Coping Well:Implementing the Principles

of Stress Resilience

N. Lee Smith, MD

Adjunct Associate Professor of Medicine

University of Utah

Director, Stress Medicine

Lifetree Clinical Research and Pain Clinic

Salt Lake City, Utah

Our purposes today-To identify:

• Four core principles of stress resilience– And what these have do do with mental and

physical well-being (health)

• Some specific techniques for applying these principles

What does mental stress have to do with medical illness?

INTERHEART Study: Significance of Coronary Risk Factors

(15123 MI Cases; 14820 controls; 52 countries)

0

5

10

15

20

25

30

35

40

Attributable Risk %

Smoking Depression Obesity Hypertension

Yusef S; also Rosengren A. Lancet 2004;364:937-52 and 364:953-62

Outcome Effects of Treating MI Depression with Sertraline

(SADHART Trial: n = 369)

-61

-30

-15

-30

-2

-70

-60

-50

-40

-30

-20

-10

0

Percent reduction from placebo

Mortality 2nd MI Angina CHF Stroke

Glassman AH, (SADHART) JAMA 2002;288:701-709

Many Very Common Medical Problems Involve Central Nervous

System Hypersensitivity:

• Irritable bowel syndrome

• Atypical chest pain

• Migraine and Tension Headaches

• Fibromyalgia & Myofascial Pain Syndromes

• Anxiety and depression disorders

Inhibitory track serotonin,

norepinephrine, dopamine

Interventions improving chronic pain and hypersensitivity

usually require improvements

in the central function of:• Serotonin• Norepinephrine• Dopamine• Endorphins• GABA • Deep sleep• Reduced sympathetic tone

What are the effects of cognitive-behavioral interventions on

these protective mechanisms?

• Sense of internal control Serotonin• Love, cooperation Dopamine,Endorphins

• Exercise, pos. excitement NE and DA“Turned on”-purpose Endorphins

• Deep Relaxation, Sleep, Serotonin & mindfulness sympathetic tone meditation GABA (?)

Coping Styles and Health 45 year Harvard Study (Vaillant, et al)

Coping Styles

• Denial

• Blaming and victimizing – denying personal responsibility

• Repression, intellectualizing

• Mature, adaptive – Internal control, connectedness, humor

Coping Styles and Health: Outcomes

• Styles 20 years later tended to be the same (with no intervention)

• Middle age (53): % chronic illness or death:

– Mature adaptive style: 3%– The others combined: 37%

• Additional analysis: – optimism (hope) and altruism (meaning) were

important for outcome

Vaillant G, et al; also Seligman M and Peterson C Learned Optimism 1990s

Connectedness and Health

• Roseto, PA study– 1/6 the national average of MIs and CV death– Average exercise, smoking, obesity, hypertension

• Multifactorial analysis —The keys: – Strong sense of community: unconditional support —

Social and family ties —Elderly honored

• When these deteriorated: MI rates = average —Stewart Wolf, Temple Univ.

• (Compare 10000 Israeli men with CAD risk)

Stress Hardiness The Three C’s”

• Control– Internal source of power to choose responses– Refusal to be a victim

• Challenge– Sees change as opportunity– Enjoys growth– Tightly linked to hope

• Commitment– Curiosity and deep involvement– Finding meaning and purpose

Suzanne Kobasa and Salvatore Maddi

Four Principles of Stress Resilience Clearly Related toImproved Health Outcomes

• An internal locus of control

• A sense of connectedness

• A sense of purpose and meaning

• HopeKarren K, Smith NL, Hafen B, Frandsen K: Mind-Body Health… (3rd edition) 2005 (San Francisco, Benjamin Cummmings Publ)

Dealing with Times of Chaos

What gives a sense of control?

–Hope

–Loving support

A Sense of Connectedness:

• To one’s deepest self

• To other people• To the larger sources

of one’s power

Is the way I’m handling this situation:

Connecting us more deeply?

or

Disconnecting us?

Does stress reduction work?

If so, what are the keys to success?

Stress and Heart Disease

What are the

cardiotoxic components of

Type A behavior?

• Cynicism

• Hostility and anger

• Relationship problems

Anger/Hostility and Carotid DiseaseMiddle aged women- over 3 years

0

1

2

3

4

5

6

7

Percent progression on IMT

Lowest Highest

Trait Anger QuartilesRaikkonen K Psychosom Med 2004;66:903-908

Stress Reduction ReducesCarotid Atherosclerosis

• A meditation-based stress reduction program reduced carotid intimal thickening– compared with health education

in hypertensive African Americans– carotid intimal thickening = predictive of coronary disease

• The meditation group: decrease in carotid intima-media thickness of -0.098 mm

• Control group: increased of 0.054 mm Castillo-Richmond A. Stroke 2000;31(3):568-73

Comparing Stress Reductionand Exercise in CAD Patients

05

1015202530

Usual Care Exercise StressReduction

Intervention

Coro

nary

Eve

nts

(%

)

Blumenthal JA, et al Arch Int Med 1997;157:2213-2223

Stress Resilience can be learned

It takes practicing experientially

to do so

Creating Stress Resilience

• Is stress good or bad?

• What makes the difference?

• An important key:– How much sense of control do you feel in

dealing with it?

Animal Studies:Cancer Cell Rejection

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10

20

30

40

50

60

70

In Control Victims No Stress

Percent immune rejection of the cancer cells

-Martin Seligman, U. of Penn

The Paradox of Control

• The more you try to take control of the world out there,

the more out of control it seems

• The more you let go trying to control the external world (and stop blaming),

and instead, respond in a way that you would deeply admire as wise,

the more personal control you feel

Hindus:“You have given your power

(spirit) away.

Call your power back”

How to Create a Sense of Personal Control and Hope

• Conscious awareness“I can respond as I choose.”

• Relaxation skills: To let go and get focused

• Clarify deep values“How do I want to be?”

• Visualizing (experiencing) responding the new way

Creating Hope

• Visualizing (experiencing) one’s self handling the situation well,

in accord with wisdom and deepest values

A Sense of Personal Controlhas much to do with identifying

one’s deepest, wise values,

then creating ways to respond through them

Creating Connectedness:We have been highly conditioned to

see (and respond to) the world through eyes of fear and judging

Suppose instead, we saw through eyes of love

A truly great relationship

lift each other

safe, acceptance honest, authentic

kind

create hope

humor

honors needs

win-win

caring

Example:Overwhelmed:

“Have too much to do”

A Philosophical Checkup:Discovering the core, wise mind:

What is life really about, anyway?– Productivity in numbers generated?– Proving oneself worthy, or right?

or– Learning to love?– Becoming wise and resilient? – Making a difference?– Joy?

} Spiritual well-being

A Philosophical Checkup:Discovering the core, wise mind:

• Why did I get into my work in the first place?– external rewards? (income, status) – or intrinsic meaning?

• What is the real purpose of my work?

Journaling for Meaning

Review your day backwards, asking:• “What surprised me today?”• “What moved or touched me today?”• “What inspired me today?”

Look for the stories.

After some time, the gap to seeing the answers will narrow, until they are seen as they happen

Remen RN. Int Med News 1/15/02, p.5

What is Health? (from: World Health Organization)

Total well-being:

Physical

Mental

Social

Spiritual

control (personal)

connectedness

meaning

hope

Summary(1)

• Depression, anxiety and associated traits of cynicism, hostility and anger are highly associated with cardiovascular disease and with many very common pain problems

• Several mechanisms of this are known

• Effectively teaching stress resilience (and treating dpression/anxiety) improves health outcomes

Summary(2)

• needs to be experiential

• needs to be directed at four core (spiritual) principles:– An internal locus of control (remember the paradox)– Enhancing connectedness (oneness)– Finding purpose and meaning (in all experience)– Creating hope

To be medically effective, stress resilience training: