Abstract

The present study aims to determine the level of self–compassion, stress appraisal

and perceived social support in cardiovascular patients. Using the Non-Probability

purposive sampling technique, 100 patients of cardiovascular disease was selected from

Punjab Institute of Cardiology (PIC), Mayo Hospital, Jinnah Hospital, Sir Ganga Ram

Hospital and Rahim Yar khan hospitals. Stress was measured by Stress Appraisal

Measure Scale (SAM) and anger was measured by Clinical Anger Scale

(CAS).Descriptive Analysis was used for demographic questionnaire, to determine level

of anger. Co relational analysis was used to investigate the relationship between anger

and stress appraisal. For all statistical analysis SPSS Social Sciences Version 17 was

used. The present study result shows that there is no relationship between anger and

stress appraisal but there is a interrelationship between subscales of stress appraisal.

Among all subscales of stress appraisal measures patients obtained highest mean scores

on challenge subscales.
 Introduction

The objective of present examination is to determine the relationship between

stress appraisal, perceived social support and self-compassion in patients with

cardiovascular disease. There were numerous variables that help in the improvement of

CVD. Perceived Social Support and Self-compassion is one of the most important risk

factor that play a central role in developing cardiovascular disease. Different variables

may incorporate smoking, liquor, cholesterol furthermore low or high amounts of

lipoproteins. People are more inclined to cardiovascular disease that encounters more

stress. Self-compassion is an alternate real incline of cardiovascular disease.

Other factors may include smoking, alcohol, cholesterol and also low or high

levels of lipoproteins. People are more prone to develop cardiovascular disease that

experience more stress. Perceived social support and self-compassion was another major

predispose of cardiac illness. According to Friedman (1969) stress and cardiovascular

disease can be related to each other because both occur together. Stressful events also

produce physiological effects such as elevated serum cholesterol level, an important risk

factor for cardiovascular disease (Cider, Geothals, Kavanaugh & Solomon, 1983).

According to Atkinson (1993) stress plays an important role in the development

of chronic stress may lead to (CVD). It is seen that the studies on this issue tend to

emphasize on individuals own perception of whether social relationships are adequately

supportive or not, that is too perceived. Perceived social support can be defined as

person’s impression of if his/her social network is supported or not (Aksullu,2004).

 Perceived social support is defined as individual’s perception of whether social

network is adequately supportive or not. In this sense social support is individual’s self-

appraisal. It is argued that individuals who are loved and wanted in different parts of life

and who find help when they are in need are more satisfied with their close relationships

and feel that they are supported by others. Perceived social support is individual’s

cognitive perception that has established reliable bonds with others and that others

provide support to them (Yamaç, 2009).

Provided social support means the behaviors and actions others display. In other

words, it is considered to be behavioral assessment of support. Although the benefits of

social support for individual have been appreciated for a long time, it is accepted that

perceived social support is particularly a better precursor of health results and it is also

reported that there is a positive relation between perceived social support and stress

appraisal and low levels of self-compassion in cardiovascular disease (Yamaç, 2009).

Cardiovascular disease occurs when the blood vessel that supplies the blood the

heart are narrowed or closed blocking the supply of oxygen and nutrient to the

heart.(Mittal,2005) Coronary heart disease linked to hypertension, high level of

cholesterol and low level of physical activities. Research suggests that coronary heart

disease (CHD) begins with damage to the lining and inner layers of the coronary (heart)

arteries. Several factors contribute to this damage. They include: Smoking including

secondhand smoke, high amounts of certain fats and cholesterol in the blood, high blood

pressure, and high amounts of sugar in the blood due to insulin resistance or diabetes

Blood vessel swelling.

 Coronary artery disease (CAD) is a condition in which Plaque buildup in the wall

of the vessels that supplies blood to the heart muscle. These plaques can gradually block

the artery, or they can suddenly burst, causing a sharper obstacle. Because the heart

muscle requires a continuous supply of oxygen and nutrients to survive, obstruction of a

coronary artery rapidly leads to major problems (Pankow & Shahar 1996).

CAD is caused by Atherosclerosis. Atherosclerosis is a chronic, progressive

disorder of the arteries in which deposits of cholesterol, calcium, and abnormal cells

build up on the inner lining of the artery. (Pankow & Shahar 1996)

These plaques can cause a continuing but progressive contraction of the artery,

and as a result, blood flow through the artery becomes more difficult. When the blockage

becomes large enough, the patient may experience angina. (Pankow & Shahar 1996)

The term "heart disease" is often used interchangeably with the term

cardiovascular disease. Cardiovascular disease generally refers to conditions that involve

narrowed or blocked blood vessels that can lead to a heart attack, chest pain (angina) or

stroke. Other heart conditions such as those that affect your heart's muscle, valves or

rhythm, also are considered forms of heart disease (Pankow & Shahar 1996).

Many forms of heart disease can be prevented or treated with healthy lifestyle choices.

Cardiovascular disease symptoms may be different for men and women. For instance,

men are more likely to have chest pain; women are more likely to have other symptoms

along with chest discomfort, such as shortness of breath, nausea and extreme fatigue.

Symptoms can include:

 Chest pain, chest tightness, chest pressure and chest discomfort (angina)

 Shortness of breath
  Pain, numbness, weakness or coldness in your legs or arms if the blood vessels in

those parts of your body are narrowed

 Pain in the neck, jaw, throat, upper abdomen or back

You might not be diagnosed with cardiovascular disease until you have a heart

attack, angina, stroke or heart failure. Cardiovascular disease can sometimes be found

early with regular evaluations (Pankow & Shahar 1996).

While cardiovascular disease can refer to different heart or blood vessel problems, the

term is often used to mean damage to your heart or blood vessels by atherosclerosis a buildup of

fatty plaques in your arteries. Plaque buildup thickens and stiffens artery walls, which can inhibit

blood flow through your arteries to your organs and tissues. (Pankow & Shahar 1996)

Atherosclerosis is also the most common cause of cardiovascular disease. It can be

caused by correctable problems, such as an unhealthy diet, lack of exercise, being overweight and

smoking. . (Pankow & Shahar 1996)

Types of Cardiovascular disease:

Angina

Angina refers to the symptoms a patient experiences any time the heart muscle is

not getting enough blood flow through the coronary arteries. Angina is usually felt as a

pressure-like pain in or around the chest, shoulders, neck or arms.

 Stable Angina

Stable angina is angina that occurs in a nearly conventional mode, for example,

with hard work or after a big meal. Stable angina usually means that a plaque has become

large enough to produce an incomplete obstruction of a coronary artery. (Morris &

Tennessen, 1996)
 When a person with stable angina is at rest, the partially blocked artery is

able to meet the needs of the heart muscle. But when that person exercises, or did hard

work the obstruction prevent a sufficient increase in blood flow to the heart muscle and

angina occurs. So stable angina usually means there that there is a significant plaque in a

coronary artery that is partially obstructing the flow of blood. (Morris & Tennessen 1996)

 Acute coronary heart disease

In addition to causing obstruction by a gradual increase in their size, plaques are also

subject to sudden rupture, which can produce a very sudden obstruction. The medical

conditions caused by the break of a plaque are referred to as Acute Coronary Syndrome

(ACS). ACS is always a medical emergency. (Morris & Tennessen 1996)

Myocardial infarction

Myocardial infarction or heart attack is a more dreadful form of ACS. A heart

attack, therefore, is death of heart muscle. The seriousness of a myocardial infarction

depends largely on how much heart muscle has died. A small heart attack is one in which

only a small portion of the heart muscle dies. A large heart attack is one in which a large

portion of heart muscle dies. . (Morris & Tennessen 1996).

Major risk factors that can be caused CVD

 Smoking—Smoking increases both the chance of developing coronary artery disease

and the chance of dying from it. Smokers are two to four times more likely than are

non-smokers to die of sudden heart attack. They are more than twice as likely as non-
 smokers to have a heart attack. They also are more likely to die within an hour of a

heart attack. Second hand smoke also may increase risk.

 High cholesterol—Dietary sources of cholesterol are meat, eggs, and other animal

products. The body also produces it. Age, sex, heredity, and diet affect one's blood

cholesterol. Total blood cholesterol is considered high at levels above 240 mg/dL and

borderline at 200-239 mg/dL. High-risk levels of low-density lipoprotein (LDL

cholesterol) begin at 130-159 mg/dL, depending on other risk factors. Risk of

developing coronary artery disease increases gradually as blood cholesterol levels

increase above 160 mg/dL. When a person has other risk factors, the risk multiplies.

 High blood pressure—High blood pressure makes the heart work harder and weakens

it over time. It increases the risk of heart attack, kidney failure, and congestive heart

failure. A blood pressure of 140 over 90 or above is considered high. In combination

withsmoking, high cholesterol, or diabetes, high blood pressure raises the risk of heart

attack or stroke several times.

 Lack of physical activity—Lack of exercise increases the risk of coronary artery

disease. Even modest physical activity, like walking, is beneficial if done regularly.

 Diabetes mellitus—the risk of developing coronary artery disease is seriously

increased for diabetics. More than 80% of diabetics die of some type of heart or blood

vessel disease.(John Wiley & sons 1996)

 Age—Aging increases your risk of damaged and narrowed arteries and weakened or

thickened heart muscle.

 Sex—Men are generally at greater risk of heart disease. However, women's risk

increases after menopause.

 Family history—A family history of heart disease increases your risk of coronary

artery disease, especially if a parent developed it at an early age (before age 55 for a

male relative, such as your brother or father, and 65 for a female relative, such as

your mother or sister).

 Stress—Unrelieved stress may damage your arteries and worsen other risk factors for

heart disease.

 Obesity—Excess weight typically worsens other risk factors.

 Certain chemotherapy drugs and radiation therapy for cancer—some chemotherapy

drugs and radiation therapies may increase the risk of cardiovascular disease.

 Poor hygiene—not regularly washing your hands and not establishing other habits

that can help prevent viral or bacterial infections can put you at risk of heart

infections, especially if you already have an underlying heart condition. Poor dental

health also may contribute to heart disease. (Shaie & willis, 1991)

Heart disease is by no means restricted to the elderly of course, but it has also

been found among young people of 30 or above. It is most commonly found among

middle aged men, than older men and among women in general. About 80% of the heart

victims are male about it one in fine men will experience a heart attacks before the age of

60 (Shaie & willis, 1991)

Though there is no statistical figure as such to show the prevalence of heart

problems among Pakistani population but generally it has been found that it is increasing

gradually.
Complications

Complications of heart disease include:

 Heart failure. One of the most common complications of heart disease, heart

failure occurs when your heart can't pump enough blood to meet your body's needs.

Heart failure can result from many forms of heart disease, including heart defects,

cardiovascular disease, valvular heart disease, heart infections or cardiomyopathy

(Granto, 2008).

 Heart attack. A blood clot blocking the blood flow through a blood vessel that

feeds the heart causes a heart attack, possibly damaging or destroying a part of the

heart muscle. Atherosclerosis can cause a heart attack (Granto, 2008).

 Stroke. The risk factors that lead to cardiovascular disease also can lead to an

ischemic stroke, which happens when the arteries to your brain are narrowed or

blocked so that too little blood reaches your brain. A stroke is a medical emergency

— brain tissue begins to die within just a few minutes of a stroke (Granto, 2008).

 Aneurysm. A serious complication that can occur anywhere in your body, an

aneurysm is a bulge in the wall of your artery. If an aneurysm bursts, you may face

life-threatening internal bleeding (Granto, 2008).

 Peripheral artery disease. Atherosclerosis also can lead to peripheral artery

disease. When you develop peripheral artery disease, your extremities — usually

your legs — don't receive enough blood flow. This causes symptoms, most notably

leg pain when walking (Granto, 2008).

 Sudden cardiac arrest. Sudden cardiac arrest is the sudden, unexpected loss of

heart function, breathing and consciousness, often caused by an arrhythmia. Sudden

cardiac arrest is a medical emergency. If not treated immediately, it is fatal,

resulting in sudden cardiac death (Granto, 2008).

Cardiovascular disease CVD is process that affects the blood vessel wall; it is a

degenerative and provocative process that begins within the blood vessel causing it to

weaken, enlarge and eventually impaired blood flow through the damaged artery.

Coronary heart disease is one of the several cardiovascular diseases. Deficiency of

blood is called ischemia that’s why coronary heart disease is also known as ischemic

heart disease (Mittal, 2005). Cardiovascular disease is a condition that damages the

coronary arteries, which are among the main structure in the heart. Coronary arteries

supply the blood to the heart muscles, supplying the heart with oxygen and nutrients

that enable it to function for many years (Granto, 2008). CVD are the number 1 cause

of death globally: more people die annually from CVD than from any other cause. An

estimated 17.9 million people died from CVD in 2016, representing 31% of all global

deaths. Of these deaths, 85% are due to heart attack and stroke. Over three quarters of

CVD deaths take place in low- and middle-income countries. Out of the 17 million

premature deaths (under the age of 70) due to non-communicable diseases in 2015,

82% are in low- and middle-income countries, and 37% are caused by CVD. Most

cardiovascular diseases can be prevented by addressing behavioral risk factors such as

tobacco use, unhealthy diet and obesity, physical inactivity and harmful use of alcohol

using population-wide strategies. People with cardiovascular disease or who are at high

cardiovascular risk due to the presence of one or more risk factors such as hypertension,
 diabetes, hyperlipidemia or already established disease need early detection and

management using counselling and medicines, as appropriate (Granto, 2008).

Social support refers to the experience of being valued, respected, cared

about, and loved by others who are present in one's life. It may come from different

sources such as family, friends, teachers, community, or any social groups to which one

is affiliated. Social support can come in the form of tangible assistance provided by

others or in the form of perceived social support that assesses individuals’ confidence of

the availability of adequate support when needed. (Hengl, 1997).

Previous research shows that low social support is one of the predictors of

psychological problems and associated with self-compassion and stress appraisal. It

appears that the role of social support is very important because it is considered as a

mechanism to buffer against life stressors and promote health and wellness (Hengl,

1997).

Stress is a negative physical and psychological adjustment to circumstances that

either disrupt or threaten to disrupt the functioning of the person. Stress always has an

involvement of a relationship between people and environments. The stressor may arise

either from external sources or internal sources .External sources may include things like

danger during war time while internal sources include thought and feelings such a daily

worries, guilt and unfulfilled expectations. (Kumar & Goal 2008).

There are two part of the stress response. Appraisal and coping: appraisal refers to

the learned responses you have to typical situations. For example, when one see a

professor getting ready to hand out exams, when someone asks you for a favor ,or when
you see a group of friends in the cafeteria, what are your first thought? These thoughts

fuel our emotions (fear, sadness, happiness anger etc). So if the thought are negative the

emotions will be accordingly. Natural thoughts are likely to provoke a stress response.

Practice watching one’s appraisal tendencies, if first one response stimulates a desire to

fight or flee, no matter how appropriate it may b chances are that one is adding to the

stress in one life (Bowdoin, 2008).

The presence of a perceived social support system has been shown to be

beneficial to the recipient on multiple levels including physical, emotional, and health.

(Berkman & Syme,1979) demonstrated a correlation between higher mortality rates and

low levels of perceived social support. Research further suggests that a perceived social

support system is beneficial in buffering the stress associated with illness and life

changing events thus helping the recipient of the support better cope with problems

(Bliese & Britt, 2001).

Many researchers especially in the areas of healthcare and psychology had studied

the benefits associated with perceived social support. Of particular interest was the effect

of social support on persons already coping with an illness, especially a life threatening

illness such as cardiovascular disease. Perceived Social Support could bolster the

recipient’s feelings of belonging thus giving them strength on a psychological level.

There was some evidence to suggest that social support may also be beneficial in altering

the disease process itself and possibly amplifying the response of the immune system

(Cooper, Buller, & Sood, 2002).

The means in which social support affects stress and stressful situations is up to
debate. Researchers have questioned whether the effect is related to a buffering or

protective mechanism for a person under stress or in a stressful situation or if the effects

of social support have a beneficial effect irregardless of whether the persons are under

stress or not (Cohen & Willis, 1985). Examination of social support as a main effect

suggest a generalized beneficial effect of social support could occur because large social

networks provide persons with regular positive experiences and a set of stable, socially

rewarded roles in the community (Cohen & Willis, 1985). In this situation the person is

immersed in a positive and somewhat predictable environment allowing them to exert or

feel as though they have at least some degree of control.

Self-compassion

Self-compassion involves relating to oneself with care and support when we

suffer. Neff (2003b) defines self-compassion as consisting of three central components:

self-kindness versus self-judgment, common humanity versus isolation, and mindfulness

versus over identification. These elements combine and mutually interact to create a self-

compassionate frame of mind when encountering personal mistakes, perceived

inadequacies, or various experiences of life difficulty. Self-kindness entails being loving,

gentle, and understanding toward oneself and involves actively soothing and comforting

oneself in times of struggle. This response stands in contrast to a self-critical approach in

which one judges or blames oneself for not being good enough or for not coping well

enough with life challenges.

Self-compassion involves framing one’s experiences of imperfection in light of

the shared human experience, accepting that all people struggle in some form or another.

Rather than seeing oneself as a separate, unworthy individual, self-compassion involves

recognizing that one’s experience of imperfection is connected to the experience of

imperfection shared by all humanity. Instead of feeling cut off and isolated from others in

times of loss or failure, self-compassion fosters a deep sense of belonging. Finally, self-

compassion entails a balanced, mindful response to distress that neither stifles and avoids

nor amplifies and ruminates on uncomfortable emotions. Rather than running away with

the narrative or storyline of one’s problems and shortcomings, self-compassion involves

maintaining equanimity in the face of unpleasant experiences, opening up to life as it is in

the present moment (Neff et al. 2017).

In order to better understand what self-compassion is, it is useful to first consider

what it means to feel compassion more generally. From the Buddhist point of view,

compassion is given to our own as well as to others’ suffering. We include ourselves in

the circle of compassion because to do otherwise would construct a false sense of

separate self (Salzberg, 1997).

Compassion can be extended toward oneself when suffering occurs through no

fault of one’s own – when the external circumstances of life are simply painful or hard to

withstand. Self-compassion is equally relevant, however, when suffering stems from

one’s own mistakes, failures, or personal limitations (Neff et al. 2017).

Self-compassion allows one to meet life with an open-hearted stance in which the

boundaries between self and other are softened so that all human beings are considered

worthy of compassion, including oneself. This allows for greater emotional resilience and

psychological well-being. Western psychologists have only recently become interested in

self-compassion, although the construct is central to the 2,500-year-old tradition of

Buddhism. Interest in self-compassion has also been fueled by a larger trend toward
integrating Buddhist constructs such as mindfulness with Western psychological

approaches, exemplified in interventions such as Mindfulness-Based Stress Reduction.

While mindfulness has received more research attention than self-compassion, research

on the latter construct is growing at an exponential rate. It should be noted that

mindfulness and self-compassion are intimately linked, however. Mindfulness refers to

the ability to pay attention to one’s present-moment experience in a nonjudgmental

manner (Neff 2003a).

Self-compassion entails holding negative self-relevant emotions in mindful

awareness but also involves generating feelings of kindness toward oneself and insight

into the interconnected nature of the human experience. Methods of Researching Self-

Compassion Most research on self-compassion has been conducted using a self-report

measure developed to facilitate research on the construct called the Self-Compassion

Scale (Neff 2003a).

Self-compassion does not avoid pain but rather embraces it with loving kindness

and goodwill, generating a sense of well-being that is rooted in the experience of being

fully human. In this way, self-compassion is reminiscent of Abraham Maslow and Carl

Rogers’ conceptions of a healthy person, which emphasize unconditional self-acceptance

and ambition to reach one’s full potential. It is also an important inner resource that helps

individuals to find hope and inner strength when faced with the difficulties of life. One of

the most consistent findings in the research literature is that greater self-compassion is

linked to less depression and stress (MacBeth and Gumley 2012).

Self-compassion is associated with feelings of life satisfaction, happiness,

wisdom, optimism, gratitude, curiosity, creativity, and positive affect. Self-compassion is

also associated with greater emotional intelligence, suggesting that self-compassion

represents a more perceptive way of dealing with difficult feelings. By meeting one’s

suffering with the warm embrace of self-compassion, positive feelings are generated at

the same time that negative emotions are alleviated. Self-compassion also appears to be

an important source of coping and resilience in the face of various life stressors such as

divorce, chronic pain, or combat exposure (Zessin et al, 2015).

Compassion involves sensitivity to the experience of suffering, coupled with a

deep desire to alleviate that suffering (Goetz, Keltner, &Simon-Thomas, 2010). This

means that in order to experience compassion, you must first acknowledge the presence

of pain. Rather than rushing past that homeless woman as you’re walking down the busy

street, for example, you must actually stop to consider how difficult her life must be. This

involves pausing, stepping out of your usual frame of reference, and viewing the world

from the vantage point of another.

The moment you see the woman as an actual human being who is in pain, your

heart resonates with hers (compassion literally means “to suffer with”). Instead of

ignoring her, you find that you’re moved by her situation, and feel the urge to help in

some way. And rather than looking down at the woman or believing that she is somehow

separate and disconnected from yourself, you realize that all human beings suffer and are

in need of compassion –“there but for fortune go I.” Self-compassion is simply

compassion directed inward, relating to ourselves as the object of care and concern when

faced with the experience of suffering (Neff, 2003).

Three Elements of Self-Compassion:

Self-kindness vs. Self-judgment

Self-compassion entails being warm and understanding toward ourselves when

we suffer, fail, or feel inadequate, rather than ignoring our pain or flagellating ourselves

with self-criticism. Self-compassionate people recognize that being imperfect, failing,

and experiencing life difficulties is inevitable, so they tend to be gentle with themselves

when confronted with painful experiences rather than getting angry when life falls short

of set ideals. People cannot always be or get exactly what they want. When this reality is

denied or fought against suffering increases in the form of stress, frustration and self-

criticism. When this reality is accepted with sympathy and kindness, greater emotional

equanimity is experienced. (Neff & Dahm,2015)

Common humanity vs. Isolation

Frustration at not having things exactly as we want is often accompanied by an

irrational but pervasive sense of isolation – as if “I” were the only person suffering or

making mistakes. All humans suffer, however. The very definition of being “human”

means that one is mortal, vulnerable and imperfect. Therefore, self-compassion involves

recognizing that suffering and personal inadequacy is part of the shared human

experience – something that we all go through rather than being something that happens

to “me” alone. (Neff & Dahm,2015)

Mindfulness vs. Over-identification

Self-compassion also requires taking a balanced approach to our negative

emotions so that feelings are neither suppressed nor exaggerated. This equilibrated

stance stems from the process of relating personal experiences to those of others who are

also suffering, thus putting our own situation into a larger perspective. It also stems from

the willingness to observe our negative thoughts and emotions with openness and clarity,

so that they are held in mindful awareness. Mindfulness is a non-judgmental, receptive

mind state in which one observes thoughts and feelings as they are, without trying to

suppress or deny them. We cannot ignore our pain and feel compassion for it at the same

time. At the same time, mindfulness requires that we not be “over-identified” with

thoughts and feelings, so that we are caught up and swept away by negative reactivity.

(Neff & Dahm, 2015)

Stress appraisal

According to (Lazarus and Folkman,1984) stress is defined as “a relationship between

the person and the environment that is appraised by person as taxing or exceeding his or

her resources and as endangering his or her well-being.

It can be defined as” a feeling of tension that occurs when a person assess that a

given situation is about to exceed his or her ability to cope and consequently will on

danger his or her well being “(Hit, Miller & Colella 1978). According to Lazarus and

Folkman (1948) stress is defined as ‘’ a relationship between the person and environment
that is appraised by person as taxing or exceeding his or her resource and as endangering

his/her well being”.

Stress directly affects the behavior, mind and body of the person in many ways. The

sign and symptoms of the stress are not constant they can vary from person to person.

Some people experience the emotional symptoms such as hyperactivity and other

experience physical symptoms like heart problem. But whatever the symptoms are to

handle the stress has its difficulties. Some of the emotional symptoms of stress are

loneliness, unhappy, feeling tense, restlessness etc. some physical symptoms are

headaches, muscular tension, insomnia, chest pain, heart pain etc. (Belmote 2007)

There are so many causes of stress and the stressful events also depends on several

factors including the personality of the person, problem solving abilities, concept of life

and social support because something which is very important for a person may have no

important for other person. Whether stress is good or bad does not matter too much,

infect it depends on the personality of the person. Because all the major life changes a

person can have, can be called stressors. (Belmonte 2007)

The concept of stress can be defined very difficult because it involves so many

situations and events. Selye was the first one who gave the concept of stress. Hans Selye

was one of the founding father of the stress research. Hans Selye first introduced the

concept of stress in the 1930’s. His view in 1956 was that “stress is not necessarily

something bad it all depends on how you take it. The stress of exhilarating, creative

successful work is beneficial, while that of the failure, humiliation or infection is

detrimental.”
According to Selye (1982) similar situation are producing the response of stress.

According to Barnard &krupat (1994) every definition of stress highlights different

aspects of stress. One very common and understandable model of stress is

biopsychosocial model of stress. According to this model these are three components of

stress, an external component, an internal component and the interaction between the two

components. The external components of stress involve environmental factors and

situations. According to Cannon (1932) there are four categories of stressors, personal,

social, environment, the internal component of stress are the result of neurological and

physiological reactions. According to seley (1985) there are three phases of long term

stress in a person alarm reaction, Stage of resistance, exhaustion. The third component

involves cognitive processes. Lazarus and colleagues (1984b, 1978) also established the

cognitive theory of stress which is actually between the interaction of the internal

component of stress and external component of stress. The biopsychological model also

incorporates its social factors. (Cordon 1997)

Lazarus and Folkman (1984) proposed a model that emphasis transactional nature of

stress. Stress is a two way process the environment produces stressor & the individual

find way to deal with these. Cognitive appraisal is a mental process by which people

assessed two factors: whether a demand threatens their well being & whether a person

considers that they have the resources to meet the demand of stressor. There are two type

of appraisal primary and secondary: during primary appraisal stage a person will be

seeking answer as to the meaning of the situation with regard to their well being. One of

three types of appraisals could be made; is it irrelevant. Is it good? Is it stressful? Further

appraisal is made with regard to three implications: harm less threat, and challenges.

Secondary appraisal occurs at the same time as primary appraisals. A secondary appraisal

can actually cause a primary appraisal. Secondary appraisal includes feeling of mot being

able to deal with the problem. Stress can occur without appraisal such as when your car

involves in an accident and you have not had time to think about what has happened.

Accident can often cause a person to be in shock. It is difficult for people to make

appraisal whilst in shock as their cognitive functioning is impaired. (Lazarus &Folkman

1984)

Lazarus and Selye's define. "Stress is the inability to cope with a perceived threat to one's

mental, physical,emotional and spiritual well-being which results in a series of

physiological responses and adaptations". (Brain Luke Seawan 2001).Lazarus &Folkman

(1984) proposeda model that emphasizes the transactional nature of stress. Stress is a two

way process: the environment produce stress and the individual find way to deal with

these. There are two type of appraisal: primary and secondary. During a primary

appraisal stage a person will be seeking answers as to the meaning of the situation with

regard to their well-being. One of three type of appraisal could be made, it is irrelevant, it

is good, is it stressful. Further appraisal made with regard to three implication Harm-loss,

the threat &challenges. Secondary appraisal occurs at the same time as primary appraisal.

A secondary appraisal can actually cause a primary appraisal. Secondary appraisal

include feeling of not being able to deal with problem (Lazarus & folkman, 1984)

Perceived Social Support

Shumaker and Brownell (1984) defined social support as “an exchange of resources

between at least two individuals perceived by the provider or the recipient to be intended

to enhance the well-being of the recipient” (Lirio, 2007). Social support also means the

satisfaction of the basic needs of human being such as belonging, love, appreciation and

realizing oneself- which are among the needs hierarchy of individual- via interaction s/he

has with other individuals ( such as friends, family, superiors or professional consultants )

(Ekinci, 2003). While the provision of social support, there is an undeniable importance

of organization’s internal and external environment like friends, family members,

executives, professional consultants etc. For example coaches can be regarded as

individual consultants while motivating the organization members, providing feedbacks

and ensuring individual developments (Beduk, 2010).

Social support is a burdensome term. In the early 1980’s researchers were deep in the

initial examination of the concept of social support. The consensus of the time was a

definition that was both simplistic and concrete. Social support referred to an interaction,

person, or relationship (Veiel & Bauman, 1992). Over the last 20 years the concrete

definition evolved into a more abstract and complex explanation that encompassed more

than just interaction, person, or relationship. Today there is little agreement among

researchers and theoreticians in regards to an operational definition of social support.

However, there is some agreement in terms of characteristics that are found as a common

thread that is weaved through the multiple definitions apparent for social support. All of

the definitions imply some type of positive interaction or helpful behavior provided to a

person in need of support (Hupcey, 1998).

From the starting point of a common characteristic, further defining of social support

appears to fall into one of at least five categories of the following:

 Type of support provided

 Recipients perceptions of support

 Intentions or behaviors of the provider

 Reciprocal support

 Social networks (Hupcey, 1998).

Types of Support Provided

The first of five categories proposed by (Hupcey 1998) to classify the types of

definitions of social support is the type of support provided. The type of support

provided refers to the resources provided, what was actually given to the person or

persons. The support provided was tailored to the situation in which a person has a

perceived need. For instance, (Sarason, Levine, Basham, and Sarason,1983) state that

examples of this include: psychotherapists try to provide their clients with acceptance

needed to pursue self-examination and soldiers develop strong mutually reinforcing

support with each other that contributes to their success and survival. The type of

support provided usually meets an emotional need of the recipient as demonstrated

above. (Cobb,1976) states that perceived social support could be instrumental where

information was provided leading a person to believe that they were cared for and

loved, esteemed and valued, and/or that they belong to a network of communication

and mutual obligation. This information serves to meet the needs of the survivor

through a variety of means but mainly love and belonging.

 Furthers this notion by adding that social support contributes to a positive

adjustment and personal development. The type of support provided involves an

exchange between the provider and recipient. These authors did not offer a concrete

example of what the support was but note that it meet a need, thus the type of support

provided works to bolster adjustment and development. The type of support provided

was used to categorize definitions of support. Inherent in the type of support is a

source and recipient of such support. As previously mentioned the type of support is

dependent on the situation but also dependent upon the provider and the recipient.

The type of support can be physical or psychological but almost always meets an

emotional need of the recipient and often the provider. Defining social support as to

its type offers the researcher an opportunity to describe the support itself and briefly

touch on the source of the support and the recipient. The second category of

definitions of social support is the recipient’s perception of the support (Sarason et al

1983).

Recipient’s Perception of the Support

The second category of defining social support is the recipient’s perception of the

support. (Procidano and Heller 1983) define social support as the extent to which an

individual believes that their need for support, information, and feedback are fulfilled.

There are many factors that impact the recipient’s perception of support such as

physical setting, attitudes, and actions of others, the recipient’s attitude and actions,

and the support provided.

 Physical setting factors can greatly impact the recipient’s perception of support to

the extent that the recipient may not even be able to access the support needed or

intended for the recipient. Physical setting can impose barriers on the social support

provided thus limiting and/or prohibiting the person’s access to support. The result of

such barriers is a perception of not having social support and is usually deemed as a

negative situation by recipient and possibly provider as well. Physical setting factors

can include poor roads, lack of public transportation, bad weather, and poorly

designed buildings (Pearson, 1990). Attitudes and actions of others influence the

recipient’s perception of support as well. How the provider offers the support needed

or deemed necessary to the recipient is as important as the support offered (Hupcey,

1998; Pearson, 1990).

Providers of support must first be able to appraise the situation and determine if

help is needed, what actions to take and in what manner (Hupcey, 1998). During the

appraisal and implementation of support attitudes and actions of the provider can

greatly alter the support provided. The provider may greatly underestimate the need,

the type of support, and the length of time necessary to meet the need. The provider

may also make assumptions in regards to the support and the recipient. The provider

may assume that the support may make the person feel worse and they may also

assume what they think is needed instead of what the recipient may actually need

(Hupcey, 1998). Finally the provider may become tired, stressed, and or burned out if

the time needed extends beyond their ability to provide the support (Hupcey, 1998).
 The end result of the above factors can lead the recipient to perceive an unmet

need and overall dissatisfaction. The recipient’s attitudes and activities indubitably

influence the perception of support. (Pearson,1990) identifies such factors as low self-

esteem, fear, and suspicion of others, fear of dependency, insensitivities of others, and

a stigmatized status as personal factors that can lead the recipient to perceive a lack of

support. Other recipient factors such as personality, social role, coping ability,

independence, and history of supportive actions can influence the potential

availability of support and whether one request, needs, or receives support (Hupcey,

1998).

Finally the support provided influences the individual’s perception of support.

The support provided must meet the need of the recipient in terms of the type,

amount, and length of time (Pearson, 1990). If any of the above factors is not met the

recipient may perceive the support as not meeting their needs. The recipient’s

perception of the support provided can determine whether or not the support is

deemed as positive or potentially negative. Defining support in terms of the

recipient’s perception allows for further investigation of the potential of the support

both in a positive and negative way. How the recipient perceives the support can also

be influence by the intentions or behaviors of the provider of the support. The third

category of defining social support focuses on the intentions or behaviors of the

provider (Hupcey, 1998).

Intentions or Behaviors of the Provider

 The third category of social support definitions refers to the intentions or

behaviors of the provider. Shumaker and Brownell (1984) offer the definition social

support as an exchange of resources between two individuals perceived by the provider

or the recipient to be intended to enhance the well being of the recipient. The provider

may perceive an obligation to provide support, they may feel a need to provide support so

when they are in need they will receive support (Hupcey, 1998). Many of the factors

mentioned above in regards to the recipients perception of the support play into the

intentions and behaviors of the provider. Social support can occur in a bi-directional

manner thus the provider can also be a recipient at the same time. The models of social

support will be further discussed later in the chapter. Further examination of the

reciprocating nature of social support is further explored in the fourth category of

defining social support, reciprocal support (Hupcey, 1998).

Reciprocal Support

The fourth category of definition is reciprocal support. This category refers to the

exchange of resources between the provider and recipient (Hupcey, 1998). Definitions

focused on reciprocal support center themselves on the action of exchange. Simply put

the actual giving, receiving, and exchange of support is commonly referred to as the

function of social support (Antonucci, 1985). This category of definition takes into

account the interactions that occur between the provider and the recipient and views both

parties perception of the interaction. Definitions in this category not only view the

recipient’s perception of support but also look at the actual support as well as the

perception of the provider of the support (Hupcey, 1998). Viewing the perceptions of
both parties involved in the exchange of support shows that there can be an in

congruence. Providers usually feel that they are giving more than recipients feel they are

receiving (Antonucci, 1985; Sarason, Sarason, & Pierce, 1990). This can lead to

dissatisfaction in both parties and the possibility of limiting or withdrawing the support

provided (Hupcey, 1998). (Shumaker and Brownell,1984) note the importance of

reciprocity by stating that:

“The value of the reciprocity model for social support derives from its attention

to factors that inhibit people’s willingness to seek and accept help. By being sensitive to

situations in which the norm of reciprocity is salient investigators can assess whether

people lack access to support or are unwilling to become indebted to others.”

The fear of becoming indebted to another can form a stressful environment and

further an individual’s reluctance to ask for needed help (Hupcey, 1998). Reciprocity can

indicate a mutual exchange relationship in which the members are interdependent upon

support given and received. A reciprocal relationship can also incite a degree of

discomfort from some in that they do not feel that they will be able to return the favor and

do not want to be indebted to another. In the fifth category, definitions are in terms of the

social network or the environment in which the support occurs (Hupcey, 1998).

Social Networks

The last category of definitions is social networks. The social network is the

milieu in which the support occurs. The social network can refer to an individual, group,

or large community (Hupcey, 1998).

 The social network can be viewed as an environment in which the stage for the

exchange of support is set. The social network also refers to the individuals within that

provide and receive the support taking into consideration the characteristics of both

parties as well as the characteristics of the environment and the support itself (Hupcey,

1998). Characteristics of the recipient of the support are the properties of the individual

that influence the structure and function of the social network (Antonucci, 1985).

The properties unique to the recipient are influenced by the cultural and social

roles as well as their demographic including age, sex, and education (Antonucci, 1985;

Cohen & Willis, 1985). The person’s requirements for support are determined by these

properties and will also influence their response to support received (Hupcey, 1998).

Characteristics of the provider are similar to that of the recipient but also include an

ability to appraise a situation (Hupcey, 1998).

The provider of support must able to assess a situation determine what they think

is needed, how much is needed, and how to give what is needed (Hupcey, 1998). The

provider also must think beyond that situation at hand and determine the aftermath of the

support provided and what the lasting implications may be (Shumaker & Brownell,

1984).

The environment and support are key components of the social network. Although

the size of the network would seem to be a key factor, there is little information to

support the notion that the bigger the environment the more support available (Sarason et

al, 1990). Hupcey (1998) states that many studies are based on the premise that the

number of individuals in the support network or presence of a particular person will

influence positive outcomes. This may not be the as the person in need of support may be

reluctant to ask for support (Hupcey, 1998; Sarason et al, 1990).

Finally (Cohen and Willis,1985) suggest that there may be a threshold of support

in which increase in the 12 number of providers of support and/or the support provided

does not result in a proportionate increase in satisfaction or benefits associated with

social support (Cohen and Willis,1985).

Theoretical framework

Neff's scale (2015) proposes three interacting components of self-compassion,

which are each composed of two opposite facets. The first dimension is self-kindness

versus self-judgment. Self-kindness refers to one's ability to be kind and understanding of

oneself, whereas self-judgment refers to being critical and harsh towards oneself. The

second dimension is common humanity versus isolation. Common humanity refers to

one's ability to recognize that they are part of a related group of others and that suffering

is part of the human condition. The third dimension is mindfulness versus over-

identification. Mindfulness refers to one's awareness and acceptance of painful

experiences in a balanced and non-judgmental way. Neff describes these three

dimensions interacting to enhance and engender one another.

Richard Lazarus (2012) stress is a two-way process; it involves the production of

stressors by the environment, and the response of an individual subjected to these

stressors. His conception regarding stress led to the theory of cognitive appraisal. Lazarus
stated that cognitive appraisal occurs when a person considers two major factors that

majorly contribute in his response to stress. These two factors include:

 The threatening tendency of the stress to the individual, and

 The assessment of resources required to minimize, tolerate or eradicate the

stressor and the stress it produces.

In general, cognitive appraisal is divided into two types or stages: primary and

Secondary appraisal.

Primary appraisal

To better understand primary appraisal, suppose a non-stop heavy rain suddenly pours at

your place. You might think that the heavy rain is not important, since you don’t have

any plans of going somewhere today. Or, you might say that the heavy rain is good,

because now you don’t have to wake up early and go to school since classes are

suspended. Or, you might see the heavy rain as stressful because you have scheduled a

group outing with your friends.

After answering these two questions, the second part of primary cognitive

appraisal is to classify whether the stressor or the situation is a threat, a challenge or a

harm-loss. When you see the stressor as a threat, you view it as something that will cause

future harm, such as failure in exams or getting fired from job. When you look at it as a

challenge, you develop a positive stress response because you expect the stressor to lead

you to a higher class ranking, or a better employment.

 On the other hand, seeing the stressor as a “harm-loss” means that the damage has

already been experiences, such as when a person underwent a recent leg amputation, or

encountered a car accident.

Secondary appraisal

Unlike in other theories where the stages usually come one after another, the secondary

appraisal actually happens simultaneously with the primary appraisal. In fact, there are

times that secondary appraisal becomes the cause of a primary appraisal.

Secondary appraisals involve those feelings related to dealing with the stressor or

the stress it produces.Although primary and secondary appraisals are often a result of an

encounter with a stressor, stress doesn’t always happen with cognitive appraisal. One

example is when a person gets involved in a sudden disaster, such as an earthquake, and

he doesn’t have more time to think about it, yet he still feels stressful about the situation.

(Lazarus and folkman 2012).

Cognitive relational theory emphasizes the fundamental role of cognitive appraisal in the

stress process. Six dimensions of primary and secondary appraisal were identified: threat,

challenge, centrality, and controllable-by-self, controllable-by-others, uncontrollable-by-

anyone. According to transactional models of stress, cognitive appraisal mediates the

stressfulness of events. (Lazarus & fiolkman 1984).

Cognitive relational theory views appraisal as the process of evaluating or

categorizing the personal significance of events. Primary appraisal involves an

assessment of the importance of a transaction for one’s well-being. Encounters are

appraisal as irrelevant being positive or stressful. Three stress appraisals are

distinguished: harm/loss, threats, and challenge. Harm/loss appraisals are associated with

events that have already occurred whereas threat and challenge appraisals are most

relevant to anticipated events. Primary appraisal can be categorized as being irrelevant,

benign-positive or stressful. In case a situation is not perceived to be damaging in any

way, the primary appraisal is seen as irrelevant, as the outcome of the situation does not

affect us in any way. A situation is perceived as benign-positive when the possible

outcome is positive and likely to help us in some way. The emotions related to this

appraisal include joy, exhilaration, love and peacefulness. A situation is said to be

stressful if the outcome is likely to be negative and in the form of challenge, threat or

harm/loss. The emotions associated with this appraisal include fear, anger and sadness.

Secondary appraisal is primarily concerned with the evaluation of what can be done about

the situation. It involves a complex assessment of one’s coping options. Perception of

situational control is assumed to play an important role in secondary appraisal. Such

appraisals reflect the individual’s evaluation of the efficacy of personal coping resources

in meeting situational demand. Whenwe are faced with an adverse situation, something

needs to be done to control it and avoid any subsequent repercussions. Secondary

appraisal follows primary appraisal of a situation. This necessarily includes evaluation of

the situation and a suitable reaction. This essentially addresses what can be done to cope

with a particular situation. The reaction to the situation is decided by carefully analyzing

what is at stake and what can be done to reduce negative

consequences.(Lazarus&fiolkman,1984)

Perceived social support

 There are several proposed models for the exchange of social support as well as

proposed models of social support interactions. The provider recipient model suggests a

flow of support from provider to recipient in which one provider meets all needs of the

recipient. The next model is the primary secondary provider model. In this model a

secondary providers assists the primary provider in meeting the needs of the recipient.

The final proposed model is the multiple provider model. This model consists of several

providers involved in meeting the needs of the recipient. Within the models of support

various social support interactions can occur. In an example of this particular situation,

the recipient can provide direct reciprocal actions toward the provider instantaneously or

the exchange can occur at a later time or because of past relationships with the provider,

there is no need to reciprocate (Hupcey, 1998). Another social support interaction

involves a chain reaction type of support where the initial provider provides to a recipient

and the recipient in turn providers to a second person in need (Hupcey, 1998) (Appendix

E). Support can also occur in ways that may not be positive or meet needs of recipient

and provider. For instance, the provider can provide more support than is reciprocated

while the reverse can also occur in which the recipient provides more support than is

received (Hupcey, 1998). The final two proposed models of social support interactions

occur in a way that neither the provider nor recipients needs are met. In the first of these

models the interaction between the provider and recipient is stressful even though

behaviors may be intended to be supportive (Hupcey, 1998). The last of these proposed

models in which neither the provider nor the recipients needs are met suggests the

support provided is negative, perceived as negative, and/or the outcome is negative

(Hupcey, 1998).
Support is to be perceived as a positive experience however it can also occur in a

negative way and thus the needs of all parties involved may or may not be realized or

met. Models can be used to understand social support in a more concrete way. Social

support is influenced by multiple variables and differs from person to person. To better

examine and understand social support as it pertains to individuals a need to measure its

presence is essential. Through increased exploration of the concepts of social support,

researchers are striving to provide information to further the understanding of social

support and its role in human beings (Hupcey, 1998).

Literature review

Batts & Leary (2010) found that People who are high in self‐compassion treat

themselves with kindness and concern when they experience negative events. The present

article examines the construct of self‐compassion from the standpoint of research on

coping in an effort to understand the ways in which people who are high in self‐

compassion cope with stressful events. Self‐compassionate people tend to rely heavily on

positive cognitive restructuring and less so on avoidance and escape but do not appear to

differ from less self‐compassionate people in the degree to which they cope through

problem‐solving or distraction. Existing evidence does not show clear differences in the

degree to which people who are low versus high in self‐compassion seek support as a

coping strategy, but more research is needed.

Susan, David and Conley (2013) conducted a research on social support and

happiness is reviewed. Research consistently finds that people who perceive their family

and friends as supportive report greater happiness than those who doubt their social

network’s supportiveness. The link between perceived support and happiness reflects
both the trait-like personality of support recipients, as well as social interaction. Within

social interaction, the effects of objectively supportive providers appear to be surprisingly

small. Instead, relational influences appear to be the single largest determinant. Relational

influences occur when a recipient sees a provider as more supportive than one would

expect given: (1) the recipient’s tendency to see providers as supportive and (2) the

provider’s objective supportiveness. Theoretical approaches for understanding these

findings are reviewed.

Neff & Stephanie (2006) conducted Two studies to examine the relation of self-

compassion to psychological health. Self-compassion entails being kind and understanding

toward oneself in instances of pain or failure rather than being harshly self-critical;

perceiving one’s experiences as part of the larger human experience rather than seeing

them as isolating; and holding painful thoughts and feelings in mindful awareness rather

than over-identifying with them. Study 1 found that self-compassion (unlike self-esteem)

helps buffer against anxiety when faced with an ego-threat in a laboratory setting. Self-

compassion was also linked to connect versus separate language use when writing about

weaknesses. Study 2 found that increases in self-compassion occurring over a one-month

interval were associated with increased psychological well-being, and that therapist

ratings of self-compassion were significantly correlated with self-reports of self-

compassion. Self-compassion is a potentially important, measurable quality that offers a

conceptual alternative to Western, more egocentric concepts of self-related processes and

feelings.

Borne et al (2019) conducted a study to evaluate the relationship between

perceived social support and cardiovascular outcomes among postmenopausal women

enrolled in the Women's Health Initiative Observational Study. We examined the

relationships between perceived social support and incident coronary heart disease

(CHD), total CVD, and all-cause mortality. Participants were Women's Health Initiative

Observational Study women, ages 50 to 79 years, enrolled between 1993 and 1998 and

followed for up to 10.8 years. Social support was ascertained at baseline via nine

questions measuring the following functional support components:

emotional/informational, tangible, positive social interaction, and affectionate

support.Among women with prior CVD (n = 17,351) and no prior CVD (n = 73,421),

unadjusted hazard ratios ranged from 0.83 to 0.93 per standard deviation increment of

social support. Adjustment for potential confounders, such as smoking and physical

activity levels, eliminated the statistical significance of the associations with CHD and

CVD. However, for all-cause mortality and among women free of baseline CVD, the

association was modest but remained statistically significant after this adjustment (hazard

ratio = 0.95 [95% confidence interval, 0.91-0.98]). No statistically significant association

was observed among women with a history of CVD.After controlling for potential

confounding variables, higher perceived social support is not associated with incident

CHD or CVD. However, among women free of CVD at baseline, perceived social

support is associated with a slightly lower risk of all-cause mortality.

Homan et al (2017) conducted a research on Self-compassion and physical health:

Exploring the roles of perceived stress and health-promoting behaviors. Growing

evidence indicates that self-compassion is associated with better physical health, but the

pathways that mediate this relationship are not well understood. This study tested a serial

mediation model that linked self-compassion, perceived stress, health behaviors, and a
comprehensive index of physical health. A sample of 176 individuals completed an

online survey posted on Amazon’s Mechanical Turk. Self-compassion had an indirect

effect on physical health via both mediators and through the sequential pathway,

suggesting that taking a kind, accepting and mindful stance toward one’s flaws and

failures may have benefits for reducing stress and promoting health behaviors.

Similarly Karatas and Bostanoglu (2017) conducted this study was performed to

assess perceived social support and psychosocial adjustment in patients with coronary

heart disease. Methods: Participants were 250 patients referred to the cardiology

outpatient clinic of a university hospital in Ankara, Turkey, between December 2013 and

March 2014. Data were collected using a participant information form, the

Multidimensional Scale of Perceived Social Support, and the Psychosocial Adjustment to

Illness Scale-Self-Report. Data were analysed using frequencies, percentages, mean

scores, and Pearson's correlation coefficient. Results: Patients' mean perceived social

support scores were relatively low and patients' mean scores for psychosocial adjustment

considered to be poor. Subgroups in the psychosocial adjustment and social support

scales were significantly associated. Conclusion: This study's results indicate that

patients' social support is linked to their psychosocial adjustment to coronary heart

disease. As psychosocial adjustment is inhibited in patients who lack sufficient social

support, sources of social support of patients should be identified and facilitated.

A study done by Adeeb at al (2017) to measure the relationship among quality of

life, perceived social support, and death anxiety in cardiovascular patients. This cross-

sectional study measured the quality of life, perceived social support and death anxiety

among cardiovascular patients through purposive sampling from two public hospitals
(Bahawal Victoria Hospital Bahawalpur and Shaikh Zayed Hospital Rahim Yar Khan) of

Southern-Punjab, Pakistan, conducted from March, 2016 to December, 2016. Only out-

patients on follow up checkup with no diagnosed comorbidity were included in the

study.Three questionnaires were used for data collection WHO-QOL, Perceived Social

Support and Death Anxiety Scale. A total of 132 cardiovascular patients were included in

the study. Quality of life and perceived social support negatively correlated with death

anxiety (p < .05). Better quality of Life was found to be more in males with M (SD)

=71.94 (12.33) as compared to females M (SD) = 65.23 (17.08) at t=4.50. Perceived

social support and death anxiety was found higher in females M (SD) = 65.27 (11.22) as

compared to males M (SD) = 55.39 (14.83) t=-7.71. Quality of life and perceived social

support were at lower level and death anxiety was higher among cardiovascular patients.

Gender played a significant role in quality of life, social support and death anxiety in

cardiovascular patients. Keywords: Quality of life, Perceived social support, Death

anxiety, cardiovascular patients, Pakistan.

Other study done by Khan et al (2011) to evaluate the prevalence and clustering

pattern of cardiovascular disease (CVD) related lifestyle factors and their association

with CVD among patients with type 2 diabetes. We also examined the association of

these factors with various socio-demographic characteristics. A total of 1000 patients

with type 2 diabetes were interviewed in a cross-sectional, multi-center study in out-

patient clinics in Karachi, Pakistan. In this study 30.3% study participants had CVD.

Majority of the patients were physically inactive and had adverse psychosocial factors.

Forty percent of the study participants were exposed to passive smoking while 12.7%

were current smokers. Only 8.8% of study subjects had none of the studied lifestyle
factor, 27.5% had one, while 63.7% had two or three factors. CVDs were independently

associated with physical inactivity, adverse psychosocial factors, passive smoking and

clustering of two or three lifestyle factors. Physical inactivity was more prevalent among

females and patients with no/less education. Proportion of adverse psychosocial factors

were higher among females, elders and patients with no/less education. Clustering of

these lifestyle factors was significantly higher among females, elderly and no/less

educated patients. These results suggest the need of comprehensive and integrated

interventions to reduce the prevalence of lifestyle factors.

WHO (2011) reports that cardiovascular diseases (CVDs), especially coronary

heart diseases (CHD), are the number one cause of premature death worldwide. About

17.3 million people died in 2008, representing 30 % of all global deaths, and almost 23.6

million people are expected to die from CVD, mainly from heart disease and stroke, by

2030. Also the estimated disability-adjusted life years (DALYs) are expected to rise from

a loss of 85 million DALYs in 1990 to a loss of about 150 million DALYs globally in

2020, classifying CVDs as the leading cause of productivity loss worldwide.

Didem et al (2012) found that the Levels of Perceived Social Support on the

Responsible Persons of the Hospital Units.The purpose of this study was to determine

social support levels perceived by responsible persons working in units at a university

hospital in Konya province and to propose possible suggestions to improve social

supports of them. Eighty five responsible persons of the hospital units enrolled in this

research. Data were collected using the Multidimensional Scale of Perceived Social

Support (MSPSS). Data were analysed statistically by an Independent Samples t-Test,

One way ANOVA and the Mann–Whitney U test. In correlation analysis, Pearson's
Correlation Coefficient was used. A p value of <0.05 was considered as statistically

significant. In conclusion, statistically significant difference was found between the

Perceived social support levels of responsible persons of the hospital units and the

personal variables.

Broody (1988) found that among people ever 65 heart disease accounts for half of

all deaths. While another study done by wister& Gee (1994) has indicated that by

analyzing data drawn from 1986 national motility follow back survey in America it has

been found that among 1656 men and 1299 women half of CVD male deaths occurred at

age under 65 years whereas deaths among woman were concentrated at older age so there

is variation of mortality risk from heart disease across the life course.

Khan (2008) investigated stress appraisal and psychological well-being of

medical professionals working in emergency unit in Pakistan.It was hypothesized that

there is a relationship between stress appraisal and mental health of medical professionals

dealing with emergency fatalities. Sample consist of 51 medical professionals were

selected from Ganga ram hospital Lahore, Jinnah hospital Lahore and services. A

questionnaire (GHQ 28), Stress appraisal measurement (SAM).Data was analyzed using

MAOVA, t-test and correlation analysis. Result showed that a number of medical

professionals show negative stress appraisal.

Akin et al (2011) conducted a study to examine the relationships between self-

compassion and social support. Participants were 273 university students. In this study,

the Self compassion Scale and the Multidimensional Scale for Social Support (MSPSS)

were used. The relationships between self-compassion and social support were examined
using correlation analysis. Results indicated that there are significant relationships

between these variables. Self-kindness, common humanity, and mindfulness, positive

dimensions of self-compassion were found correlated positively with social support.

Positive dimensions of self-compassion represent that, in the event of negative life-

experiences, individual’s approach toward him/herself is warm, gentle, and kind.

Likewise, Rafique (2004) conducted a research on stress, anger, hostility and

locus of control as risk factor for acute myocardial infarction and also to find whether

these psychological factors differ in cases with CVD and their age and gender matched

control. Case control research design was used. The hypothesis of the study was that

there was significant relationship between psychological factor and risk of myocardial

infarction. The sample included for both male and female within age range of 45 to 65

years. Control from the community was matched for age and gender up to 5 years.

Structured tools included the perceived stress scale, anger was measured by anger

expression scale and hostility was measured by personality deviance scale. Result show

that there was significant association of locus of control and hostility with acute

myocardial infarction. Anger did not turn out to be a significant risk factor of AMI.

Rationale of the Study

The main purpose of this study is to examine the relationships of self-compassion,

stress appraisal and perceived social support in cardiovascular patients. Empirical

investigations with Self-compassion, stress appraisals emotions experienced and their

possible combined effect upon health will be beneficial for the patients and general

public. The present study will give important findings in the field of health psychology.
Furthermore, a study from Pakistan reports men to have a greater risk of

developing CVD than women. It is believed that, the results of the study will show that

perceived social support is significantly risk factor of CVD. This research, will try to

combine the appraisal theory of stress self-compassion and perceived social support

experience, through the use of stress appraisals, self-compassion and perceived social

support at the same time. Since in these areas, appraisals have central role, it is believed

that, the results will show a link between self-compassion, stress appraisal and perceived

social support.

Secondly, to the knowledge of researcher of the present study, the self-

compassion, social support from family, friends and others, stress appraisal of situation

and its relationship with CVD have been a small number of studied in Pakistani sample

yet. A clear understanding would be helpful for making the most suitable intervention

plan for the patients. So it is necessary to conduct such a research that will investigate

that how stress appraisals have impact on self-compassion and CVD. And the present

study will also provide help in designing intervention plan which would be more

indigenous and fulfill the local needs.

Aims of the study

The aim of the study is to investigate the relationship between self-compassion stress

appraisals and perceived social support in cardiovascular patient. This research will give

the answer of the following question.

 Whether there is relationship between self-compassion, stress appraisal and

perceived social support.

  Whether stress is prevalent in patients with CVD.

 Whether patients with CVD are using negative stress appraisal strategies

 Whether high perceived social support associated with low stress appraisal in

patient with CVD.

 Whether self-compassion reduce stress in patient with cardiovascular disease

 Whether self-kindness, common humanity, and mindfulness, positive dimensions

of self-compassion were positively correlate with perceived social support.

Hypothesis

 Self-compassion and negative stress appraisal are prevalent in patients with

cardiovascular disease.

 There is likely to be a relationship between self-compassion, stress appraisal and

perceived social support in cardiovascular patients.

 Self-kindness, common humanity, and mindfulness, positive dimensions of self-

compassion were positively correlate with perceived social support.

 High perceived social support associated with low stress appraisal in patient with

CVD.
 Method

The part of the research include on research design employed, the area, the

process of obtaining the research sample, the instruments used, the data collection

procedure, and the statistical treatment that was utilized as well as analysis of data.

Research design

The research will be conducted through quantitative cross sectional research

design, participants will be selected through purposive sampling.

Participants

A purposive sample was selected for data collection. The research participants

comprised of 200 patients suffering from cardiovascular disease with mean age was 54.93

and SD was 10.32. The sample was drawn from outdoor units of different hospitals of

Lahore that were Punjab Institute of Cardiology, Mayo Hospital, Sir Ganga Ram Hospital,

Services Hospital and Jinnah Hospital and Rahim Yar Khan hospital.

Inclusion Criteria

 Sample size will be N=150 will be included.

 All type of heart disease will be included.(Heart failure, Congenital heart disease,
Coronary artery disease, Myocardial infarction,etc)
 Individual of age less than 60 will be included.
 Both Males and Females will be included.

Exclusion Criteria

 More than 60 will be excluded

 Non Pakistani will be excluded
 Individuals with physical and mental impairments will be excluded.
Measures

The research instrument used in this study is a questionnaire that is composed of three
parts.

Multidimensional scale of perceived social support

(Zimet,G.D,Dahlem.N.W,Zimet,S.G.&Farley,G.K.1988).

Perceived social support was measured using Multidimensional Scale of Perceived Social

Support (MSPSS) that 12 items assessing 3 sources of support: Family, friends, and significant

other. Items are rated on a 5-point Likert-scale. The original version of the MSPSS had adequate

psychometric properties.Reliability of the Iranian form of the MSPSS was reported using

Cronbach's alpha coefficient for a total scale, and subscales from between 0.84 and 0.91 and test-

retest consistency was from between 0.72 and 0.85.

Part III is Self-Compassion scale will be used. (Batool.A & Jabeen. A, 2017).It has 27
items which divided into further 3 subscales.

F1.Self-kindness

F2. Mindfulness

F3. Spirituality

Stress appraisal measure (SAM, Edward j. peacock &Paul T.P Wong, 1989).

Stress appraisal measures developed by Peacock and Wong (1990) was used in the current

study to investigate the relationship between stress appraisal, perceived social support and self-

compassion in patient with cardiovascular disease. The Stress Appraisal Measure (SAM) was

developed to assess the dimension of primary (threat, challenge and centrality) for a specific
anticipated stressor. The stress appraisal measures (SAM) consist of 28 items measure the

aggregated life event and was originally designed to measure cognitive appraisal of anticipatory

stressor. Each item has 5 point scale. Six dimension of primary and secondary appraisal were

defined: threat, challenge, centrality, and controllable-by-self, controllable-by-other,

uncontrollable-by-anyone.the SAM include 7 subscales which assess both primary and secondary

appraisal as well as overall stressfulness. The scale was named as stress (comprising 4 items 1, 4,

10, 24), threat (comprising 4 items 11,19,20,28) challenge (comprising 4 items 5,6,7,9) centrality

(comprising 4 items 8,26,27,13) control by self (comprising 4 items 12,14,22,25) control by other

(comprising 4 items 3,15,17,23) and uncontrollable ( comprising 4 items 2,16,18,21). Urdu

translated version by Ali and Majeed (2013) was used for present research. Cronbach alpha of

Urdu version was (.75).

Procedure

Permission for data collection was taken from the Head of cardiology Departments of four teaching

hospitals of Lahore. Then data collection was initiated. Written informed consent was taken from

each patient. Brief description of nature and purpose of the present study was provided to the

patients and they were also informed that the collected information were remain confidential and

was used only for academic and research purposes. All measures was administered individually to

each patient.

 Data will be collected through using scale directly administered in interview.

 The Stress Appraisal scale will be used.
 Pre-testing of the scale will be planned to satisfy for the selection of the participant.

Analysis
Descriptive analysis was used for demographic questionnaire and to determine the manifestation

of stress appraisal, perceived social support and self-compassion in the present patient sample.

Statistical Package for Social Sciences version 20 (SPSS) will be used for all the analysis. Results

will be discussed in the light of previous literature.

 Frequencies or Percentages
 Pearson Correlation
 Regression analysis

Ethical Considerations

Before going into field and during data collection, all ethical standards of APA were

followed.

 First of all permission for using the tools of data collection were taken from the related

authors and translators.

 Permission for data collection was taken from related hospitals.

 Written informed consent was taken from each patient.

 Brief description of nature and purpose of the present study was provided to the patients

and they were also be informed that the collected information was remain confidential

and was used only for academic and research purposes.

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