activity, or sleep; Change in
elimination patterns; Increased pulse, respiration, blood pressure.
Safety / security Feels threatened or nervous; Use ineffective
coping mechanisms; Inattentiveness.
Love or Belongingness: Withdrawn and isolated; Blames others for
own faults, Demonstrates aggressive behavior; Over dependency on others.
Self esteem: Becomes a workaholic; Attention seeking behavior
Self actualization: Refuses to accept reality; Centers on own
problems; Demonstrates lack of control.

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 Stress in computer users: In this 21st era of knowledge explosion,
use of computers and internets are common. Regular computer users are at risk to
develop health problems and most of these problems are preventable.

Stress in healthy individuals:

Stress in a healthy person may promote health and prevent illness. For
example, fear of developing lung cancer may motivate a person to stop smoking.
Stressors in health, also facilitate normal growth and development, by providing
stimulus for learning constructive adaptive behaviours, problem solving abilities,
encouraging social relationships and developing spiritual strength. Chronic stress in
children may cause decreased functioning of pituitary gland and thus decreased
production of growth hormone and thus to retarded growth.
The 2 physiological systems in particular are extremely susceptible to
the destructive effects of prolonged stress are the circulatory & immune systems.
o Circulatory system: Fight or flight responses causes the heart rate
to increase and peripheral vasoconstriction and thus, inceased BP, Increased
respiration, etc may cause. The long term stress may damage the heart & arteries and
thus causes hypertension, CHD, etc. Studies on female monkeys at Wake forest
university [2009] discovered that, individuals suffering from high stress have
increased levels visceral fat in their body and thus causes hormonal and metabolic
changes and eventually leads to heart diseases.

o Immune system: In the resistance reaction of the GAS, immune

system is suppressed, so the person is more susceptible to diseases. Most of the
peoples under stress, may develop minor infections like colds. In the long term stress,
long term suppression of immunological systems may cause development of
malignancies. Autoimmune disorders like Graves disease [hyperthyroidism],
Rheumatoid arthritis, Myasthenia gravis
o Other systems:
Gastrointestinal systems: Peptic ulcer disease , Ulcerative colitis
[often seen in obsessive personalities exacerbations occur by stressful life events],
Irritable bowel syndrome [Common in people who are tense and anxious].

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Esophageal reflux, constipation, diarrhea, dry mouth, nausea, loss of appetite, etc also
may develop.
Respiratory systems: Many people who suffer from asthma find
their symptoms are worse during periods of psychological stress. Addressing the
fears and reassurance helps to reduce the severity of the attack.
Skin: In the fight or flight response, sweating occurs , goose bumps
appears, and appears pale as their peripheral capillaries constricts. Sweaty cold
palms, Prolonged periods of psychological distress may cause exacerbation of
eczema and psoriasis.
Aches: Long periods of acute distress , such as at the end of a
stressful day, tension of the antagonistic muscle causes, muscles and joints to ache.
Tense muscles are associated with psychological distress and relaxed muscle with
tranquility. Stiffness of neck may also present.
Migraine: Stress is highly influential in the history of migraine
attacks and headaches.
Substance misuse: People experiencing stress may turn to alcohol,
nicotine and other illegal substances to relieve their symptoms. Although these
substances provide short term relief, continuous usage may cause addiction,
dependence, tolerance, etc and thus causes deterioration of health. Sleep disturbances
are present.
o Mental illness: Most of the mental disorders are caused due to
stressful life events. The most common mental disorders that arise from
psychological distress are anxiety and depression.
o Accidents or unsafe behavior: Increasing levels of arousal make it
difficult for individuals to concentrate and this in turn leads to an increase in
accidents. In an attempt to meet tight deadlines, individuals sometime Ignore safe
working practices, thus exposing themselves or others to risk.
Stress in illness: The effect of stress on sick or injured are negative.
Stress can cause illness and illness causes stress. The presence of an illness or a
disability demands new coping skills at a time when homeostasis is challenged.
Stress associated with hospitalization: Entry into a hospital is a
threat to ones identity. Hospitalization is highly stress producing situation due to:

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o Eating different foods at different times
o Having a stranger as room mate.
o Sleeping in a different bed and pillow.
o Being awakened at odd hours.
o Feeling too hot or too cold.
o Smelling hospital odors.
o Hearing strange hospital noises.
o Restricted movements
o Having too many visitors
o Worry about bills, jobs, or family concern
o Being uncertain of ones diagnosis
o Not understanding medical language
o Being dependence on others for self care
o Embracement about revealing body parts or intimate details
o Having to deal with large number of health care workers.

Family stress: The stress that affects an ill person also affect the
family members. Stressors for the family include change in the family structure and
roles, anger & feelings of hopelessness and guilt, loss of control over normal
routines, and concern for future financial stability. The family thus is an integral part
in the assessment, planning, nursing interventions, and evaluation of actions to
promote adaptation to stress. The inclusion of family members in problem solving,
teaching and learning activities, and physical care helps both the patient and family to
maintain their self esteem and feeling of worth.
Caregiver burden is the prolonged stress of the family member who
cares the person in home for long periods. This stress response includes chronic
fatigue, sleep disturbances, and an increased incidence of stress- related illness, such
as high blood pressure & heart rate
Prolonged stress:

Prolonged or long-term stress is a serious threat physical and emotional health. As

the duration, intensity or number of stressors increases, a persons ability to adapt is
lessened. The failure of adaptive mechanisms is also influenced by a persons state of
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health and past experiences with stress. Long- term stress affects physical status,
increasing the risk for disease or injury. Recovery and return to normal function are
also compromised by prolonged stress.

Stress in older adults:

Stress, with resultant anxiety, is a risk in the older population. Possible causes for
development of anxiety are:

o Invasive or health- related tests or examinations.

o Surgical procedures
o Diagnosis of chronic illness [diabetic mellitus, cancer, cardiovascular diseases]
o Declining physical and or mental capabilities
o Retirement
o Loss of spouse or significant others
o Social isolation
o Chronic pain
o Alcohol abuse
o Dependence on others

Stress of patient in ICU:

Admission to an ICU may signal a threat to the life and wellbeing of
the patient who is admitted. Patient may feel negative experiences in ICU because of
the fear, anxiety, sleep disturbances, cognitive impairment, and pain or discomfort.
The patient may develop ICU psychosis. The nurse has to assess, anticipate and
monitor the response to the illness; Minimize and redirect the ineffective behavior of
the patient in ICU to reduce their stress.
Stress in Maternal and child health:
Pregnancy and child birth are normal life events, yet women are
exposed to a significant amount of stress. Many mothers may also experience distress
and anxiety simply because they didnt anticipate or did not know about the normal
psychological upheavals, emotional changes, and adjustment that are integral to the
childbearing process. Midwives, therefore, have a vital role to play in assisting

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women and their partners to prepare for the physical, social, emotional and
psychological demands of pregnancy, labour, puerperium and parenthood.

FACTORS AFFECTING STRESS AND ADAPTATION

1. Sources of stress:
2. Types of stressors:
3. Personal factors:
A persons adaptation to stress, whether positive or negative, is
influenced by a number of personal factors. Ones physiologic reserve and genetic
inheritance are important in maintaining homeostasis and adapting to stressors. The
ability to adapt is decreased in the very young, the very old, and those with altered
physical or mental health. People who have strong support systems and relationships
better able to adapt to stress and remain healthy.
STRESS IN NURSING PROFESSION
Nursing involves activities and interpersonal relationships that are
often stressful. The nurses feel overwhelming because of the continuous stress and
anxiety. This result in a complex of behaviors called BURNOUT. Burnout is a state
of exhaustion that results from repeated emotional pressure. According to Maslach,
[1982] there are three main symptoms of burnout:
o Emotional exhaustion- The person feel emotionally drained and unable to give
more.
o Depersonlization- The individual becomes isolated and hardened towards
others.
o Decreased sense of personal accomplishment- The individual is unable to deal
with problems positively and may trivialize any achievements.
The nurses or health care professionals lose their concern and feelings
for their clients and come to treat them in detached or even dehumanized ways. It is
an attempt to cope, by distancing oneself, with the stress of intense interpersonal
work. It hurts both the clients and the health care provider.
Strategies to reduce the burnout:
o Keep staff-client ratios low.
o Short the work shifts.

20
o Encourage staff members to express, analyze, and share the feelings about the
burning out.
o Proper delegation of the work
o Councelling services.

THE NURSING PROCESS FOR THE MANAGEMENT OF STRESS

The client faces an array of potential stressors, or demands that can have health
consequences. The nurse needs to be aware of the situations that are likely to
result in stress and also must assess the client's appraisal of the situations. The
major areas that provide the nurse with useful guide in
the assessment process include demands, human response to stressors and
coping. It is always better to observe the following indices of stress,
in which some are psychologic, some are physiologic, some behavioral, and
some reflect social behavior and thought process.

ASSESSMENT:
Stress and anxiety are problems that nurse encounter in patients of all
ages and in all settings. Stress is assessed through a health assessment, including a
nursing history and physical assessment. Risk factors for, or indicators of, stress may
be identified through standardized tests or open ended questions to elicit information.
The patients willingness to share information is affected by the level of stress
experienced as well as the coping or defense mechanisms in use.

Nursing History: The nursing history assists the nurse in identifying stressors
and how the person perceives and cope with stress.

Physical assessment: The relationship between psychological stress and

physiological disturbances makes it possible to assess stress level using physiological
measurements. For eg: one effect of stress is perspiration; this leads to greater
electrical conductivity of the skin surface, which can be measured using a
galvanometer. Heart rate and blood pressure are also indicators, as these become
elevated in a person under stress.

21
 Assessment of the person: Assess the following characteristics in the person
who are at high risk of developing stress.
o Rigid and self punishing moral standards
o High and unrealistic expectations
o Too much dependence on others
o Inability to master change or learn new ways of dealing with frustration
o Easily prone to extreme emotional responses of fear, anxiety and depression
o Type A personality persons
o Stressful life events such as birth, death, marriage, divorce,etc.

Assessment of the family: Assess the familys perception of the problem, and
whether it is supportive of the clients effort at coping.
Assessment of the environment: Occupations with a high degree of stress;
adverse environmental influences like too much of lighting, temperature, etc.
Hospital anxiety and depression scale: The hospital anxiety and depression
scale [Zigmond & Snaith 1983] is widely used to identify anxiety and depression. It
is a self-administered questionnaire and consist of 14 questions . 7 questions measure
traits of anxiety,and next 7 traits of depression. With a score greater than 8 indicates a
pathological state. The patient must have sufficient insight into their problems to
complete this instrument. Its main advantage is that it helps to differentiate between
anxiety and depression. When used within the nursing assessment, this enables the
nurse to optimize subsequent interventions.
Social readjustment rating scale: This is put forward by Holmes &Rahe [1967]
It is a fixed number of life events and assumes that these invoke similar stress
response in everyone. Its main use is to gain insight into major life events
contributing to a patients background level of stress and it is possible to use this
instrument within a nursing assessment. As it only lists a limited number of events, it
is inappropriate to use this instrument alone, as it may not record all the salient
factors that invoke stress. If this instrument is used it must be supplemented in two

22
ways : with additional information about how patients interpret the threat posed by
the stressors; and with identification of any stressors not listed.
Self reporting: As stress is the unique interpretation of threat, the instruments
used for stress assessment are not reliable. Stress is a psychological construct, and
because only the individual experiencing it knows its true meaning, using a rigid
model of assessment becomes difficult. A self reporting method may prove more
effective.
Stress points / Bio dots /Stress cards: The hand and foot temperature are the
simplest and easiest measure of stress. The warm hands indicates relaxed state & cold
hands as tensed. If the temperature of the extremities are below790 F, indicates
chronic tension, 790 -840 F indicates nervous, 840- 900 F indicates alert and active.90-
950 F indicates calm, above 950 F indicates deeply relaxed.
The Bio dots or Stress squares are commercially available liquid crystal materials
that change colours for stress related temperature changes. If the colour of the bio dot
is black, the temperature is below 79.60 F, that indicates chronic tension. Violet
colour indicates temperature of 89.60 F and indicates alert and active. The principle
behind Stress cards are also same like Bio dots.
1. NURSING DIAGNOSIS:
Anxiety related to conflicts about values and goals in life, threat to self
concept, threat of death, threat of or change in health status, threat to or change in
environment or role, situational or maturational crisis, or unmet needs.
Ineffective coping related to inability to maintain lifestyle changes.
Defensive coping related to loss of job and economic insecurity.
Disturbed thought process related to panic state.
Ineffective denial related to continued smoking behavior.
Decisional conflict related to placement of parent in nursing home.
Imbalanced nutrition: less than body requirement related to inadequate caloric
intake
Caregiver Role strain related to long-term stress of care for chronic disease.
Social Isolation related to feelings of worthlessness and apprehension
following diagnosis of chronic illness.
Spiritual distress related to inability to accept diagnosis of terminal illness.

23
 Hopelessness related to presence of disabling physical injuries.
Disturbed Sleep pattern related to anxiety about terminally ill spouse.
2. OUTCOME IDENTIFICATION AND PLANNING:
The expected outcomes of the plan of care may include that the patient
will achieve the following:
Decrease in the level of anxiety by verbalizing feelings and using support
systems.
Develop effective coping skills through problem-solving skills and anxiety-
reducing techniques.
Describe a reduction in anxiety and an increase in comfort.
3. IMPLEMENTATION:
Interventions are directed towards relief of acute or chronic stress. A
nurse can help the person to examine the situation, identify possible solutions, and
accept his feelings without guilt or fear. People suffering from acute stress related
illness often need to change their lifestyle and ways of relating to others.

__Non-Pharmacological methods:
The non pharmacological methods effectively reduces stress and encourage to
develop a healthier lifestyles. So these methods helps to prevent future problems.

Teaching Healthy Activities of Daily Living: A persons normal lifestyle

greatly influences his or her perceptions of and reactions to stressors. Exercise, rest,
and good nutrition are important components of stress reduction.
Exercise: Regular exercise helps to maintain physical and emotional health.
Exercise improves ones general sense of wellbeing, relieves tension, and enables one
to cope better with day-to-day stressors.
Rest and sleep: Rest and sleep help the body to maintain homeostasis and
restore energy levels. Adequate rest can provide insulation against stress, but stress
may interfere with ones ability to sleep.
Nutrition: Nutrition plays an active role in maintaining the bodys homeostatic
mechanisms and in increasing reactions to stress.Obesity and malnutrition are major
stressors and greatly increase the risk for illness.

24
 Encouraging use of support systems: Support systems provide emotional
support that helps a person identify and verbalize feelings associated with stress.
They provide information and services, maintaining positive self concept, and
establishing new relationships and social roles. In addition, families and support
groups provide an accepting environment, allowing the person to explore problem-
solving methods try out new coping skills
Encouraging use of Stress management techniques:
Keeping a stress- awareness diary:
Keeping a stress awareness diary helps people identify how particular stresses
result in predictable symptoms. This diary helps to discover and chart their own
personal stressful events and characteristics reactions
I.Relaxation techniques:
Relaxation techniques are useful in many situations, such as
childbirth, pain, anxiety, illness, anger, etc. Relaxation promotes a body reaction
opposite to that of fight or flight response ,ie respiratory rate, metabolic rate, blood
pressure, etc. Relaxation helps a person to control his or her feelings and behaviors.
Two relaxation activities, to be practiced 3or 4 times a day are deep breathing and
progressive muscle relaxation.
Deep Breathing:
Sit, stand, or lie with your spine straight. Place one hand on the chest
and the other on the abdomen. Inhale slowly and deeply so that the abdomen pushes
the hands up. Visualize the lungs slowly filling with air. Hold the breath for a few
seconds. Exhale through the mouth by making a soft, whoosing sound. Continue to
take long, slow, deep, breaths for at least 10 minutes at a time, once or twice as a day.
Progressive Muscle Relaxation:
o Active Muscle relaxation; By lying down or by sitting in a chair with feet
firmly on the floor, first tighten your right hand into a fist and notice how it feels.
Hold the tension for 5-7 seconds. Loosen your grip, and then relaxed for 20-30
seconds, and let the tension slip away. Continue to tighten-hold-relax each muscle
group: hands, arms, shoulders, face, chest, back, abdomen, legs, feet. Caution should
be taken while doing with muscles of neck and back to avoid soft tissue injury.
Tightening the muscles of the toes and feet too vigorously could also result in

25
 uncomfortable muscle cramps. Avoid active progressive relaxation in postoperative
clients because that will cause pain.
o Passive Muscle Relaxation; the muscles are not tensed. The relaxation begins
with muscles easiest to relax [in the toes] and progress to muscles most difficult to
relax [in the head]. The sequence of muscle relaxation is from, feet, lower legs, knees
and upper legs, hips and buttocks, lower backs, lower arms and arms, chest and
diaphragm, abdomen, pelvis, and genitals, neck, forehead, and upper face, mouth and
jaw.
II.Meditation:

Meditation is a kind of self discipline that helps one achieve inner peace and
harmony by focusing uncritically on one thing at a time. Meditation has four
components: quiet surroundings, a passive attitude, a comfortable position, and a
word or mental image which to focus. A person practicing meditation sits
comfortably with closed eyes, relaxes the major muscle groups, and repeats the
selected word silently scene and mentally place in it while breathing slowly in and
out. This should be performed for 20 to 30 minutes twice a day. Avoid meditation
within 2 hours after eating a heavy meal, because digestion interferes with the ability
to relax.

The state of meditation is equivalent to a state of deep rest. It takes

the brain to alpha state : electrical impulses of 8-14 cycles per second. At deep
meditation level [Samadhi state], brain goes to the state of electrical impulses of 4-7
cycles/second and leads to deep relaxation. The heart rate slows, the body uses less
oxygen, metabolic wastes like lactate sharply reduces & It will reduce the occurrence
of insomnia, asthma, hypertension, stroke, heart diseases etc.

Sudarsana kriya of Art of Living: It takes the brain to higher beta state then takes the
brain to deep relaxation, thus exercises & expands the brain / mind capacity.

III.Yogasanas:
This is exercising different parts of the body, combined with controlled
breathing. The postures are stretch & hold, compress & hold. It creates flexibility,
hollowness, lightness and helps in flow of oxygen, food, water, electric signals and

26
 flow of energy in the body freely. The pranayamma which is the main component
increases oxidation & liberation of energy in every cell of the body. It stimulates
nerve tips in lungs which have connection to the brain area where pituitary gland is
situated.

IV.Music Therapy:
Music produces endorphins in the brain, these natural opiates from
hypothalamus reduces pain intensity. Relaxation with music will be used in dental
procedures, to lower blood pressure and music with 60 beats per minute can help
those with cardiac dysrhythmias achieve a more relaxed heart rate. It is recommended
to pay attention to breathing while listening to music. Slow and deep breathing
enhances the relaxing effect of music.
V.Breathing Exercise:
Breathing calmly and deeply keeps the blood well oxygenated and
purified. It helps remove waste materials from the blood and clears thinking. The
following exercises are designed to facilitate proper breathing.

Awareness of breathing:

Take time to pay attention to your own breathing. Begin by placing one hand just
below the ribcage, and taking a deep breath. Notice the changes happening while
breathing.

Deep breathing:

During deep breathing, you move the diaphragm downward and fill the lower part of
the lungs with air. The chest upward as the upper part fills.

Ten-To-One Count:

This exercise is also quick and simple. Inhale, taking a deep breath, while saying the
number 10 to yourself. Then exhale slowly, letting out all the air in your lungs. Inhale
again, saying the number 9 to yourself. As you exhale, tell yourself: I feel more
relaxed than I did at number 10. With your next breath, say the number 8 to
yourself, As you exhale, remind yourself: I feel more relaxed than I did at number

27
 9. Continue counting down and experience increasing calmness as you approach the
number1.

Alternated-Nostril Breathing:

This will help to reduce tension and sinus headaches. First, close off your right nostril
by lightly pressing it with your right thumb. Now inhale through your left nostril as
slowly and quietly as possible. Remove thumb from the right nostril and use your
forefinger to close off the left nostril. Now exhale slowly through your right nostril.
Inhale through your right nostril as slowly and quietly as possible and follow the
same procedure as done previously. The basic cycle begin with 10 breaths and can be
increased up to 25 breaths.

VI.Anticipatory guidance :

Anticipatory guidance focuses on psychologically preparing a person for an

unfamiliar or painful event. Nurses can use this technique to teach patients about
procedures and surgical experiences. When patients know what to expect, their
anxiety is reduced and their coping mechanisms are more effective. A related process
is anticipatory socialization, in which people prepare themselves for roles to which
they aspire but do not yet occupy. This process can be effectively use for the
potential parents for the effective parenting.

VII.Guided Imagery:
Guided imagery or positive visualization uses a persons own
imagination and positive thinking to create powerful mental pictures or images to
reduce stress or promote healing. This technique strongly demands on repeating the
phrase Every day in every way I am getting better and better 20 times a day to
yourself on awakening. Relaxing through visualization is enhanced by constructing in
ones own mind a relaxing environment. Some find the soothing sounds of a seashore
calming; others prefer to imagine themselves floating above the world on a soft
cloud. The person concentrates on the mental image created by him and becomes less
responsive to stimuli like pain. The nurse sits by the patient and reads a description of
the scene or an experience that the patient has described as happy, pleasant, or
peaceful. The patient is then guided through the image. As the patient becomes
28
 more and more focused on the scene, the nurse needs only verbally paint the
picture at intervals.
VIII.Body Scanning:
Body Scanning helps increase awareness of muscular tension. Make
sure that the spine is straight before beginning body scanning and maintain a good
posture. Begin by closing the eyes and turn the attention to internal world. Focus on
the toes and move up slowly and ask to yourself: where am I tense? Become aware of
all of the muscles in your body and especially the parts of the body that feels more
tensed. Most of the persons fail to feel the tension in our body because we direct most
of our tension to the outside world. It is important to differentiate between external
awareness [stimulation of the five senses from outside world.] and internal awareness
[physical sensations or emotional discomfort or comfort within the body]. The
distinction helps people separate the world from ones physical reactions to it. Being
able to recognize the tension in our bodies is the first step we can take in reducing
stress.
IX.Autogenic Training:
Autogenic training is used in stress reduction and holistic health
centers to teach self regulation of the autonomic nervous system. The course of the
training takes 4 to 10 months. The autogenic training is based on the achievement of
the following 6 physiologic outcomes:
1) Heaviness in the extremities;
2) Warmth in the extremities;
3) Regulation of the heart beat;
4) Regulation of breathing;
5) Abdominal breathing;
6) Cooling of the fore head. Once the clients learn to perform the 6 standard exercises
designed to achieve these results, they may go on to learn meditative exercises
specifically developed for each client. Caution should be taken for patients with
serious physical symptoms.
X.Self Hypnosis:
Self Hypnosis is accomplished by oneself without the help of a second
party as hypnotist- to achieve significant relaxation, to make positive suggestions for

29
 change, to increase learning and remembering, and to uncover significant but
forgotten events. Most people can achieve significant relaxation with self hypnosis.
This can be self taught through books on the subject.
XI.Therapeutic Touch:
Therapeutic touch is a conscious, deliberate act composed of 3 steps
called centering, scanning and rebalancing. The healer first prepares for the
procedure through centering, the discovery of an inner physical and psychological
stability in which the healer achieves a sense that all faculties are under command.
This gathers and focuses the healers energies on the client and excludes extraneous
thoughts from the mind, a process that is similar to meditation. The healer then scans
the client from head to foot without touching the clients body, attempting to sense
temperature changes or feelings of pressure. These areas indicate a congestion and
imbalance. To mobilize or rebalance these areas, the healer places the hands with
palms facing away from the client, in the area where pressure is felt and moves the
hands away from the clients body in a sweeping gesture while consciously directing a
flow of energy to the client.
Providing Crisis Intervention:
As Crisis is a situation that cannot be resolved by usual coping
mechanisms, the person cannot function normally and requires interventions to regain
equilibrium. Crisis Intervention is a five-step problem-solving technique designed to
promote a more adaptive outcome, including improved abilities to cope with future
crises. The steps are:
o Identify the problem
o List all possible solutions
o Choose the right one
o Implement the plan
o Evaluate the outcome

Pharmacological Methods:
The routine use of drugs as part of stress management is not
advocated, but in severe instances where pathologies develop, the use of medication

30
is helpful. Two categories of drugs are commonly prescribed: anxiolytics, and anti
depressants.
Anxiolytics: These drugs provide immediate relief from the unpleasant
feelings associated with stress. The danger is that as the underlying problems remain
unresolved, the individual will continue to take the drug to avoid the symptoms of
stress and chances for dependence are there.
Antidepressants: These drugs are sometimes prescribed when individuals
experience prolonged periods of distress. Some of the antidepressants are sedatives.
The antidepressants will also helps to improve self esteem of the patient helps in
positive thinking, and empower them to address the cause of their problem.
Complementary Remedies:
Use of herbal remedies are popular as stress reducing remedies
inspite of the side effects. Most frequently used are:
Valerian: It is used as an anxiolytic agent and having sedative properties.
Hypericum perforatum (St Johns wort): It is a widely prescribed medication. It is
thought to work in a similar way as the SSRIs work. Generally it has fewer side
effects than conventional anti depressants, but skin sensitivity to sun, GI
disturbances, dry mouth, restlessness, sedation, etc may present as side effects.

Stress management strategies:

a) Take a Deep Breath: When you feel uptight try taking a minute
to slow down and breathe deeply. Breath in through your nose and out through your
mouth. Try to inhale enough so that your lower abdomen rises and falls. Count as you
exhale slowly.

Practice Specific Relaxation Technique: Relaxation techniques are extremely

valuable tools in stress management. The practice of one of the Relaxation techniques
like meditation, deep muscle relaxation, etc can provide a wonderfully calming and
relaxing feeling that seems to have lasting effect for many people.

b) Manage Time: One of the greatest source of stress is poor time

management. Give priority to the most important thing and do those first. If a
particular unpleasant task faces you, tackle it early in the day and get over with it; the

31
rest of your day will include much less anxiety. Most importantly do not overwork
yourself, schedule time for both work and recreation.
c) Connect with Others: A good relationship with others will help you
to keep away from sadness, boredom and loneliness.
d) Talk it Out: When you feel something, try to express it. Share your
feelings. Talking with someone else can help clear your mind of confusion so that
you can focus on problem solving. Also writing down problems in paper can assist
you in clarifying the situation and allow you a new perspective.
e) Take a Minute Vacation: Take a moment to close your eyes and
imagine a place where you relaxed and comfortable. Notice all details of your chosen
place, including pleasant sounds, smells, etc. Otherwise channel the mental agony
by reading books, playing relaxing music, etc.
f) Monitor Your Physical comfort: Physical comfort is the main thing
that maintains the mind comfortable. Dont wait until your discomfort turns into a
real problem.
g) Get Physical: When you feel nervous, angry, or upset, release the
pressure through physical activity. Most experts recommended doing 20 minutes of
aerobic activity daily will reduce stress.
h) Take Care of Your Body: Healthy eating and adequate sleep fuels
your mind as well as your body. Well nourished bodies are better prepared to cope
with stress. Increase the amount of fruits and vegetables in daily diet.
i) Laugh: Maintain your sense of humor, including the ability to
laugh at yourself.
j) Know your limits: There are many circumstances in life beyond
our control, consider the fact that we are living in an imperfect world. Know your
limits. If a problem is beyond your control and cannot be changed at the moment,
dont fight the situation. Learn to accept what is, for now, until such time when you
can change things.
k) Think Positively: Refocus the negative to be positive. Make an
effort to stop negative thoughts.
l) Develop a Sense of Life Meaning: Clarify your values and
deciding what you really want out of your life, can help you feel better about yourself

32
and have that sense of satisfaction and centeredness that helps you deal with the
stresses of life. A sense of spirituality can help with this.
m) Compromise: Consider co-operation or compromise rather than
confrontation. A little give and take on both sides may reduce the strain and help you
feel more comfortable.
n) Have a Good Cry: A good cry during periods of stress can be a
healthy way to bring relief to your anxiety, and it might prevent a headache or other
physical consequences of bottling things up.
o) Avoid Self Medication: Alcohol and other drugs do not remove the
conditions that cause stress. Although they may seem to offer temporary relief, these
substances only mask or disguise problems. In the long run, alcohol use increases
rather than decreases stress, by changing the way you think and solve the problems
and by impairing your judgment and other cognitive capacities. Medications should
be taken on the advice of a doctor.
p) Look for the Pieces of Gold Around you: Pieces of gold are
positive or enjoyable moments or interactions. These may seem like small events but
as these Pieces of gold accumulate they can often provide a big lift to energy and
spirits and help you begin to see things in new, more balanced way.

4. EVALUATION :
The evaluation of the plan of care is based on the mutually established
expected outcomes. It is important to observe both verbal and cues when evaluating
the usefulness of the plan. In general, the plan is considered to be successful if the
patient and family achieve the following:
Verbalize causes and effects of stress and anxiety
Identify and use sources of infection
Use problem solving to find solution to stressors
Practice healthy lifestyle habits and anxiety reducing techniques.
Verbalizes a decrease in anxiety and an increase in comfort

CONCLUSION :
Stress is an everyday term for feeling pressured and it has profound
effect on an individuals physical and psychological well being. It is therefore
33
important for nurses to understand the processes associated with these effects as it
will help them to manage the stress that occur in their own lives, and also enable
them to help patients recognize how stress can contribute to their illness.JOURNAL
CONTENT

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Positive thinkingFind accurate and free articles by leading

doctorsIndianWomensHealth.com

When thinking of ways to reduce stress in life, usually techniques like meditation,
yoga and journaling come to mind. These are great techniques, to be sure. But getting
a new best friend can also have many stress relieving and health benefits. While
human friends provide great social support and come with some fabulous benefits,
this article focuses on the benefits of furry friends: cats and dogs! Research shows
that, unless youre someone who really dislikes animals or is absolutely too busy to
care for one properly, pets can provide excellent social support, stress relief and other
health benefitsperhaps more than people! Here are more health benefits of pets:

34
Pets Can Improve Your Mood:For those who love animals, its virtually impossible
to stay in a bad mood when a pair of loving puppy eyes meets yours, or when a
super-soft cat rubs up against your hand. Research supports the mood-enhancing
benefits of pets. A recent study found that men with AIDS were less likely to suffer
from depression if they owned a pet. (According to a press release, men with AIDS
who did not own a pet were about three times more likely to report symptoms of
depression than men who did not have AIDS. But men with AIDS who had pets were
only about 50 percent more likely to report symptoms of depression, as compared to
men in the study who did not have AIDS.)

Pets Control Blood Pressure Better Than Drugs: Yes, its true. While ACE
inhibiting drugs can generally reduce blood pressure, they arent as effective on
controlling spikes in blood pressure due to stress and tension. However, in a recent
study, groups of hypertensive New York stockbrokers who got dogs or cats were
found to have lower blood pressure and heart rates than those who didnt get pets.
When they heard of the results, most of those in the non-pet group went out and got
pets!

Pets Encourage You To Get Out And Exercise: Whether we walk our dogs
because they need it, or are more likely to enjoy a walk when we have
companionship, dog owners do spend more time walking than non-pet owners, at
least if we live in an urban setting. Because exercise is good for stress management
and overall health, owning a dog can be credited with increasing these benefits.

Pets Can Help With Social Support: When were out walking, having a dog with
us can make us more approachable and give people a reason to stop and talk, thereby
increasing the number of people we meet, giving us an opportunity to increase our
network of friends and acquaintances, which also has great stress management
benefits.

Pets Stave Off Loneliness and Provide Unconditional Love:Pets can be there for
you in ways that people cant. They can offer love and companionship, and can also
enjoy comfortable silences, keep secrets and are excellent snugglers. And they could
be the best antidote to loneliness. In fact, research shows that nursing home residents

35
reported less loneliness when visited by dogs than when they spent time with other
people! All these benefits can reduce the amount of stress people experience in
response to feelings of social isolation and lack of social support from people.

Pets Can Reduce StressSometimes More Than People: While we all know the
power of talking about your problems with a good friend whos also a good listener,
recent research shows that spending time with a pet may be even better! Recent
research shows that, when conducting a task thats stressful, people actually
experienced less stress when their pets were with them than when a supportive friend
or even their spouse was present! (This may be partially due to the fact that pets dont
judge us; they just love us.)

Its important to realize that owning a pet isnt for everyone. Pets do come with
additional work and responsibility, which can bring its own stress. However, for most
people, the benefits of having a pet outweigh the drawbacks. Having a furry best
friend can reduce stress in your life and bring you support when times get
tough.RESEARCH ABSTRACT

Effects of Stress and Psychological Disorders on the Immune System

David B. Beaton

Rochester Institute of Technology

This is a review of the psychological field of psychoneuroimmunology (PNI) and

how psychopathology has an impact on the immune system. Two areas of study of
PNI are examined: first, how the psychosocial environment affects the health of an
individual along with the impact stressors play on the immune system; second, the
effects of psychopathology on the immune system and how perceived stresses are
assessed. Coping strategies are also looked at where in some cases they have shown
abilities in strengthening the immune system. The understanding of PNI is crucial in
understanding the association between immunity, depression, stressors, and
psychosocial aspects, along with their interactions with each other and their causal
relations.

36
This is a review of a growing new field called psychoneuroimmunology (PNI), which
incorporates facets of psychology, immunology, and neurosciences amongst many
other fields. It attempts to understand the interactions between the nervous system,
immune system and psyche. This is a rich area of research in which much work has
done with many different theories. Specifically, one highly active area of research is
where psychologists have been studying the effects that stress and psychopathology
have on the immune system. This research has found correlations between stress,
depression and the immune system.

The Immune System

The immune system is basically an interaction between cells and cellular products.
The white blood cells (leukocytes), which are the main fighter cells of the immune
system are made up of three classes; lymphocytes, monocytes, and granulocytes.
Each type of cell has its own functions. Lymphocytes for instance, are subdivided
into B cells, T-helper cells, T-suppressor cells, and natural killer cells. B cells are
generally responsible for the production and secretion of antibodies. T-cells are
responsible for making close and direct contact with the antigen. The other T cells are
responsible for regulating the immune system; T-helper cells enhance whereas T-
suppressor cells decrease the response.

In measuring the immune response, there are two basic ways; quantitatively
measuring levels of cells, or second by using a functional measurement. In
quantitative measurements, they are either a measure of the number of cells in a
given volume of blood, or a percentage of each type of cell. In a functional
measurement, lymphocytes, for example, are exposed to a non-specific antigen
(mitogen) and the results of the exposure are then observed (O'Leary, 1990).

The psychosocial state of a person can have direct impacts on the immune system.
For instance, stress has many different effects on the endocrine systems, including
the well known fight or flight activation which is activations of the sympathetic
adrenal-medullary (SAM) system, the hypothalamic-pituitary-adrenocortical (HPAC)
system, and other endocrine systems.

37
Effects of Stress on the Immune System

Internal factors such as stress have been implicated in causing a deficient immune
system because of the nature of the body's response in dealing with this problem. The
capabilities of the immune system are diminished after frequent activation of the
autonomic nervous system in the case of chronic stresses. The immune system is
downgraded to be able to continuously functioning.

In a large study involving parents of both children with cancer and parents with
children who were relatively healthy, the results showed that chronic psychological
stress might reduce the immune system's reactions to hormonal secretions that were
normally used to fight the inflammatory response (Miller, Cohen, & Ritchey, 2002).

Perceived mood also seems to play a role in immune system effectiveness. Having a
positive attitude seems to correlate with an increased ability of the immune system in
fighting diseases. In cases where patients have exhibited fear before a surgery, they
have had a longer healing time afterwards. Correlations were observed in the number
of lymphocyte cells and the person's level of optimism.

Cardiovascular diseases are another area where stress could have a negative effect.
The natural response of the fight or flight activation mechanism could have a
decidedly negative impact on the cardiovascular system. Since the activation of the
fight or flight system involves an increase in the heart rate, a frequent activation
could increase the possibility of a heart attack or other negative aspect of the disease.
Specifically, a study was done in an industrial work environment in which a much
higher frequency of cardiovascular mortality was found to correlate with an
environment in which there was very little reward incentive (Kivimaki et al., 2002).

Even in relatively less dangerous health problems, mood can have an effect. A study
with the common cold and emotions showed that participants with happy emotions
exhibited a greater ability to fight off the cold when given a squirt of the rhinovirus
(Jones, 2003).

38
A study done on students in an academic environment during exam time produced
some convincing results. In the study, the level of T-cells and responses to mitogens
was lower. Secondly, there was a higher self-reported occurrence of health problems,
such as, upper respiratory-tract infections (O'Leary, 1994).

In the case of external factors, the social environment could play a huge role in
immune functioning. If a person has an effective social support web, it has been
shown to effectively increase the immune's systems abilities. The cardiovascular
system could also have a positive response to this type of social support. Having
positive social support could aid in blood pressure regulation, thus reducing the
probability of a heart or related disease.

Coping Strategies

The definition of stress can be confusing. It can be a stimulus or demand, a response,

or it may involve a process that involves both. Seyle is the champion of the
commonly believed process of the physiological response; the alarm stage, resistance
stage, and the exhaustion stage or also known as the general adaptation strategy.
Lazarus promoted an alternative to this theory that also involves the emotional or
psychological based response of the individual when faced with a stress. In his
model, cognitive factors come into play like the cultural background of the individual
or past experiences. First an individual determines the degree of threat that is
perceived by the stress. Next coping strategies are assessed by the individual to
effectively deal with the confronted situation.

Cox determined that both physiological and psychological components were equally
important. He also recognized that each individual incorporated their own coping
strategies.

The strategy an individual uses to cope with stress has in some studies shown a
strong relationship with the ability of the immunes system. In the case of cognitive-
behavioral stress management therapies, there has been shown effective means at
reducing stress. The ability to proactively handle how one deals with their stress in

39
everyday life could alleviate the constant activation of the endocrine system, which in
turn increases the effectiveness of the immune system (Jones, 2003).

Inhibition of emotions could be another stress factor negatively affecting health.

Bottling up negative emotions seems to tie up resources of the immune system.
Individuals who disclosed a tragic event seemed to have an elevated immune
response and generally were healthier than those who inhibited expression of these
emotions. There is considerable evidence that talking about problems and using
mental health services, decreases the number of sick days, and lowers health costs for
these individuals (O'Leary, 1990).

Using a coping strategy which involves a denial or assessing that a particular illness
or stress is beyond the control of the individual can prove to be an ineffective
strategy. The person tries to escape reality, and refuses to use their social network to
help deal with their problem. They believe that work requirements are more
important than seeking therapy or treatments. This strategy can have a tragic result on
an individual (Jones, 2003).

A large study of individuals with Aids was conducted in which participants of the
study group were given advice on health, stress management techniques,
psychological support, and problem solving skills regarding diagnosis. Initially after
the 6-week study, there wasn't a noticeable result, but a follow up 6 months later
showed profound decreases in psychological distress and higher levels of immune
functioning (Glaser & Glaser, 1992).

Behavior Change

The field of PNI is not without controversy. One of the debatable topics is the causal
relationship between stress, depression and immune response. Depression has been
implicated in causing behavioral changes in people with major depressive disorder.
Some of these lifestyle changes can be profound, such as, not eating, drug abuse, or
disturbed sleep patterns. Some argue that it really is these "lifestyles" which is the
culprit in reduced immune functioning. Having bad nutritional habits could starve the
body of necessary nutrients to maintain high levels of white blood cells. As a result,
40
the immune system downgrades its functioning and the person becomes more prone
to diseases or inflammatory.

In a study done with depressed women and physical activity, 42 to 63 percent of the
differences in immune functioning were observed to be related to physical activity.
The study observed 32 depressed women and 32 non-depressed women. The
production of lymphocytes was measured to determine the immune system's
functioning (Hendersen, 1999).

Patients with cancer can have significant lifestyle changes as a result of their
condition. They will have poor eating habits because of nauseating feelings which
were not directly related to their treatments or conditions. They have disturbed sleep
patterns, such as insomnia or waking up early. They also frequently develop drug
problems. All of these factors seem to add additional stresses which impact the
physiological effects. Targeting these stresses has had positive results on the health of
individuals. Again, a study done with physical activity not only helped eliminate the
bad physical habits, but it also decreased the depression and gave the clients a
positive outlook (Anderson, Glaser, & Kiecolt-Glaser, 1994).

On top of lifestyle changes, a person's response to a known acquired disease, or even

having symptoms of a disease could be another factor. A person under heavy stress or
extreme depression may forgo seeking treatments for physical illness, thus increasing
the likelihood of an escalation in the physical problem.

Effects of Psychological Disorders on the Immune System

Depression and Stress

The issue of whether stress causes depression or vice versa is another area of concern
for PNI. Some wonder if depression is caused by stress or if depression itself is a
form of a stressor. Pinpointing which is the primary cause of reduced immune
response in PNI can be difficult.

Because both can be products of each other, it can be almost impossible to determine
which has a more important role in effecting an individual's health. Stress can come
41
in many forms. Anxiety causes stress, depression causes stress, and life events can
also cause stress. On the other hand, stress can also trigger a major depressive
disorder.

One theory of how stress can cause depression has its roots in the brain's mood and
pleasure pathways. The stress exposure can cause the glucocorticoid hormone to be
overly active which causes a depletion of norephinehprine levels in locus coeruleus
neurons. This has an effect of slowing the attentiveness within the individual. They
become emotionless and inactive (Salzano, 2003).

Perceived stress is quite possibly a cause in and of itself as well. One person may see
a stressor as a far greater problem than another individual who may not feel the same
degree of "stress" from the stressor. If an individual experiences great anxiety
because of constant thought about a stressor, their fight or flight mechanism could be
in perpetual heightened response. Just thinking about the stressor could set off the
elevated response. These stresses amount to a constant initiating of the response
multiple times a day if the thoughts preoccupy the individual.

Schizophrenia and the Immune System

There is a considerable amount of evidence that schizophrenic patients have longer

healing times after major surgeries. A study investigated the levels of plasma
interleukin in the blood of twenty-five control and schizophrenics during all stages of
the surgery process of hemicolectomy and sigmoidectomy. Plasma IL-8 levels were
significantly lower in the schizophrenic patients after surgery. Plasma cortisol
concentrations were significantly lower during surgery for the schizophrenic patients
as well. The conclusion of the study was that schizophrenic patients had a reduced
ability for cytokine to fight inflammations. The reason for the findings could be
explained by a schizophrenic's hypothalamus-pituitary-adrenal dysfunction. The
endocrine system has close interactions with the immune system (Kudoh, Sakai,
Ishiria, & Matsuki, 2001).

Summary and Future Considerations

42
This paper has shown that the immune system is not an isolated entity from the
psychosocial state of an individual. A person experiences many stressors throughout
a day and lifetime. These stressors are affecting the ability of the immune system to
function at the highest possible level. Many important studies have shown that there
is a correlation between these stressors and a person's health.

A person's psychological state is also a prominent factor in health. Depression

influences the health of a person either by having a direct relationship with the
immune system, or by indirectly influencing how a person takes care of themselves.

It is difficult to doubt that immunity and a person' psyche are interrelated, but what is
difficult to explain is the causal relationship. What is really causing what? Some
argue that stress causes depression, which causes the immune system to function
improperly because resources are tied up in activating the fight or flight mechanism.
Others argue that depression causes stress, which then causes fight or flight. And yet
another group argues that a person's psychological state causes the individual to
indirectly affect their health by bad nutritional, physical and sleep patterns.

Future studies need to address these issues. First, long term studies on people who
both exhibit and don't exhibit depression and their daily stresses need to be done. The
stresses these individuals experience and their responses, whether they are physical
or not, need to be catalogued. Is the person experiencing stress directly related to the
depression, or is depression a non-factor in the stresses. The person's health
throughout the time they are experiencing the problems must be measured in
different degrees. The degree of health problems, and their associated stressors or
depressive states needs to be compared to determine whether stress or depression is
the prominent factor.

Lastly, and most important, a person's physical habits need to be monitored to

determine if the immune response is solely, partly or not at all affected by the
individual habits and not the stressors or depression.

The purpose of this review was to show that a person' psychosocial environment is a
primary cause either directly or indirectly in how a person feels physically, or
43
recovers from illness. This could have profound implications in future treatments
administered to people with morbid diseases. Psychotherapy and behavioral therapy
may prove to be an extremely useful tool in helping these individuals to recover or
deal with their illness without inhibiting the natural abilities of the immune system. If
we know the true cause effect relationship, we could develop these psychosocial
treatments to specifically deal with not only the individual's health state, but also
their depression or stressors, which in turn could improve the chances of physically
recovering.

Peer Commentary The Role of Stress in Physiological Disorders

Andrew P. Ochtinsky, Rochester Institute of Technology

The basic premise of this paper was that psychosocial environment and
psychopathology have measurable effects on the immune system. The paper showed
this to be true and suggested that coping techniques for stress can greatly improve a
person's physical health.

Chronic psychological stress, such as dealing with a terminal illness in the self of or a
loved ones, has been shown to reduce immune effectiveness. Positive attitude
correlates strongly with increased ability of the immune system to fight pathogens.
Performance stress, such as that of students during an examination period, seems to
correlate with a decrease in disease-fighting cells and the response of the immune
system to mitogens. Persons with an effective social support structure have been
shown to have stronger immune abilities. Thus, other things being equal,
psychosocial environment has a very powerful effect on the immune system.

Stress-coping mechanisms have an effect on the immune system. Those using

cognitive-behavioral stress management therapies have been shown to have a more
effective immune system. Relief of stress can assuage the immune-decreasing
properties of strong negative emotions, which weaken immune response over time.
Coping strategies that involve denial of loss of control over personal health correlate
with decreased immune abilities. Even in individuals with acquired immune
deficiency syndrome (AIDS), positive stress management techniques and
44
psychological support were shown to have profound effects on psychological distress
and immune functioning. These arguments are absolutely convincing regarding the
effects of stress and stress management on the human immune system.

The paper showed that depression and anxiety have significant negative effects on
the immune system. These disorders cause considerable stress, which, given what
was already shown about the effects of stress, has a major effect on the immune
system. It suggested that, because depression and anxiety can have this effect, it is
important not only to treat the disorders but also to teach methods of coping with the
associated stress to prevent immune problems.

Future studies could definitely address methods of coping with stress and
psychological disorders to increase the effectiveness of the immune system. This
paper might have suggested the efficacy of certain types of therapy in positively
affecting the immune system by way of reducing and managing stress, thus providing
direction for future studies. It is also important to suggest that all individuals, not just
those with psychological disorders, can benefit greatly from stress management
techniques, given that there is no upper limit on immune performance.

Overall, the paper illustrated its points very nicely and with few flaws. It was
effective in convincing me of the role of stress in physiological health.

Peer Commentary The Role of Prior Protective Factors

Kathryn O. Tacy Rochester Institute of Technology

This paper gave an overview of psychosocial and psychological implications in states

of heightened stress. The causal factor was a main focus of attention and inquiry, as
well as the effects of stress on the physical and psychological self.

Attitude, social networks, and a healthy diet are woven together in their importance
for physical and mental health. Attitude is one thing humans have great control over,
but for the most part people choose to let their attitude run them, or they think their
situation has to change before their attitude can change, which is usually not the case.
When faced with a challenge of any sort, people make a decision how it is going to
45
affect them. The outcome of that decision is a big indicator of the events to follow.
People can choose to take a positive attitude, which could lead to better judgment-
making and a quicker recovery from the situation. People can also choose to see only
negative aspects, which often clouds other avenues or opportunities. These choices
are not so cut and dry, however, and can sometimes be realized a short time after the
fact. This is a point where perhaps one is capable of making a stronger decision
having gone through some of it already. Having a good social network of family and
friends is a great stress reducer if used properly. Being able to trust those people with
your vulnerability can be hard to do but does not have to be. People must remember
that reciprocity is important for a good "shoulder to lean on" relationship. Diet is
another big factor in overcoming physical or mental illness. Even though depression
and stress can cause poor eating habits, a good diet to start with will help keep one
better prepared in any event.

Another serious aspect of wellbeing is fear. By fear I mean the lack of a willingness
to get medical and psychological treatment due to the fear of discovering a real
problem. The irony of this situation is that, by a lack of "check-ups," a person runs an
even greater risk of not getting treatment or getting treatment that may be too late to
have a profound effect. Another serious aspect of wellbeing is habit. If a person
succumbs to a depressive state, then unhealthy eating habits and states of mind can
become routine. After a person overcomes depression, these problems may be
overlooked and become future coping mechanisms, which can lead to long-term
dysfunction that may repeat the cycle that was first to be overcome!

This paper gave good arguments for both sides of the causal conflict and had good
emphasis on coping and pharmaceutical therapy and its dual importance in recovery.
I would, however, be interested in an elaboration on a few points. The percentage
range of 42-63% for immune efficacy in physically active women seemed a bit vague
to me. Was it 63% or was it 42%? There seemed to be a lot of room for causal
interpretation here. Lastly, there was a report of nausea in cancer victims that was
said not to be due to current conditions or therapy and that caused an increase in good
eating habits. It was previously stated, however, that these lifestyle changes were a
result of their current conditions. If the nausea was not due to any of the above
46
mentioned circumstances, then what was its cause? Was there some outlier at work
here? Overall this paper was effective in getting across the seriousness of stress and
its potential implications for the immune system, as well as stating the importance of
prior well being.

Peer Commentary The Immune System: Quite a Mouthful

Jason J. Zodda Rochester Institute of Technology

Think about your last bad day. How did you feel? Were you a little more tired then
usual? Did you feel unusually fatigued? The chances are you probably did. Why does
this happen?

No one really knows for sure why the immune system acts weak when one thinks it
should function strongly. The evolutionary perspective is the strongest view on the
market. It claims that the immune system is suppressed during periods of stress to
serve as a protective function in the evolution of our species. The belief is that it
helps prevent people from developing autoimmune diseases (Carson, Butcher, &
Mineka, 2002).

In David B. Beaton's "Effects of Stress and Psychological Disorders on the Immune

System," he mentioned a few reasons why the immune system is suppressed, but in
sum, this was what the paper lacked most. The author briefly mentioned a correlation
between lymphocyte cells and the amount of healing time after surgery, but he did
not describe it any further.

Beaton mentioned an interesting connection between the body's "fight or flight"

response and the cardiovascular system. He made a strong point on how the increase
in heart rate during the bodily response can possibly lead to a heart attack or some
other negative affect on the cardiovascular system.

Finally, Beaton described the relation between schizophrenia and the immune
system. Schizophrenic persons have a longer rehabilitation time after surgery. The
conclusion was that schizophrenic persons' hypothalamus-pituitary-adrenal
dysfunction, which worked along with the immune system, was at fault. Another
47
important finding was that schizophrenic persons have a lower ability for cytokine (a
protein) to fight inflammations.

Beaton should elaborate more on why the immune system fails when under stress.
The points that Beaton made on the "flight or fight" response and the schizophrenic
relation were very compelling, and I hope to see more information about these topics
in his author response. This paper was clear and attention-grabbing. I hope it will
lead to more investigation on this important topic.

Author Response Just Scratching the Surface of Psychoneuroendocrinology

David B. Beaton Rochester Institute of Technology

I really appreciated the commentaries on my paper--they were well thought-out and

had great points. One point seemed to be a consensus among the peer commentators--
that I could have elaborated more on some of the studies and ideas presented. I wish I
could have. This area of research has ocean depths of research and ideas, and it has
not even began to touch on the potential knowledge that can and will be gained in the
future. I could have gone on for pages, but unfortunately I needed to compress the
paper into a format that readers would enjoy without becoming entrenched too deeply
in details.

Otchinsky suggested that I elaborate on the efficacy of different coping techniques.

In reply, it seems that behavior therapies have been the most successful. Specifically,
using exercise as a treatment appears to have a universal benefit for almost all types
of stress and greatly helped persons with diseases. This makes sense, considering that
personal health decisions play a prominent role in immune functioning. It would also
make sense that this relieving of "caged in" tension by venting through exercise
would have great benefits on the psychological state of an individual.

Tacy first questioned the nausea that cancer patients felt that were not related to their
treatments and what they meant for physical habits. The nausea I was referring to was
the sick-to-the-stomach feelings that people get when they are under great stress. We
have all felt sick just by thinking of something stressful, and as a result we lose our

48
appetite. So in this case the thoughts about cancer bring about stress and poor eating
habits. Targeting this stress through behavior therapy allowed cancer patients to
decrease stress and increase positive emotions.

Tacy also questioned the statement that 42 to 63 percent of differences in immune

functioning were related to exercise. Not every woman had the same results from
exercise; some had only 43 percent improvement, whereas others had 63 percent
improvement. This finding corroborates the understanding that even in a worst-case
scenario there are dramatic results from using exercise in a stress-reducing regime.

Zodda suggested that I elaborate on how the immune system is actually affected.
When I began the paper, I originally wanted to go in depth in this area, but I soon
realized that I would need more than just one paper to fairly address the immune
system. I decided purposefully to shy away from most of the extremely technical
details so as not to bore readers. But to put the findings in a nutshell, the immune
system is a perfectly balanced system of cells that do their jobs and then quit using
resources when their jobs are complete. Persons under stress throw off the balance of
their immune system. As a result, certain immune cells become overactive and thus
prevent other ones from functioning as they should. The communication among cells
is broken down, and the entire immune system becomes unstable and ineffective.

I hope this response addresses some of the questions brought up by the peer
commentators. Admittedly, there are still weaknesses in the paper, but overall I hope
that the paper allows readers to enjoy a high level understanding of
psychoneuroendocrinology. I know that for myself, studying these topics has allowed
me to take a second look at how I deal with everyday stressors.

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