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
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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
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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
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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
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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
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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.
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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
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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
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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)