hjertesykdom.type d utsatt the biopsychosocial dimensions to stress and its affects on the heart

7/31/2019 Hjertesykdom.type D Utsatt the Biopsychosocial Dimensions to Stress and Its Affects on the Heart

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The biopsychosocial dimensions to stress

and its affects on the heart

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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 person’s 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 personality’s 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 person’s 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 EuropeanSociety 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

person’s 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 patient-

centred 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.

References

Adameova, A., Abdellatif, Y., Dhalla, N. S (2009), 'Role of the excessive amount of circulating

catecholamines and glucocorticoids in stress-induced heart disease', Canadian Journal of Physiology& Pharmacology, Vol. 87, (7), pp. 493-514.

Cohen, S., Williamson, G. M (1988), 'Perceived stress in a probability sample of the United States,

in S. Spacapan and S.Oskamp' (eds) The social Psychology of Health, pp17-67, Newbury Park,CA: Sage. Cited by Stroebe, W (2000), Social Psychology and Health, pp. 207-234, second

edition, UK: Open University Press.

Cooper, C, L (2005), Handbook of Stress Medicine and Health, second edition, USA: CRC Press.

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Engel, G. L (1977), 'The Need for a New Medical Model: A Challenge for Biomedicine', Science,

196, (4286), pp: 129-136.

Gianni, M., Dentali, F., Grandi, J, Anna Maria, Sumper, G., Hiralal, Rajesh., Lonn, E (2006),

'Apical Ballooning syndrome or takostubo cardiomyopathy: a systemic review', European Heart

Journal , 27, pp: 1523-1529 Cited by Kumar, R., Naveen, K. G. (2008), 'Current Status of Cardiovascular Risk Due To Stress', The Internal Journal of Health, 7 (1).

Goldstein, D. S (2003), 'Catecholamines and Stress', Endocrine Regulations, 37, pp: 69-80.

Kumir, R., Naveen, K, G (2008) 'Current Status Of Cardiovascular Risk Due To Stress', The Internal Journal of Health, 7 (1).

Lambert, E., Dawood, T., Esler, M. D., Barton, D. A., Eikelis, N., Bayles, R. G., Lambert, G. W(2007), 'Psychological Stress and the Development of Heart Disease', Current Psychiatry Reviews,

3, (4), pp: 252-258.

Levi, L. (2005) Introduction: Spice of Life or Kiss of Death? in Cooper, C, L. (2005), Handbook of Stress Medicine and Health, second edition, USA: CRC Press.

Lin, C. H (2009), 'Exploring Facets Of A Social Network To Explicate The Status Of SocialSupport And Its Effects On Stress', Social Behaviour And Personality: An International Journal ,

37, (5), pp: 701-710.

Martini, F. H., Nath, J. L (2009), Fundamentals of Anatomy& Physiology, eighth edition, USA:

Pearson ltd.

Meisel, SR., Kutz, I., Dayan, K I., Pauzner, H., Chetboun, I., Arbel, Y., David, D (1991) 'Effect of

Iraqi missile war on incidence of acute myocardial infarction and sudden death in Israeli civilians',

Lancet , 338: 660-1 Cited by Stroebe, W (2000), Social Psychology and Health, pp: 207-234, 2nd

Edition, UK: Open University Press.

National Institute for Health and Clinical Guidance (NICE) Depression: the treatment and

management of depression in adults, available online:

http://egap.evidence.nhs.uk/CG90/unnumbered_section_4 , accessed on 13th April. 2011.

Ogden, J (2007), Health Psychology: a textbook , fourth edition, Open University Press, United

Kingdom, pp: 221-271.

Polman, R., Borkoles, E., Nicholls, A. R (2010), 'Type D personality, stress, and symptoms of

burnout: The influence of avoidance coping and social support', British Journal of Health Psychology, 15, (3), pp: 681-696.

Priest, H (2010), 'Effective psychological care for physically ill patients in hospital', Nursing

Standard , 24, (44), pp: 48-56.

Semmer, N. K., McGrath, J. E., Beehr, T. A (2005), Conceptual Issues in Research on Stress and

Health in Cooper, C. L (2005), Handbook of Stress Medicine and Health, second edition, USA:CRC Press, pp: 1-43.

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http://egap.evidence.nhs.uk/CG90/unnumbered_section_4

http://egap.evidence.nhs.uk/CG90/unnumbered_section_4



Smeltzer, S. C., Bare, B. G., Hinkle, J. L., Cheever, K. H (2007), Brunner& Suddarth’s Textbook

of Medical-Surgical Nursing , eleventh edition, Lipponcott Williams& Wilkins.

Stroebe, W (2000), Social Psychology and Health, pp: 207-234, 2nd Edition, UK: Open University

Press.

World Health Organisation (WHO), The top ten causes of death, available online:http://www.who.int/mediacentre/factsheets/fs310/en/index.html , accessed on: 12th April 2011.

Hunter, N (2011) Stress management shown to help CVD: ESC calls for EU wide programme to

help patients, Cardiology Professional Time Critical, Vol. 6, (1), pp: 6.

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http://www.who.int/mediacentre/factsheets/fs310/en/index.html

http://www.who.int/mediacentre/factsheets/fs310/en/index.html

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