Stress:
Better Ways to Handle It
November 12, 2013
Stress:
Better Ways to Handle It
Presented by:

Connie Marsh, MD
Associate Medical Director
Senior Behavioral Health, Via ...
Stress

Reality is the leading cause of stress
among those in touch with it.
--Lily Tomlin
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 recog...
Stress in America
Annual nationwide survey by American
Psychological Association, began 2007

Stress levels remain high an...
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
 Sedent...
True or False
1. Men are more concerned about stress
than women.
2. Women use more coping strategies for
stress than men.
...
Stress in America
Women report higher stress levels
Women use many strategies
Men less concerned about managing stress
and...
Stress in America
Men less likely to view stress as impacting
health
Link between stress and physical health
harder for me...
Stress in America
Generations:
 Gen X>Millennials>Boomers>Matures


Ability to manage stress appears to improve with
age...
Stress
“Non-specific response of the body to any demand
for change.”

“Condition or feeling experienced when a person
perc...
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 indiv...
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 seve...
Stress
Body doesn't distinguish between physical
and psychological threats.
If a lot of stress, chronically, body's stress...
Stress
Long term exposure to stress disrupts nearly
every system in the body.

Eventually, long term stress rewires the
br...
Nervous System
Sympathetic nervous system signals
adrenals to release norepinephrine and
cortisol
 Increased heart rate
...
Stress
Endocrine Response to Stress
Cortisol linked to increased fat accumulation
around organs (visceral fat in abdomen)
 More ...
Endocrine Response to Stress
Inflammation
Chronic exposure to stress hormones
 Weakens immune system
 Change structure o...
Chronic Stress: The Bad Stuff
Immune System
Chronic Stress=Decreased Immunity
 Depressed and stressed people have lower
response to vaccines
 Increase...
Immune System
Chronic Stress=Inflammatory Activity
Cytokines=Inflammation
 Atherosclerosis


Damage to coronary arteries...
Heart
Chronic mental stress
 Contributes to development and progression of heart
disease

Depression increases the risk
...
Heart***
Psychosocial treatment, 3000 patients
 Stress management and health education
 Reduced

emotional distress
 Re...
Brain
Depression is risk factor for stroke
Men with work-related stress build up plaque
in carotid arteries (36% vs. 21%)
...
Brain: The Really Bad News
Chronic stress overloads the brain with
powerful hormones for only short term duty
Chronic over...
Brain: Hippocampus
Chronic stress damages the hippocampus
 The part of brain central to learning and
memory
 Probably du...
Brain: Hippocampus
Excess cortisol
 Difficult to think or retrieve memories
 Befuddled or confused in severe crisis, min...
Brain: Hippocampus
Atrophy (decreased volume)
 PTSD
 Severe depression (reversible with meds)
 Cushing's disease
 Alzh...
Brain
Stress can cause lasting changes
Stress response affects
 Hippocampus—smaller volume (memory and
learning)
 Amygda...
Brain
Chronic stress
 Amygdala larger (more anxiety and fear)
 Hippocampus smaller (less effective memory)
Together, may...
Brain
Adverse life events cause stress and
shrinking in prefrontal cortex
 Self control/impulse control
 Emotions
 Gluc...
Brain
Chronic stress causes dysfunction and/or
shrinking of areas associated with
 Reasoning, decision making, emotions, ...
Brain
 Should take reducing and managing our
stress level very seriously

 Chronic stress alters brain function in
the p...
Recognition
Stress can creep up, starts to feel normal
Don't notice effects even as symptoms
persist
The more body's stres...
Recognition:
The Body's Warning System
Physical
 Aches, pains, GI upset, dizziness, chest pain,
rapid heart beat, frequen...
Recognition:
The Body's Warning System
Cognition
 Poor memory, concentration, and judgment,
pessimism, anxious thoughts, ...
Stress: Better Ways to Handle It
Management
Stress management is key, NOT stress
elimination

Challenge
 To attempt to keep sympathetic nervous
system fro...
Cognitive Behavioral Therapies
 Correcting cognitive distortions
 Relaxation response
 Mindfulness
 Time Management
 ...
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
bodil...
Relaxation
Herbert Benson, Massachusetts General Hospital

The Relaxation Response
 20 minutes of relaxation/day for 8 we...
The greatest weapon against stress is our
ability to choose one thought over another.
--William James
Cognitive Behavioral Therapies
Stress response determined by
 Cognitive appraisal of situation


Significance/meaning of...
Cognitive Behavioral Therapies
Cognitive Restructuring
 Become aware of and change maladaptive
thoughts, beliefs, expecta...
Cognitive Distortions
 My achievements define my self worth.
 My professional identity is my personal






identit...
Cognitive Distortions
 Everyone feels guilty if they “play” or rest.
 It is OK to get almost all of my needs met
by help...
Cognitive Behavioral Therapies
 CBT= improved several psychiatric
conditions including anxiety, depression,
PTSD
 Time m...
Cognitive Behavioral Therapies
 Meditation=improved amygdala and
hippocampus structure
 Relaxation Training=dampens acut...
ExerciseExerciseExerciseExercise
ExerciseExerciseExercise
 Ameliorates age related neuron loss
 Protects brain from insu...
Exercise
 Older walkers can increase
hippocampal size by walking (size
compared after one yr of walking)

 Fitness train...
Exercise for your Brain
 30 minutes for 5 days/week
 Moderate cardiovascular workout







Fast walk/jog
Swimming...
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 ...
Management of Electronic World

TAKE A NEWS/ELECTRONIC WORLD
BREAK
Stress Reduction







Exercise
Meditation
Guided imagery
Nap
Massage
Yoga







Tai chi
Music
Biofeedback
Ti...
Stress Management
Remove or alter the stressor
Change the perception of the stress
Reduce the physiologic sequelae of stre...
Management Summary
Understand how you experience stress
Learn your stress signals
Look at how you deal with stress
 Keep ...
Management Summary
Improve general self care
 Sleep
 Healthy eating
 Exercise
Make time for an activity you enjoy
Pract...
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...
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
Better ways to handle stress
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Better ways to handle stress

  1. 1. Stress: Better Ways to Handle It November 12, 2013
  2. 2. Stress: Better Ways to Handle It Presented by: Connie Marsh, MD Associate Medical Director Senior Behavioral Health, Via Christi Behavioral Health Clinical Associate Professor Department of Psychiatry and Behavioral Sciences University of Kansas School of Medicine-Wichita
  3. 3. Stress Reality is the leading cause of stress among those in touch with it. --Lily Tomlin
  4. 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? 4
  5. 5. Stress in America Annual nationwide survey by American Psychological Association, began 2007 Stress levels remain high and exceed what Americans believe to be healthy
  6. 6. Stress in America What are the big three?  Family  Economy  Health  Work  Money  Relationships
  7. 7. Stress in America Causes:  Money  Work  Economy
  8. 8. Stress in America Americans still managing stress in unhealthy ways  Overeating, unhealthy foods  Alcohol/drugs  Sedentary behaviors    music napping reading
  9. 9. 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.
  10. 10. 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
  11. 11. 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 12
  12. 12. 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
  13. 13. 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.
  14. 14. Stress Increased stress results in increased productivity up to a point.
  15. 15. 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**
  16. 16. To achieve great things, two things are needed:  a plan and not quite enough time. --Leonard Bernstein
  17. 17. Stress Much is known about acute stress Less is known about chronic stress
  18. 18. Stress If temporary, physical effects usually temporary  Example   Test anxiety among college students increased severity of acne Condition diminished after exams over
  19. 19. 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.
  20. 20. 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.
  21. 21. Nervous System Sympathetic nervous system signals adrenals to release norepinephrine and cortisol  Increased heart rate  Increased BP  Increase blood glucose levels
  22. 22. Stress
  23. 23. 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
  24. 24. Endocrine Response to Stress Inflammation Chronic exposure to stress hormones  Weakens immune system  Change structure of chromosomes 27
  25. 25. Chronic Stress: The Bad Stuff
  26. 26. Immune System Chronic 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
  27. 27. Immune System Chronic 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
  28. 28. 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. 32
  29. 29. 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
  30. 30. 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. 35
  31. 31. 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 36
  32. 32. 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)
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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)
  38. 38. 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
  39. 39. 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.
  40. 40. 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.
  41. 41. 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
  42. 42. 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 50
  43. 43. Stress: Better Ways to Handle It
  44. 44. 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
  45. 45. Cognitive Behavioral Therapies  Correcting cognitive distortions  Relaxation response  Mindfulness  Time Management  Stress Management  Meditation
  46. 46. Cognitive Behavioral Therapies Easily accessible  CBT manuals  Smart phone apps  Internet sites
  47. 47. 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
  48. 48. 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
  49. 49. The greatest weapon against stress is our ability to choose one thought over another. --William James
  50. 50. 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  59
  51. 51. 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
  52. 52. 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.
  53. 53. 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.
  54. 54. 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
  55. 55. Cognitive Behavioral Therapies  Meditation=improved amygdala and hippocampus structure  Relaxation Training=dampens acute “stress reaction”  CBT, Tai Chi=improved immunity to vaccines
  56. 56. ExerciseExerciseExerciseExercise ExerciseExerciseExercise  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.
  57. 57. 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 5580
  58. 58. 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?
  59. 59. Exercise Exercise does more to bolster thinking than thinking. Many people skip exercise at the time it is needed most.
  60. 60. Electronic World Pressures of today’s connected world  Email  Cell phones  Constant internet Increasingly difficult to switch off and concentrate on personal priorities.
  61. 61. Management of Electronic World TAKE A NEWS/ELECTRONIC WORLD BREAK
  62. 62. Stress Reduction       Exercise Meditation Guided imagery Nap Massage Yoga      Tai chi Music Biofeedback Time out: short walk Reading
  63. 63. Stress Management Remove or alter the stressor Change the perception of the stress Reduce the physiologic sequelae of stress Use alternative coping strategies
  64. 64. 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
  65. 65. 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
  66. 66. A life of being, having, and doing enough --Wayne Muller 2010
  67. 67. Management NOW Relax NOW  Visualization  Deep breathing  Repeat word or phrase  Change thought
  68. 68. 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)
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