34.2 Effects of Stress on Health and Wellness

Physiological Needs

When the effects of stress reach a life-threatening point, a patient becomes critically ill. The patient care setting is most often an intensive care unit (ICU) and includes multiple providers, such as pulmonologists and other specialist physicians, ICU nurses, therapists (e.g., respiratory, physical, speech, occupational), dietitians, and spiritual care providers. The goal of care is to return homeostasis by meeting basic physiological needs such as adequate neurological, cardiovascular, and pulmonary function. Maladaptive resistance apparent in these systems is often the root cause of chronic diseases evident in other organs.

For those patients who are not critically ill but show signs of chronic adaptation-induced disorders, treatment focuses on managing the condition(s). This includes primary care and specialist consultations aimed at symptom and disease-progression improvement or stabilization of the symptoms associated with chronic stress. Chronic stress manifests as a breakdown of systems affected by ANS (specifically sympathetic) overstimulation. When stress is chronic, there is a lack of relaxation, or physiological downtime. The harmful effects appear in both physical and psychological changes and behaviors.

Some examples of long-standing effects of increased cortisol, norepinephrine, and epinephrine include hypertension (HTN), tachycardia, headache, hyperglycemia, hyperlipidemia, gastrointestinal upset, and anorexia. Kidney damage may ensue from effects of chronic HTN and hyperglycemia; cardiovascular effects are also common, secondary to HTN, coronary artery disease, and subsequent issues such as myocardial infarction, HF, and peripheral vascular disease. These diagnoses, symptoms, and effects can be related to basic human physiological needs. Following are some examples:

• Nutrition: Diagnoses may change a person’s recommended diet to restrictions of electrolytes and water; weight-loss (cardiovascular) or weight-gain (COPD) diets may be indicated.
• Weakness and fatigue: Organ dysfunctions may cause disability, as the patient becomes unable to tolerate activities. Job loss may ensue, leading to loss of shelter and financially based needs like clothing or food.
• Reproduction (or sexual pleasure, which appears more directly under love and belonging): Physical activity can be impaired to the point of sexual intercourse becoming uncomfortable, complicated, or impossible.

Safety and Security

Similar to physiological needs and consequential negative effects of stress on the ability to meet them, safety and security can be affected by health and wellness changes. Development or exacerbation of anxiety is a possible effect of an overactive SNS or as a result of other systemic pathophysiological changes. The impact of anxiety on a person’s behaviors and subsequent ability to establish or maintain a safe and secure environment can be significant. The following are some examples:

• Safety and security: may be affected by physiological or psychological changes (e.g., job loss leading to loss of shelter)
• Resources: an inability to provide for other financially based resources (e.g., health insurance, transportation, positive activities)
• Anxiety: may affect perception of safety; person may make poor decisions

Love and Belonging

Anxiety and long-term results of chronic stress, such as weakness and fatigue, can hinder the physical ability to participate in meaningful, intimate relationships, broader social friendships, and activities. Isolation, loss of lower levels of need achievement, and difficulty establishing connections are possible consequences of negative stress effects.

Sexuality and performance of sexual intercourse can be impacted, as effects of diagnoses like HTN or diabetes take their toll. Meanwhile, increased physical needs increase the need for love and belonging even more. Patients may not only need help with care, they may also need more emotional presence and support. They may lose their sense of belonging and of their normal roles, increasing feelings of inadequacy.

Self-Esteem

The aging process itself is associated with normal physiological changes, such as loss of muscle mass and related strength, slowing of neurological responses, and hearing and vision changes. Stress-induced chronic illness and some of the effects of particular disorders may involve weight gain (e.g., hyperlipidemia, DM, HF, weight loss [e.g., COPD, anorexia]) or disability. Any or all of these situations are likely to have negative effects on establishing or maintaining self-esteem. Additionally, physiological changes can affect patients’ roles in their families or social circles as well as their ability to fulfill their obligations. Isolation is also a likely consequence of stress effects related to self-esteem.

Self-Actualization

Unmet needs on any of the other levels of human needs ultimately impact self-actualization. This is the pinnacle of the needs, the utmost in fulfillment, or fulfillment of potential (McLeod, 2024). As Maslow put it, “What a man can be, he must be” (1943/2000). It has been noted that few people achieve this level of human needs, as it requires advancing beyond the normal state of homeostasis to a unique level of creativity and elevated homeostasis through “peak experiences” (McLeod, 2024).

For many, chronic disease from stress adds further barriers to achieving a level of self-actualization. For example, when someone is experiencing a common combination of adaptation-related ailments, COPD, heart disease, and DM, it becomes difficult to seek out and focus on higher levels of homeostasis when the body is battling hard merely to achieve normal functions while struggling with oxygenation, perfusion, and hormonal regulation. That said, some people find that physical challenges and established disabilities provide the opportunity to develop themselves intellectually. Some who are limited physically manage to reach heights of fulfillment and achievement that doubtless place them in the realm of the self-actualized.

Negative Effects on the Body Systems

Long-standing, or chronic, stress has similarly long-standing impacts on the human body. Such effects are attributed to negative or ineffective adaptation during the resistance stage of the GAS. Such a loss of the ability to restore homeostasis allows for breakdown of body systems, including the immune system. This is reflective of the exhaustion phase of the GAS, as the resources associated with resistance and adaptation are diminished. Effects are seen in what Selye described as “diseases of adaptation” (1956/1976, p. xvii).

As Selye researched the chemicals released as a result of stressful experiences, he determined a difference between diseases caused by microbial invasion or toxins, for example, and those resulting from an adaptive response to stressors. Selye attributed several diseases or disorders to the reactions of chronic exposure to corticoids and pituitary hormones. His research dates back to the 1920s during his medical school education, and while there have been many developments in medicine since that time, he identified several disease processes as related to stress, which have been supported as such over the years. Some of the terms he used are no longer used to refer to the ailments, but the disorders are still recognized as related to chronic stress. Examples, using current terminology, include the following:

• hypertension
• arteriosclerosis
• myocardial infarction
• cardiac hypertrophy
• edema
• nephritis, nephrosclerosis
• proteinuria
• inflammatory diseases/disorders

The following are some additional disorders and habits that have been recognized as frequently being related to stress:

• hyperlipidemia
• nutritional imbalances
• obesity
• alcohol and other substance misuse
• smoking
• COPD
• sedentary habits
• DM

In addition to cortisol, it is important to consider another corticosteroid, aldosterone, which is not a glucocorticoid but a mineralocorticoid. Release of aldosterone is not typically associated with the stress response in the way that cortisol and glucocorticoids are, but certain stressors may result in its secretion. An example is a patient who is hypovolemic (e.g., from blood loss or severe dehydration) and presents with hypotension.

In an effort to correct the low blood pressure and restore homeostasis, the stress response is initiated, including stimulation of the renin-angiotensin-aldosterone system. By a series of responses in various organs (liver, kidneys, lungs), the enzyme angiotensinogen interacts with renin to form angiotensin I, which is activated to produce angiotensin II by an enzyme reaction (angiotensin-converting enzyme) primarily in the lungs. Angiotensin II is a powerful vasoconstrictor, which prompts secretion of aldosterone from the adrenal cortex. Therefore, by two mechanisms, vasoconstriction and sodium retention with subsequent water retention, homeostasis is achieved, as seen by a normal blood pressure.

Negative Effects on Immunity

The stress response involves a process beginning with the body’s recognition of the stressor, leading to the hypothalamus’s release of CRH. Circulating CRH causes adrenocorticotropic hormone (ACTH) secretion from the anterior pituitary gland. ACTH stimulates the release of corticosteroids from the adrenal glands. The most notable is the glucocorticoid cortisol. Mineralocorticoids are also secreted from the adrenal glands; aldosterone is such a steroid. Its release is associated with fluid and electrolyte balance.

The stress effect on immunity involves both glucocorticoids and mineralocorticoids. Glucocorticoids have anti-inflammatory properties, and they reduce the immune response. There is a balancing act involved with patients who experience chronic maladaptive disorders, as the stress response has already been implicated in the release of cortisol, epinephrine, and norepinephrine. Patients’ bodies eventually lose the ability to compensate, with resultant disorders like DM and HTN demonstrating the long-term exposure to glucocorticoids and catecholamines.

Meanwhile, the mineralocorticoid aldosterone has also been synthesized more often as a compensatory mechanism, with effects of sodium and water retention, and signs and symptoms of fluid volume excess (e.g., HTN) again, as well as development over years of cardiovascular disorders including myocardial infarction and HF. This entire cycle of chronic results of general adaptation finally has patients reach the exhaustion phase, when the lack of resources and the long-term damage finally catch up. Immune system function decreases, patients become more prone to infections, or autoimmune diseases may develop. At this stage of the GAS, exacerbations of diseases like HF or COPD can cause major setbacks, with lengthy hospitalizations, rehabilitation or skilled nursing needs, or mortality.

Development of Poor Health Habits

Some people are surrounded by the necessary items to face and withstand stressful situations. Particularly optimistic individuals are able to frame stressful circumstances as eustress, and while the physiological response involves the same chemical reactions, the temporary nature combined with resilience minimizes the negative effects and allows for more positive adaptations. Unfortunately, many people are not in such affirmative environments, and they have developed coping mechanisms that are ultimately destructive. There are those who are born into settings filled with poor coping abilities. Long-standing decisions about nutritional choices, cooking habits, and the importance of exercise are examples of settings and behaviors that surround people and impact health.

When poor health is established, this in itself is a stressor, and it can place the patient firmly within the cycle of chronic stress, maladaptation, and ultimately exhaustion. Feeling ill can wear a person down; even an optimistic person can feel the burden and sadness ensuing from an illness or a chronic diagnosis. Such depression and not feeling well can be apparent through a lack of energy and motivation.

The following are some examples of ineffective coping mechanisms:

• overeating (food as a source of comfort)
• anorexia (not eating as a method of control)
• substance use disorders (alcohol, drugs use as means of escape)
• smoking (as a way of reducing stress)
• isolation (feeling too physically or mentally unwell to participate in social activities)

Unfortunately, these maladaptive coping methods perpetuate or worsen stressful circumstances and associated disorders; if not replaced by positive coping techniques and improvements in health and wellness, they may lead to detrimental effects within family units.

Negative Effects on the Family

Stress-related effects cause an assortment of challenges and problems for families. Physical and psychosocial effects impact not only the patient but families as well. The toll from maladaptive coping may mean family members have to do more for the patient in completion of activities of daily living and in supporting the patient with work or lack thereof. Often, people who have developed poor coping strategies are in an environment where others around them also do not employ positive coping methods. This leads to dysfunctional behaviors, such as enabling each other’s actions and further reinforcing chronic stress and its negative effects.

Manifestations of negative family effects related to stress include addictive behaviors, frustration and anger, relationship strain, interpersonal violence, and mental health diagnoses. The earlier part of the chapter presented some of the effects of ACEs that result from the environment surrounding a child and described how they cause chronic activation of the stress response. Some examples are a child living with someone with a mental illness, substance misuse or addiction, having a parent or caregiver who is incarcerated, violence, or parents with marital strain or dysfunction. The contribution of ACEs to the development of physical and mental health problems is significant, especially when more than one ACE is experienced. Diagnoses that have been identified with ACEs include DM, liver and heart diseases, stroke, cancers, and autoimmune diseases.

Because of the multigenerational influence of ACEs, recommendations focus on prevention of the experiences. Preventive measures as outlined by the Centers for Disease Control and Prevention (CDC) are designed to minimize the behaviors and environments that contribute to ACEs, thereby reducing the negative impacts caused by chronic stress on families. The CDC (2022) strategies include the following:

• strengthening economic supports to families
• promoting social norms that protect against violence and adversity
• ensuring a strong start for children
• teaching skills
• connecting youth to caring adults and activities
• intervening to lessen immediate and long-term harms

Maturational

The first crisis type is maturational crisis. The term maturational indicates these are the sorts of events that happen in a person’s life, and while they are normal occurrences, for some people they can cause a crisis. This may be influenced by other events in the person’s life that add to the level of stress, pushing the person to a stress point that reaches critical levels.

Patients who have developed positive adaptation and coping mechanisms tend to take such occasions in stride, coping with the extra busyness of the affair skillfully and without (or with minimal) anxiety, the experience reflecting eustress. For those whose coping techniques are maladaptive, however, such events as a wedding or the birth or adoption of a child can climb to the point of anxiety and on to crisis levels as previously used coping systems are not effective enough to address the rising stress level.

Situational

While maturational crises are common occurrences that are considered normal life events, a situational crisis results from an incident that comes as a surprise. A situational crisis is exemplified by being fired or laid off from a job, moving for a new job, or a death in the family. Even those who can typically withstand added stress may find themselves overwhelmed by all the emotions and added stress involved in such a significant circumstance.

Some who have remarkable support systems and their own internal strength and coping can minimize even situational stress. Many, though, are impacted by situational stress, and without interventions assisting them with new coping mechanisms and means of adapting, the response carries them into higher levels of anxiety and disequilibrium. Patients in the higher stages of crisis are likely to require more interventions, additional support, and exploration of novel methods of adaptation in order to overcome the combined psychophysiological distress and restore homeostasis.

Adventitious

Crises such as those resulting from traumatic incidents like a flood, hurricane, terrorist attack, or violent crime are categorized as adventitious. These are crisis events that take a person (or group) by surprise. An adventitious crisis may affect one person or several, and perhaps even an entire community or region. This type of crisis may not advance through the levels as shown in Table 34.3 but may appear already as a high-level crisis and be accompanied by a complete failure of previously used coping techniques.

As with the other types of crises, there is a loss of psychophysiological homeostasis. In the case of an adventitious crisis, it may be more complicated to restore equilibrium, as the level of devastation may impact an individual patient in a more significant manner, for example, in the case of a victim of a violent crime. Or, as in the case of natural disasters like hurricanes and tornadoes, there may be such tremendous damage and so many people may be impacted that support systems and resources are depleted. See Table 34.4 for characteristics and examples of different categories of crises.