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The biopsychosocial dimensions to stress and its affects on the heart

The aim of this assignment is to discuss the biopsychosocial aspects of stress and its association with coronary artery disease. According to Cooper (2005) stress is when an individual experiences physical, or psychological distress which exceeds their ability to cope. The stimulus that evokes this distress is known as a stressor which can be physical such as heat, cold, pain or psychological such as the loss of a job (Smeltzer et al. 2007). When an individual experiences stress their body goes through a process of psychological and biological changes in order to regain homeostasis. If this does not occur, physical and psychological functions can become disordered and illness can occur (Smeltzer et al. 2007). Stress can aggravate patho-physiologic processes (Goldstein, 2003). Coronary artery disease (CAD) is an important model for the effects of stress as it is the second leading cause of death worldwide (WHO, 2008). The classic risk factors for coronary artery disease are high blood pressure; increased cholesterol, smoking and diabetes which are also related to stress (Ogden, 2007). The physiological response to stress helps an individual to cope with stressful events (Martini& Nath, 2009). Hans Selye (1956) developed a model known as the general adaption syndrome (GAS) which outlines the physiological reactions to stress and is divided into three phases: the alarm, resistance and exhaustion phase. The alarm phase is the initial stage and involves the sympathetic nervous system (SNS). The SNS stimulates the release of catecholamines (i.e. adrenaline & noradrenaline) (Martini& Nath, 2009). This stimulates and constricts cardiac muscles and peripheral blood vessels, causing a faster heart rate and an increase in blood pressure. This enables more blood to be pumped to essential organs needed during stress such as the heart, brain and skeletal muscles. Blood flow to less essential areas is reduced (Smeltzer et al. 2007). An elevation in the respiration rate and dilation of the bronchioles in the lungs increases the blood oxygen levels (Martini& Nath, 2009). The alarm phase can only last for a short period as if it continued it would result in death (Smeltzer et al. 2007). The resistance phase increases and maintains cortisol levels. This is achieved by the hypothalamic-pituitary-adrenocortical activation (HPA) response (Ogden, 2007). This involves the release of cortisol from the adrenal gland. Cortisol is a steroid hormone that increases the blood
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sugar through gluconeogenesis from the metabolism of fat, protein and carbohydrate (Smeltzer et al. 2007). Other hormones involved are antidiuretic hormone (ADH) released from the posterior pituitary and aldosterone, released from the adrenal cortex. These hormones promote sodium and water retention, incase of fluid loss from injury and perspiration (Smeltzer et al. 2007). However this can lead to hypernatremia causing circulatory collapse (Martini& Nath, 2009). The exhaustion phase occurs after prolonged levels of stress (Kumar et al. 2008). Hormone related complications can occur due to glucocorticoids causing immune suppression, anorexia, muscle and fat loss and increased lipid levels (Seltzer et al. 2007). According to research the cardiovascular system is prone to the effects of stress due to changes in the sympathetic and parasympathetic systems, which adversely affect the heart (Kumar et al. 2008). Increased heart rate and force of cardiac contractions lead to a greater oxygen demand (Adameova et al. 2009). Stress causes an altered heart rate, elevated blood pressure and vasoconstriction of coronary arteries, providing the foundations for cardiac disease. Myocardial infarction a sub group of CAD is caused by damage to the heart muscle due to an interruption of coronary artery circulation, a result of coronary artery disease (Martini& Nath, 2009). Evidence shows that myocardial infarction is caused by acute emotional stress as well as physical stress by causing an increase in catecholamines and cortisol levels (Kumar et al. 2008). To highlight that stress is a risk factor for myocardial infarction research shows that a person suffering from stress, but without pre-existing coronary artery disease, can be at risk of myocardial dysfunction (Gianni et al. 2006, cited by Kumar et al. 2008). According to Stroebe (2000) stress is likely to cause coronary artery disease due to various physical reactions. Catecholamines and cortisol activate fat stores increasing lipid levels in the blood causing high cholesterol influencing the accumulation of atherosclerosis. Catecholamines also increase blood coagulation which could influence the development of a clot blocking the coronary arteries, various factors that can contribute to myocardial infarction. The effects of stress on the heart was demonstrated in a study conducted examining the effects of Iraqi missile attacks and the incidence of myocardial infarction among citizens (Meisel et al. (1991) cited in Stroebe (2000). In this study there is evidence of an increase in the incidence of acute myocardial infarction during the beginning of the gulf war compared to a control carried out
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before the attacks (Stroebe, 2000) highlighting the relationship between psychosocial stress and cardiac events. Goldstein (2003) states that most researchers have abandoned both Canon and Selyes models of stress, stating that Selye and Canon focus mainly on external stressors with little reference to any psychological influence thus implying that individuals are passive to stress (Ogden, 2007). The development of the transactional model of stress by Lazarus (1970) introduced the concept of appraisal which explains how individuals can have a different response to a stressor according to how an individual assesses or appraises a situation (Ogden, 2007). There are two types of cognitive appraisal, primary appraisal when a stressor is perceived as being stressful and secondary appraisal how a person appraises their coping resources i.e.: social support (Ogden, 2007). This theory enabled new forms of treatment which emphasise the employment of self control techniques such as self efficacy which encourages a persons belief in their capabilities. (Ogden, 2007) states that the most commonly used definition of stress was developed by Lazarus and Folkman, who explain stress as a transaction between people and the environment. The experience of stress can differ for many people due to the influence of variables such as personality and social support (Ogden, 2007). Polman et al. (2010) conducted a study on type D personality and perceived stress. Type D is associated with social inhibition and negativity and is a recent emerging risk factor for CVD. The study reveals two methods of coping resignation and withdrawal coping that mediate the relationship between type D personality and perceived stress (Polman et al. 2010). Type Ds show a tendency towards negative affectivity and social inhibition (Bulik-Oginska, 2006) which negatively affects social support. Type D individuals report higher feelings of subjective stress than non-type Ds and are inclined to employ avoidance coping when faced with stressors which elevate the stress experienced. Research indicates that type D is a major risk factor for mortality among cardiovascular patients; with evidence showing type D males suffer an increased cardiac output during stress compared to non-type D or females (Williams et al. 2007). Empirical evidence indicates that social support can lower the risk of developing coronary heart disease and can help recovery. Social support is thought to be a form of defence to stress where people can turn to friends and family for advice and assistance which could affect their ability to
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cope (Stroebe, 2000) which type D personalitys neglect. Social support can through esteem, advice and companionship, an absence of support can increase stress. A study showed that students in Taiwan exhibit high levels of perceived stress and experience low levels of social support. This study concluded that if these students were integrated with local people as well as the other Chinese students it may help alleviate stress levels. This concept of social support as an important factor with regards to a mental health problem is supported by NICE (2009). Polman et al. (2010) suggests that coping is a possible mediator for type D personalities and stress. Coping is an attempt to deal with a stressor. Prolonged demanding situations can cause depletion of coping skills resulting in distress (Semmer et al. 2005). Two examples of coping mechanisms are problem-focused and emotion focused (Stroebe, 2000). Problem-focused coping is aimed at managing a stressful situation such as a looming exam. To reduce the possible stress the student may prepare for the exam this is known as problem-focused coping. If emotional anxieties occur the student could engage in negative health behaviour such as smoking or consuming alcohol in order to relax known as emotion-focused coping, the direction the student takes will depend on the coping resources available (Stroebe, 2000). An increased allostatic load due to an accumulation of stressors can reduce a persons ability to cope and result in illness (Ogden, 2007). Earlier in the assignment the physical impact of stress was discussed in relation to coronary artery disease, it is also important to note how negative health behaviour (i.e.: smoking) can also accelerate the development of atherosclerosis. According to Cohen& Williamson (1988) cited by Stroebe (2000) people who are suffering from stress are less likely to be physically active and more inclined to consume alcohol, cigarettes and poor nutritional food which will have a negative impact on their cardiac health. To emphasise the importance of approaching stress from a psychological perspective a study published in Archives of internal medicine found that a cognitive behavioural therapy (CBT) produces a 41% reduction in fatal and non fatal recurrent cardiovascular events, with the European Society of Cardiology (ESC, 2011) stating that stress management programmes should be made more accessible across Europe for patients with coronary artery disease. According to Priest (2010) there is evidence to suggest that nurses successfully provide for a patients physical care and needs however the psychological care is neglected. This poses the
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question is a holistic biopsychosocial care model employed in healthcare today or does the physical aspect of care still dominate? Priest (2010) refers to the concept of holism as central to the biopsychosocial model of care, suggesting that nursing care should involve all aspects of a persons state of being and not simply the physical diagnosis. To enable nurses provide psychological care to patients, awareness of psychological issues is essential to employ patientcentred listening and communication (Priest, 2010). It is important that nurses inform patients that stress is a modifiable factor that can be managed through a healthy lifestyle, stress reliving activities and various therapies to help manage stress such as CBT. Although scepticism surrounded the concept of psychological factors influencing the development of heart disease it is obvious from research that acute and chronic stress can influence cardiovascular disease. Research into this field could help to develop a better understanding of the basis of psychological heart disease enabling preventative strategies being developed (Lambert et al. 2007). In nursing and medical clinical practice, it is important to approach patient care from the biopsychosocial aspects. Stress, in its various forms, aggravates patho-physiological processes and needs to be addressed from a multifactorial viewpoint. In agreement with Engel (1977) exclusion of either psychological or the biological aspect of care can interfere with patient care. Although the current healthcare system is striving for holistic care there is still room for improvement.

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