Better ways to handle stress

Stress:Better Ways to Handle It

November 12, 2013

Stress:Better Ways to Handle It

Presented by:Connie Marsh, MD

Associate Medical DirectorSenior Behavioral Health, Via Christi Behavioral Health

Clinical Associate ProfessorDepartment of Psychiatry and Behavioral SciencesUniversity of Kansas School of Medicine-Wichita

Stress

Reality is the leading cause of stress among those in touch with it.

--Lily Tomlin

4

Stress

On a scale of 1-10 (1=no stress, 10=max stress), what is your stress level for the past one week?

How do you recognize when you are stressed?

How do you most often manage stress?

Stress in America

Annual nationwide survey by American Psychological Association, began 2007

Stress levels remain high and exceed what Americans believe to be healthy

Stress in America

What are the big three? Family Economy Health Work Money Relationships

Stress in America

Causes:

Money

Work

Economy

Stress in America

Americans still managing stress in unhealthy ways

Overeating, unhealthy foods Alcohol/drugs Sedentary behaviors

music napping reading

True or False

1. Men are more concerned about stress than women.

2. Women use more coping strategies for stress than men.

3. The ability to manage stress does improve with age.

Stress in America

Women report higher stress levels

Women use many strategies

Men less concerned about managing stress and say they are doing enough

More men than women use no strategies at all

12

Stress in America

Men less likely to view stress as impacting health

Link between stress and physical health harder for men to recognize

Men more likely to be diagnosed with types of illnesses exacerbated by stress

High BP Type 2 diabetes Heart disease

Stress in America

Generations: Gen X>Millennials>Boomers>Matures

Ability to manage stress appears to improve with age

Millennials More likely to engage in sedentary activities to

manage stress More likely to engage in unhealthy behaviors

Stress

“Non-specific response of the body to any demand for change.”

“Condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize.”

--Hans Selye 1936

Stress disrupts equilibrium.

Stress

Increased stress results in increased productivity up to a point.

Stress

Same stressor differs across individuals Sense of little or no control always stressful

Expectations Many individuals create their own stress

because of faulty perceptions Could learn to correct**

To achieve great things, two things are needed:

a plan and not quite enough time.

--Leonard Bernstein

Stress

Much is known about acute stress

Less is known about chronic stress

Stress

If temporary, physical effects usually temporary

Example

Test anxiety among college students increased severity of acne

Condition diminished after exams over

Stress

Body doesn't distinguish between physical and psychological threats.

If a lot of stress, chronically, body's stress response is “on” most of the time.

Stress

Long term exposure to stress disrupts nearly every system in the body.

Eventually, long term stress rewires the brain, leaving person more vulnerable to anxiety, depression, cognitive problems.

Nervous System

Sympathetic nervous system signals adrenals to release norepinephrine and cortisol

Increased heart rate Increased BP Increase blood glucose levels

Stress

Endocrine Response to Stress

Cortisol linked to increased fat accumulation around organs (visceral fat in abdomen)

More dangerous

Fat cells secrete hormones that disrupt functioning of liver, pancreas, brain Insulin resistance

27

Endocrine Response to Stress

InflammationChronic exposure to stress hormones

Weakens immune system Change structure of chromosomes

Chronic Stress: The Bad Stuff

Immune SystemChronic Stress=Decreased Immunity

Depressed and stressed people have lower response to vaccines

Increased morbidity and mortality in infectious diseases (HIV), autoimmune disorders, cancer

Higher incidence of certain infectious diseases: common cold, Epstein-Barr virus

Delayed wound healing Greater severity of disease

Immune SystemChronic Stress=Inflammatory Activity

Cytokines=Inflammation Atherosclerosis

Damage to coronary arteries• Predicts major cardiac events in men

Worsens course of many chronic diseases Diabetes and heart disease

Associated with depressed mood, anxiety, decreased memory

32

Heart

Chronic mental stress Contributes to development and progression of heart

disease

Depression increases the risk Development/progression of coronary artery disease

for 10-20 years Heart attack/mortality increased risk is 1.5 to 2.0 3-6 fold increased risk of death 6-18 months after

heart attack.

Heart***

Psychosocial treatment, 3000 patients Stress management and health education

Reduced emotional distress Reduced BP, heart rate, cholesterol

If no treatment, at 2 year follow up 70% greater mortality 84% higher cardiac recurrent event rate

35

Brain

Depression is risk factor for stroke

Men with work-related stress build up plaque in carotid arteries (36% vs. 21%)

Sustained anxiety associated with increased wall of thickness of carotids.

36

Brain: The Really Bad News

Chronic stress overloads the brain with powerful hormones for only short term duty

Chronic overproduction damages and kills brain cells

Brain: Hippocampus

Chronic stress damages the hippocampus

The part of brain central to learning and memory

Probably due to glucocorticoids (secreted from adrenals during stress)

Brain: Hippocampus

Excess cortisol Difficult to think or retrieve memories Befuddled or confused in severe crisis, mind

goes blank Glucose diverted from brain to muscle

Excess stress (excess exposure to cortisol) accelerates the degeneration of hippocampus

Hippocampus is part of feedback loop to STOP excess cortisol, so if damaged, can't shut it off

Brain: Hippocampus

Atrophy (decreased volume) PTSD Severe depression (reversible with meds) Cushing's disease Alzheimer's dementia

Rate of dementia 65% higher in women with midlife stress

**Some effects reversible if stress reduced

Brain

Stress can cause lasting changes

Stress response affects

Hippocampus—smaller volume (memory and learning)

Amygdala—increased function (regulates fear and emotions)

Prefrontal cortex—decreased function

Brain

Chronic stress Amygdala larger (more anxiety and fear) Hippocampus smaller (less effective memory)

Together, may then INCREASE anxiety and stress

Can't connect feeling of fear to memory of event

Left with lots of generalized anxiety

Brain

Adverse life events cause stress and shrinking in prefrontal cortex

Self control/impulse control Emotions Glucose/insulin levels Cognition (attention, concentration, executive

functioning)

Cumulative effect (not individual trauma)

Brain

Chronic stress causes dysfunction and/or shrinking of areas associated with

Reasoning, decision making, emotions, self control, forming and retrieving memories

CHRONIC STRESS CAUSES BRAIN CHANGES THAT IMPAIR OUR ABILITY TO COPE WITH FURTHER STRESS

Brain

Should take reducing and managing our stress level very seriously

Chronic stress alters brain function in the present, and seriously alters function for years to come.

Recognition

Stress can creep up, starts to feel normal

Don't notice effects even as symptoms persist

The more body's stress system activated, the easier it is to trip, and the harder it is to shut off.

Recognition:The Body's Warning System

Physical Aches, pains, GI upset, dizziness, chest pain,

rapid heart beat, frequent infections

Emotional Moody, irritable, short temper, anxious, feeling

overwhelmed, lonely, isolated

50

Recognition:The Body's Warning System

Cognition Poor memory, concentration, and judgment,

pessimism, anxious thoughts, constant worry

Behavior Changes in eating or sleeping, neglecting

responsibilities, isolating

Stress: Better Ways to Handle It

Management

Stress management is key, NOT stress elimination

Challenge

To attempt to keep sympathetic nervous system from acting

Use techniques to active/use “relaxing” part of nervous system

Cognitive Behavioral Therapies

Correcting cognitive distortions Relaxation response Mindfulness Time Management Stress Management Meditation

Cognitive Behavioral Therapies

Easily accessible CBT manuals Smart phone apps Internet sites

Relaxation

Relaxation response Natural protective mechanism against

overstress which allows us to turn off harmful bodily effects

Leads to quieting of overactive sympathetic nervous system

Relaxation

Herbert Benson, Massachusetts General Hospital

The Relaxation Response

20 minutes of relaxation/day for 8 weeks

Relaxation: yoga, prayer, meditation, deep breathing, tai chi, progressive muscle relaxation, biofeedback, guided imagery

Resulted in changes at cellular level: turned off genes that are activated by stress

The greatest weapon against stress is our ability to choose one thought over another.

--William James

59

Cognitive Behavioral Therapies

Stress response determined by Cognitive appraisal of situation

Significance/meaning of the event• Harmful=anxiety, depression• Challenging=positive outcome

Coping efforts because of the cognitive appraisal

Repertoire of coping skills Expectation that skills will be effective

Cognitive Behavioral Therapies

Cognitive Restructuring Become aware of and change maladaptive

thoughts, beliefs, expectations. Educate: excessive or prolonged emotional

reactions often the result of distorted cognitions Monitor and analyze dysfunctional thoughts Challenge and change the cognitive distortions

Cognitive Distortions

My achievements define my self worth. My professional identity is my personal

identity. I don’t need help. I don’t need support. It’s faster to do it myself than to show

someone. I should rarely have to say NO. Commitments to work/family are more

valuable than time spent on self care.

Cognitive Distortions

Everyone feels guilty if they “play” or rest. It is OK to get almost all of my needs met

by helping others. Others needs are more important than my

own. If I’m asked to help, I should. If I don’t do it, it won’t get done.

Cognitive Behavioral Therapies

CBT= improved several psychiatric conditions including anxiety, depression, PTSD

Time management=better physical health Mindfulness=improved attention on MRI Stress management=reduced inflammatory

response

Cognitive Behavioral Therapies

Meditation=improved amygdala and hippocampus structure

Relaxation Training=dampens acute “stress reaction”

CBT, Tai Chi=improved immunity to vaccines

ExerciseExerciseExerciseExerciseExerciseExerciseExercise

Ameliorates age related neuron loss Protects brain from insults Stimulates neuron growth, especially in

hippocampus (remember-memory) Fortifies the connections between neurons Enhances mood and improves anxiety Gives body change to practice dealing with

“stress”, forces physiological systems to communicate more efficiently.

Exercise

Older walkers can increase hippocampal size by walking (size compared after one yr of walking)

Fitness training increased cognitive performance in study of people age 55-80

Exercise for your Brain

30 minutes for 5 days/week Moderate cardiovascular workout

Fast walk/jog Swimming Dancing Biking Tennis Rowing

Add a companion for motivation, but ultimately it is up to you.

What is your excuse?

Exercise

Exercise does more to bolster thinking than thinking.

Many people skip exercise at the time it is needed most.

Electronic World

Pressures of today’s connected world Email Cell phones Constant internet

Increasingly difficult to switch off and concentrate on personal priorities.

Management of Electronic World

TAKE A NEWS/ELECTRONIC WORLD

BREAK

Stress Reduction

Exercise Meditation Guided imagery Nap Massage Yoga

Tai chi Music Biofeedback Time out: short walk Reading

Stress Management

Remove or alter the stressor

Change the perception of the stress

Reduce the physiologic sequelae of stress

Use alternative coping strategies

Management Summary

Understand how you experience stress

Learn your stress signals

Look at how you deal with stress Keep what is working Change unhealthy coping behavior

Tap into support of healthy family/friends

Analyze your schedule

Management Summary

Improve general self care Sleep Healthy eating Exercise

Make time for an activity you enjoy

Practice gratitude

Laugh

Make one health-related commitment

A life of being, having, and doing enough

--Wayne Muller 2010

Management NOW

Relax NOW Visualization Deep breathing Repeat word or phrase Change thought

Management NOW Cognitions

List of thoughts Don’t take it personally This too shall pass My attitude is in my control There is no right answer No one is going to die (hopefully)