Definition/Introduction

Coping is defined as the thoughts and behaviors mobilized to manage internal and external stressful situations.[1] It is a term used distinctively for conscious and voluntary mobilization of acts, different from 'defense mechanisms' that are subconscious or unconscious adaptive responses, both of which aim to reduce or tolerate stress.[2] 

When individuals are subjected to a stressor, the varying ways of dealing with it are termed 'coping styles,' which are a set of relatively stable traits that determine the individual's behavior in response to stress. These are consistent over time and across situations.[3] Generally, coping is divided into reactive coping (a reaction following the stressor) and proactive coping (aiming to neutralize future stressors). Proactive individuals excel in stable environments because they are more routinized, rigid, and are less reactive to stressors, while reactive individuals perform better in a more variable environment.[4] 

Coping scales measure the type of coping mechanism a person exhibits. The most commonly used scales are COPE (Coping Orientation to Problems Experienced), Ways of Coping Questionnaire, Coping Strategies Questionnaire, Coping Inventory for Stressful Situations, Religious-COPE, and Coping Response Inventory.[5] 

Coping is generally categorized into four major categories which are[1]: 

1. Problem-focused, which addresses the problem causing the distress: Examples of this style include active coping, planning, restraint coping, and suppression of competing activities.
2. Emotion-focused, which aims to reduce the negative emotions associated with the problem: Examples of this style include positive reframing, acceptance, turning to religion, and humor.
3. Meaning-focused, in which an individual uses cognitive strategies to derive and manage the meaning of the situation
4. Social coping (support-seeking) in which an individual reduces stress by seeking emotional or instrumental support from their community. 

Many of the coping mechanisms prove useful in certain situations. Some studies suggest that a problem-focused approach can be the most beneficial; other studies have consistent data that some coping mechanisms are associated with worse outcomes.[6][1] Maladaptive coping refers to coping mechanisms that are associated with poor mental health outcomes and higher levels of psychopathology symptoms. These include disengagement, avoidance, and emotional suppression.[7] 

The physiology behind different coping styles is related to the serotonergic and dopaminergic input of the medial prefrontal cortex and the nucleus accumbens.[4] The neuropeptides vasopressin and oxytocin also have an important implication relative to coping styles. On the other hand, neuroendocrinology involving the level of activity of the hypothalamic-pituitary-adrenocortical axis, corticosteroids, and plasma catecholamines were unlikely to have a direct causal relationship with an individual's coping style.[8] 

Issues of Concern

Patients using maladaptive coping mechanisms are more likely to engage in health-risk behaviors than those with appropriate mechanisms. They are also more non-adherent and more likely to use cigarettes or alcohol.[9]

Coping influences patients' compliance to therapy and the course of the disease by lifestyle changes. In disorders where non-medicinal treatment plays a role in the progression, coping mechanisms are important in determining the severity of such conditions. Coping styles may be helpful in patients' educational programs or psychotherapy, and paying attention to them could contribute to the prevention of sequelae.[10][11]

The importance of coping styles does not only affect the patients alone but also their physicians and nurses. Healthcare workers are more likely to choose a problem-oriented coping mechanism while the tendency to choose avoidance decreases with age and employment duration. The incidence of burnout syndrome decreases with the use of problem-oriented coping mechanisms, social integration, and the use of religion.[12][13]

Clinical Significance

Understanding coping mechanisms is a cornerstone in choosing the best approach to the patient to build an effective doctor-patient relationship. The need to monitor the patient's level of distress and coping mechanisms arise because patients who adopt maladaptive mechanisms are more likely to perceive their doctors as being disengaged and less supportive. This perception is clinically significant because about one out of four cancer patients use a maladaptive coping mechanism.[14]

The relation between maladaptive coping mechanisms and numerous disorders has been established. Psychiatric disorders such as PTSD, anxiety, and major depression, and somatic symptoms were all correlated with coping styles related to avoidance.[15] This scenario holds for other disorders such as hypertension and heart diseases, where maladaptive coping strategies were used by patients who had more severe symptoms.[16] 

Nursing, Allied Health, and Interprofessional Team Interventions

Teaching patients and their caregivers appropriate coping skills can have a significant impact on the way they perceive their condition, the severity of the symptoms, and the psychological distress associated with it. In patients diagnosed with lung cancer, assertive communication was associated with less pain interference and psychological distress; coping skills effects extend to family caregivers who reported less psychological distress when practicing guided imagery. Other coping mechanisms as mindfulness might not be as beneficial in certain situations.[17] [Level 2]

Physicians, psychiatrists, physical therapists, nurses, and health educators share the role of educating patients to become more responsible for their health. Interprofessional involvement can help patients cope better with the symptoms of their illnesses. Coping skills training programs didn't prove to be effective in reducing pain severity among knee osteoarthritis patients. They did not confer pain or functional benefit beyond that with surgical and postoperative care, but combining both physical exercises and coping skills training with treatment had a more significant improvement.[18][19][20] [Level 1, Level 2]

Nursing, Allied Health, and Interprofessional Team Monitoring

Understanding the coping styles is central to support the patient's coping efforts. Talking with the medical staff to seek information and social support was the most popular coping strategy in anxious surgical patients. Monitoring patients' coping strategies using various coping scales (e.g., COPE, Ways of Coping Questionnaire, Coping Strategies Questionnaire) can help in evaluating the patient's psychological status and continued improvement.[21]