While we tend to think of stress as inherently negative (distress), it’s also recognised that there is a positive form of stress – referred to as eustress – which includes motivation, excitement, and energy. There are two emotions that are particularly associated with the stress response – anger and fear, which respectively result in the desire to fight or flight. Dr Shelagh Wright provides a fascinating overview of what happens to the human body in dealing with stress – looking at the nervous system, the neuroendocrine system, etc. She says that the experience of chronic pain is potentially the most damaging form of stress. To effectively survive persistent pain, one needs to learn how to manage it and its stresses. For people living with fibromyalgia, these insights are particularly relevant. Fibromyalgia is a common chronic widespread pain disorder; neurochemical imbalances in the central nervous system are associated with central amplification of pain perception. Following Lazarus and Folkman (1984), Dr Wright highlights that effective coping depends on resources related to health and energy, positive belief, problem-solving skills, social skills and material resources. She explains strategies such as emotion-focused coping (e.g. stress control techniques), relaxation techniques (e.g. diaphragmatic breathing or pranayama in yoga), progressive muscular relaxation, autogenic training, and cognitive behavioural therapies. By practicing approaches such as these, people can learn to better deal with stress and experience a more balanced life. Dr Shelagh Wright is a chartered psychologist and registered nurse. Having qualified with Wirral Autogenic Training Centre in 2001, she retrained as an autogenic therapist with the British Autogenic Society in 2016 and established her business, AutogenicTrainingIreland.

1. Stress Management &
Relaxation Techniques
Shelagh Wright BAS PGCertAT
Autogenic Trainer
info@autogenictrainingireland.ie

2. 2
Distress: Negative Stress
•Crushes
•Oppresses
•Unusual events
carried beyond
rational limits

3. 3
Eustress: Positive Stress
• Motivates
• Excites
• Energizes

4. Three different approaches to
stress:
•An engineering, or stimulus based
approach (Hooke’s Law, 17th century)
•A medicophysiological, or response based
approach (Selye, 1950s)
•A dynamic psychophysiological response,
intervening between stimulus and
response, mediated by cognitions
(thoughts) (eg Lazarus & Folkman, 1980s)

5. Early 20th Century Physiologist Walter B. Cannon
coined the terms:
• ‘homeostasis:’ slow feedback mechanism
• focused especially on the role and effects of adrenaline in maintaining
the constancy of the body’s internal environment (Cannon 1926).
• the concept is an absolutely vital one for survival.
• ‘Fight or flight’ response: a survival instinct to fight or run with the
biological purpose to cope with stressors

6. Anger and Fear
•two emotions especially associated
with the stress response:
• anger
• fear
• anger produces the urge to fight
• fear promotes the urge to run and
hide

7. The nervous system (NS)
_____________________________________________________________________
central NS peripheral NS
___________________ ___________________________________
brain spinal cord somatic NS autonomic NS
________________________________________
sympathetic NS parasympathetic NS
increased heart rate decreased heart rate
dilated airways decreased airflow
inhibited digestion improved digestion
constricted blood vessels dilation of blood vessels
increased mental alertness
mobilised fat and sugar
increased ability of blood to clot
increased sweating
decreased saliva flow increased saliva flow
secretion of adrenaline and noradrenaline (acute)
cortisol (chronic)

10. Endocrinologist Hans Selye 1950s:
• Stress is the nonspecific response of the body to any
demand placed upon it to adapt,
• stress: ‘ all of the non-specifically induced changes
produced by a noxious agent’
• formulated a response-based approach to stress: activation
of two neuroendocrine systems:
• the sympathetic-adrenal medullary system (SAM)
• the hypothalamic-pituitary-adrenal complex system (HPA)

14. Hans Selye 1950s: General Adaptation
Syndrome
Stage 1
Alarm Reaction
Stage 2
Resistance
Stage 3
Exhaustion

15. Stress hormones
Emotion Anger Fear Depression
Stress
Hormones/
Behaviour
Aggressive
‘fight’
Withdrawn
‘flight’
Submission;
loss of
control
Adrenaline increase large
increase
no change
Noradrenaline large
increase
increase no change
Cortisol no change increase large increase
Changes in stress hormones related to emotions and behaviour

16. IASP Definition of pain
“An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.”
(IASP, 1986)

17. Chronic pain
• Unpleasant sensory and emotional experience which
may be elicited by injury or disease, usually
perpetuated by factors that are removed from the
original cause of pain and extending beyond the
expected period of healing (>3 months)

18. Chronic Pain is a stressor!
• The physiological, emotional and cognitive changes
brought on by chronic pain are almost identical to
those experienced as a result of chronic stress
• The experience of chronic pain is potentially the most
damaging form of stress
• To effectively survive persistent pain one needs to
learn to manage it and its concomitant stress (Sadigh,
2012)

21. General Systems Theory
http://www.panarchy.org/vonbertalanffy/systems.1968.
html
Ludwig von Bertalanffy (1968)
Engel: biopsychosocial medicine (1960-1970s)
Melzack & Wall: Gate Control Theory (1965)
Saunders: concept of Total Pain (1964)

22. George Engel Professor of Psychiatry & Medicine,USA
• Biopsychosocial model (1970s) based on General Systems
Theory.
• Includes physical, social, psychological and behavioural
dimensions in examination of patient as partner.
• Showed importance of listening to the patient & doctor-
patient relationship.
• Identified role of interpersonal relationships throughout life in
regulating mental and bodily processes

23. 1. Biomedical model is insufficient to
explain pain and disability
2. The BPS rejects simplistic models of
pain, also psychogenic models of pain
3. Adherence to the biomedical model of
pain can harm patients
Denis Turk
(1987)
Gordon Waddell
(1987)
The Biopsychosocial Model and pain

24. Biopsychosocial model
Pain DisabilityTissue
Damage
Disuse
Catastrophizing
Jobsatisfaction
Coping
Socioeconomic status
Personality
Social Support
Doctor
Shopping
Genetics
Stress
Avoidance
Depression

25. Science of Fibromyalgia
• Common chronic widespread pain disorder
• Neurochemical imbalances in the central nervous system are
associated with central amplification of pain perception
• Allodynia: heightened sensitivity to stimuli not normally painful
• Hyperalgesia: increased response to painful stimuli
• Disorder of pain processing
• Ascending and descending pain pathways operated abnormally
• Central amplification of pain signals –volume control up too high

26. Mechanisms in Fibromyalgia
• Central amplification partly due to genetics and environmental influences;
life time susceptibility and symptom severity
• FM is a clinical condition with disturbances in the stress system,
abnormalities in the hypothalamic-pituitary-adrenal (HPA) axis and in the
serotonergic system
• Perception of pain skewed to right on ‘bell shaped curve’ for people with
FM
• Increased volume control setting and pain intensity, irrespective of
peripheral nociceptive input ( painful stimuli on the body limbs) in FM
• New studies show potential benefits of health education programmes for
symptom management for patients with FM

30. Psychobiological disregulation
•Term coined by Schwartz in 1977; refers to brain & biological
systems regulated via feedback mechanisms
•Neuroendocrine, developmental and mental factors in
pathogenesis of chronic disorders
•Psychosomatic (mind-body) disorders are a function of
dysregulation; genetic and experiential factors involved in
disregulation
•Disruption in one system, over time results in a system wide
state of disorder and disregulation

31. Allostasis: a fast feedforward mechanism
• Neurobiologist Peter Sterling & Epidemiologist James Eyer
(1988) aimed to explain physiological basis for changes in
patterns of human morbidity and mortality .
• Aimed to find cause of link between prevalence of
hypertension and deaths from renal, cerebral and
cardiovascular diseases in post WWII baby boomers.
• Argued that only possible link between the
sociopsychological and physiological phenomena is the brain

34. Pain Confrontation
Recovery
Disuse
Disability
Depresssion
No fear
Fear of movement,
pain, (re)injury
Catastrophizing
Hypervigilance
Avoidance
Fear-Avoidance & Kinesiophobia
Injury
(Leeuw et al., 2007; Vlaeyen et al., 1995)

37. Richard Lazarus & Susan Folkman (1984)
• emphasis has changed from environmental stressors
and responses to a consideration of personal
perceptions of environmental events
• meaning an event has for a person, based on the
person’s feelings of threat, vulnerability and ability
to cope

38. Effective coping
depends on resources related to:
•health and energy; positive belief; problem solving
skills; social skills & material resources;
confers psychological benefits by increasing:
• self-esteem; sense of control; self-efficacy
problem-focused coping includes:
• problem-solving; decision making; information
gathering & goal setting

39. Emotion-focused coping
Maladaptive:
• Smoking; alcohol consumption;
sickness absence; substance abuse;
Adaptive:
• stress control techniques:
• aimed at changing internal
environment
• change perception of stressor
• increase sense of control and efficacy

40. The Relaxation Response
(Benson, 1975)
• Counteracts harmful effects of stress
• Requirements:
• A quiet environment (not essential)
• A mental device
• A passive attitude
• A comfortable position (not essential)

41. The relaxation response promotes
• A decreased heart rate
• Lowered metabolism
• Decreased rate of breathing
• Slower brain waves

42. Purpose of Relaxation Techniques
• Deactivate the five senses
• body's sensory system
• Decrease stimuli and their associated perception
• Replace stimuli and perceptions with
• non-threatening sensations that
• promote the relaxation response

43. Relaxation Technique Requirements
• Use with coping strategies
• Know several techniques
• Regular practice
• Frequency
• Duration

44. Diaphragmatic Breathing
•One of the easiest and most
effective methods of relaxation
•Basically
•controlled deep breathing
•In yoga, this technique is called
• the pranayama

45. Four phases of concentrated
diaphragmatic breathing
• Phase I
• inspiration
• Phase II
• a very slight pause before exhaling
• Phase III
• exhalation
• Phase IV
• another slight pause after exhalation
• before the next inhalation is initiated

46. Progressive Muscular Relaxation
•Muscles respond
• to thoughts of perceived threats
• with tension or contraction
•Muscular tension
• the most common symptom of stress
• can lead to:
• stiffness, pain, discomfort, distorted and
disaligned posture and joint stability

47. Typical phase for each muscle group
using PMR
• First contraction: 100% @ 5-10 seconds
• release and relax (exhale)
• compare relaxation to contraction
• Second contraction: 50% @ 5-10 seconds
• release and relax (exhale)
• compare relaxation to contraction
• Third contraction: 5-10% @ 5-10 seconds
• release and relax (exhale)
• compare relaxation to contraction

48. Autogenic Training
• Originated at beginning of 20th century from research
on hypnosis by Schultz, a German neurologist
• Aims to enable the person, through passive
concentration, to revert from sympathetic activity to
parasympathetic activity
• Designed to reinforce the organism’s natural tendency
for homeostasis (Luthe & Schultz, 1969)

49. Autogenic Training requirements
• 3 basic positions; 6 simple mental exercises
• Use of diary during trainee programme
• Regular daily practice
• Use of body scan prior to AT session
• Use of cancelling technique after AT session
• Support with lifestyle adjustments-ideally reduce alcohol & caffeine,
increase exercise; healthy diet; quit smoking.

50. Cognitive-Behavioral Therapies
• Emphasis on self-management
• Share 4 common components
• Education
• Skills acquisition
• Cognitive and behavioral rehearsal
• Generalization and maintenance

51. Physical activity
• Promotes excretion of anger hormones
• Reduces feelings of anger
• Promotes secretion of body’s natural pain killers: endorphins
• Enhances ‘feel good’ factor, feelings of mastery & control
• Improves health, well-being, strength & fitness
• Benefits enhanced in ‘green environment’
• Converts negative energy to positive energy & use
• Exercise bike is basic gym

52. Empowerment through stress management
Pressure or
demand
alteration of
socio-political,
economic and
physical
environment
brain cognitive
modification
stress response physiological
modification
stress
awareness
coping behaviour behavioural
modification
outcome self-
help/professional
intervention

53. References
Anderson, S.C; Cryan, J.F. & Dinan, T. (2017) The Psychobiotic Revolution. Washington DC; National Geographic.
Benson, H. (1975, 2000) The Relaxation Response. New York; HarperTorch.
Borysenko, J (1988, 2007) Minding the Body, Mending the Mind. USA; Da Capo.
Cannon.W.B. (1929) Organisation for physiological homeostasis . Physiol Rev. 9:399-431
Carruthers, M. (1979). Autogenic Training. Journal of Psychosomatic Research, 23, 437-440.
Engel, G.L. (1977) The need for a new medical model: a challenge for biomedicine. Science, 196: 129–136.
Engel, G.L. (1980) The clinical application of the biopsychosocial model. American Journal of Psychiatry, 137:
535–544.
Jacobsen, E. (1929). Progressive relaxation. Oxford, England: Univ. of Chicago Press.
Kermani, K. (1996) Autogenic Training: The Effective Way to Better Health. London; Souvenir Press.

54. References
Lazarus, R.S. (2006) Stress and Emotion. USA; Springer
Lazarus, R.S. & Folkman, S. (1984) Stress Appraisal and Coping. New York; Springer.
Robertson, I. (2016) The Stress Test; How pressure can make you stronger and sharper. London;
Bloomsbury.
Sadigh, M.R. (2012) Autogenic Training A Mind-Body Approach to the Treatment of Chronic Pain
Syndrome and Stress-Related Disorders.2nd Edition.USA; McFarland
(3rd Ed available 6th June 2019)
Selye, H. (1956,1976) The Stress of Life. New York; McGraw-Hill.
Schwartz, G. E. (1977). Psychosomatic disorders: Psychosomatic disorders and biofeedback: A
psychobiological model of disregulation. In J. D. Maser & M. E. P. Seligman (Eds.), A series of
books in psychology. Psychopathology: Experimental models (pp. 270-307). New York, NY, US:
W H Freeman/Times Books/ Henry Holt & Co.
Sterling , P. & Eyer, J. (1988) Allostasis : A new paradigm to explain arousal pathology. In
Handbook of Life stress , Cognition and Health (ed.S.Fisher, J.Reason),pp.629-47

55. Sample of info
1,2 Available on Google Scholar:
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56. Websites:
Arthritis Ireland https://www.arthritisireland.ie/
Chronic Pain Ireland https://www.chronicpain.ie/
International Association for the Study of Pain Advocacy ICD 11
https://www.iasp-pain.org/
Irish Pain Society IPS ASM Speakers’ presentations 2016
https://irishpainsociety.ie/