Stress Part I Stress Research Part II Stress

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Stress Part I: Stress Research Part II: Stress Management Anita Webb, Ph. D. John

Stress Part I: Stress Research Part II: Stress Management Anita Webb, Ph. D. John Peter Smith FMRP Fort Worth, Texas

GOALS u Awareness of the pervasive aspects of stress u Awareness of lifelong medical

GOALS u Awareness of the pervasive aspects of stress u Awareness of lifelong medical ramifications u Recognize stress in your patients’ lives u Learn some basic tips for dealing with stress

Objectives u Part I: Familiarity with u Medical consequences of stress u Psychoneuroimmunology u

Objectives u Part I: Familiarity with u Medical consequences of stress u Psychoneuroimmunology u Stress risk factors u Part II: u Learn simple stress busters u Consider resilience as a goal

Part I: Key Points u Stress can damage our physiology, make us sick, and

Part I: Key Points u Stress can damage our physiology, make us sick, and shorten our lives. u Psychological traits, social factors, gender, and lifestyle can affect our immune system. u Childhood stress can permanently alter physiology and cause health problems as adults.

Stress Symptoms u Somatic u Behavioral u Emotional u Mental u Social u Spiritual

Stress Symptoms u Somatic u Behavioral u Emotional u Mental u Social u Spiritual

Somatic Symptoms of Stress: Examples u Headache u Insomnia u Fatigue u Muscle tension

Somatic Symptoms of Stress: Examples u Headache u Insomnia u Fatigue u Muscle tension u Restlessness u Upset stomach u GI problems u Bruxism u Skin problems u Appetite change u Weight change u Libido change

Emotional Symptoms of Stress: Examples u Anxiety u Anger u Irritability u Depression u

Emotional Symptoms of Stress: Examples u Anxiety u Anger u Irritability u Depression u Mood swings u Crying u Apathy u Resentment

Mental Symptoms of Stress: Examples u Forgetfulness u Poor concentration u Poor attention u

Mental Symptoms of Stress: Examples u Forgetfulness u Poor concentration u Poor attention u Confusion u Dulled senses u Negative attitude u Whirling thoughts u Worrying

Social Symptoms of Stress: Examples u Isolation, loneliness u Alienation, distrust, hiding u Intolerance,

Social Symptoms of Stress: Examples u Isolation, loneliness u Alienation, distrust, hiding u Intolerance, resentment u Rejection of intimacy u Nagging u “Clamming up” u Using/abusing people

Behavioral Symptoms of Stress: Examples u Work u Home u Tardy u Irresponsible u

Behavioral Symptoms of Stress: Examples u Work u Home u Tardy u Irresponsible u Absent u Whining u Less u Screaming productive u More mistakes u Procrastinating u Disorganized u Loses things u Accidents u Impatient u Personality u Aggressive u Violent changes

Spiritual Symptoms of Stress: Examples u Emptiness u Loss of meaning u Loss of

Spiritual Symptoms of Stress: Examples u Emptiness u Loss of meaning u Loss of faith u Loss of direction u Doubt u Unforgiving

Stress Symptom Profile u Each of us has an individualized symptom profile of how

Stress Symptom Profile u Each of us has an individualized symptom profile of how we react to stress. u But we are often unaware of our own: u. Stress symptom profile u. Stress triggers u. Stress level u Learn how to identify stress warning signs u For yourself u For your patients

Medical Consequences of Stress u Severe or prolonged stress can cause breakdown of biological

Medical Consequences of Stress u Severe or prolonged stress can cause breakdown of biological systems. u All systems are susceptible u Psychological stress affects immune function and predicts infectious disease susceptibility. u (Marsland u 60 -90% 2002) of PCP visits are stress-related

Medical Consequences of Stress: Examples u Pain u Skin u Head, jaw u Neck,

Medical Consequences of Stress: Examples u Pain u Skin u Head, jaw u Neck, shoulders u Back u Chest u Arthritis u GI u Eczema u Dermatitis u Herpes u Acne u Psoriasis u Colitis u Rosacea u Gastritis u Diarrhea u Irritable u Rashes colon u Metabolic u Obesity

Medical consequences (cont. ) u u Respiratory u Asthma u Bronchitis u Sob u

Medical consequences (cont. ) u u Respiratory u Asthma u Bronchitis u Sob u Allergies u Hyperventilation Cardiovascular u u u HTN MI CAD u Arrhythmia u u Reproductive u Amenorrhea u Impotence u PMS u Infertility Immune system u u Suppression Rheumatologic u Rheum. arthritis Periodontal disease Brain damage

Stress Damage u Stress damages body directly u brain, heart, blood vessels, etc. u

Stress Damage u Stress damages body directly u brain, heart, blood vessels, etc. u And indirectly u e. g. suppresses the immune system u susceptibility to URIs umedical students (Cohen 1991) usocial conflict (Chamberlain 2004) u Depletes neurotransmitters, stress hormones u causing fatigue, anger, depression, etc.

Stress damage (continued) u Alters metabolism u causing u Alters u e. g obesity

Stress damage (continued) u Alters metabolism u causing u Alters u e. g obesity lifestyle too tired to exercise, disturbed sleep health behaviors substance abuse resumed u (What is “stressed” spelled backwards? )

Brain Damage MRI studies in 3 populations (1995 -96) u 1. Vietnam combat veterans

Brain Damage MRI studies in 3 populations (1995 -96) u 1. Vietnam combat veterans with PTSD: u 22 -26% shrinkage (Gurvits 1996 Harvard) u 2. Adults who were child abuse victims: u 12 % shrinkage (Bremner 1995 Yale) u 3. Chronic major depressive disorder: u 12 -15% shrinkage u longer duration = greater shrinkage u (Sheline 1996 Washington University)

Brain Damage: Site and Mechanism u The hippocampus can be damaged by major long-term

Brain Damage: Site and Mechanism u The hippocampus can be damaged by major long-term stress. u Neurons die, brain shrinks u Glucocorticoid toxicity u Amygdala also damaged u (Reviewed in Sapolsky 1996 Science)

Stress and Prefrontal Cortex u Short-term “working memory” u Regulates thought, behavior and emotions

Stress and Prefrontal Cortex u Short-term “working memory” u Regulates thought, behavior and emotions u Even mild stress can impair working memory (in both humans and animals) u Protein kinase C (PKC): released during stress u PKC can cause u Distractibility, impulsivity u Impaired judgment u Thought disorder u (Birnbaum 2004 Science, Yale)

Brain Damage: Reversible? u Rat Studies u Lesions were induced in hippocampus u. Easily

Brain Damage: Reversible? u Rat Studies u Lesions were induced in hippocampus u. Easily damaged by stress, CVA, etc. u Memory for water maze was impaired u Metyrapone: injected u Used for treating stress (inhibits cortisol) u Able to negotiate maze like normal rats u Reduced glucocorticoids to normal levels u (2001 Mitka Science)

Stress: Biopsychosocial Model u “Psychoneuroimmunology” (PNI) u Stress, immune system and health outcomes u

Stress: Biopsychosocial Model u “Psychoneuroimmunology” (PNI) u Stress, immune system and health outcomes u How psychosocial factors moderate the stress response u Can either protect or damage our health

PNI Research Overview u Examples of psychosocial factors: u thoughts/attitudes/beliefs u personality, self-esteem, coping

PNI Research Overview u Examples of psychosocial factors: u thoughts/attitudes/beliefs u personality, self-esteem, coping skills u lifespan development, gestational u health behaviors u work life, life events u social support, marital quality u grief, spirituality

PNI: Basic Science Research u Also mapping the biological and cellular mechanisms by which

PNI: Basic Science Research u Also mapping the biological and cellular mechanisms by which stress affects the immune system u Neurology, neuropsychology, psychiatry, immunology, infectious disease, cardiology, pharmacology, dermatology, hematology, dental sciences, oncology, etc. u “A booming, cutting edge interdisciplinary field”

Basis of PNI u Humans have 4 information-processing systems u 1. Mind u 2.

Basis of PNI u Humans have 4 information-processing systems u 1. Mind u 2. Nervous system u 3. Immune system u 4. Endocrine system u Which continually communicate with each other u Via neurotransmitters, cytokines, hormones u (Ray 2004)

PNI Research: Example Landmark study: Ader 1975 u 1. Add an immunosuppresant drug and

PNI Research: Example Landmark study: Ader 1975 u 1. Add an immunosuppresant drug and saccharine to rats’ drinking water u Result: suppresses the rats’ immune system u 2. Later (after subjects recover): u Give the same rats saccharine water with NO immunosuppresant drug u Result: suppressed the rats’ immune system

Landmark study (continued) u Conclusion u The second immune suppression was a LEARNED response

Landmark study (continued) u Conclusion u The second immune suppression was a LEARNED response via u Classical Conditioning u Research with people has demonstrated that u Immune response can be initiated by cognitive and emotional cues

PNI and Medical Mysteries u How can you explain. . . u Voodoo (Cannon

PNI and Medical Mysteries u How can you explain. . . u Voodoo (Cannon 1942) u Hypnosis: e. g warts (Surman 1973) u N. Cousin’s laugh therapy (1981) u Pseudocyesis u Placebo effect u “Belief Becomes Biology” u (Cousins)

Placebo Example u Osteoarthritic knee surgery u. Debridement or arthroscopic lavage, versus u. Sham

Placebo Example u Osteoarthritic knee surgery u. Debridement or arthroscopic lavage, versus u. Sham surgery with real incision u Equal pain relief u. Even at 2 year follow-up u(Wray u Critique: 2002 NEJM) Subjective measure

Physical Evidence for Placebo u Parkinson’s disease treatment study u. Pet scan following saline

Physical Evidence for Placebo u Parkinson’s disease treatment study u. Pet scan following saline injection u The brain released dopamine u“First study to show physical changes accompanying the placebo effect” u(Stoessl 2001)

PNI: Placebo & Depression u Meta-analysis of 19 double-blind antidepressant studies u Only 25%

PNI: Placebo & Depression u Meta-analysis of 19 double-blind antidepressant studies u Only 25% of patient improvement was due to a “true” drug effect u 75% of improvement due to placebo response u (Kirsch 1998) u Critique: Subjective measures

More Physical Evidence for Placebo: Depression u Patients who became less depressed with placebo

More Physical Evidence for Placebo: Depression u Patients who became less depressed with placebo pills showed u Increased activity in prefrontal cortex (PFC) u PFC is associated with mood, self observation u Interestingly, patients who became less depressed on antidepressant pills showed u Decreased prefrontal signals u (Leuchter 2002)

PNI and Nocebo: u The Evil Twin of placebo u “noci”: harm, injury (L.

PNI and Nocebo: u The Evil Twin of placebo u “noci”: harm, injury (L. ) u Negative expectations u Classic study: u Woman with allergies began sneezing in response to artificial rose u (Mackenzie 1886) u Man with allergy to horses had asthma attack upon seeing horses in a movie (in Hassenfeld 1993)

Nocebo and Heart Disease u Longitudinal study with 2 groups of women u Both

Nocebo and Heart Disease u Longitudinal study with 2 groups of women u Both had similar risk factors for heart disease u Some believed they were prone to heart disease u The group of women who believed that they were prone to heart disease u Had 4 x greater mortality from heart disease u Versus the non-believers u (in Reid 1992)

The “Nocebo Profile” u Be wary of patients who present with u vague, difficult-to-explain

The “Nocebo Profile” u Be wary of patients who present with u vague, difficult-to-explain complaints, plus u low expectations that treatment will help, plus u unusual and/or multiple drug side effects u (Barsky 2002) example: u “Surgeons are wary of people who are convinced that they will die. ” u For u (Benson 2002)

PNI: Emotions and the Heart u Negative emotions u Sadness, tension, frustration u Could

PNI: Emotions and the Heart u Negative emotions u Sadness, tension, frustration u Could trigger myocardial ischemia u Within an hour u More than doubled the risk of occurrence of MI u (Gullette 1997 JAMA)

Anger and Heart Health u “Hot Reactors” u People who anger easily, quickly and

Anger and Heart Health u “Hot Reactors” u People who anger easily, quickly and fully u Are often unaware of their stress levels u Had increased risk of u injury to blood vessels u atherosclerosis u myocardial ischemia u[men under age 55] u(Kamarck 1998)

Positivity and Heart Health u Positive psychological variables u Optimism, u Patients u had

Positivity and Heart Health u Positive psychological variables u Optimism, u Patients u had self-esteem, feelings of control with low scores on “positivity” 3 x greater risk of a new coronary event u “Positivity” u Is protective of cardiac health u (Hegleson 1999)

“Broken Heart Syndrome” u Stress cardiomyopathy u “Classic heart attack-like symptoms” u. Chest pain,

“Broken Heart Syndrome” u Stress cardiomyopathy u “Classic heart attack-like symptoms” u. Chest pain, SOB, pulmonary edema u Left ventricular dysfunction u Markedly elevated catecholamine levels u Precipitated by emotional stress: Reversible u Tragic or shocking event “stuns the heart” ue. g. sudden loss of loved one u 95% female, median age 63 u (Wittstein 2005 NEJM)

Long Term Effects of Grief: Bereaved Parents u “Extreme stressor”: Death of a child

Long Term Effects of Grief: Bereaved Parents u “Extreme stressor”: Death of a child u Denmark 1980 -1996 u 12, 072 deceased children, N = 19, 361 bereaved parents u Controls: N = 295, 540 “unexposed” parents u Increased risk of MI in parents who lost a child u After 6 years of follow-up u Both mothers and fathers at risk u Especially: single, low education, low social support (Li 2002)

INTERHEART study u 52 countries: N=24, 767 (half were controls) u 4 questions about

INTERHEART study u 52 countries: N=24, 767 (half were controls) u 4 questions about psychosocial life stress u Work, home, $, major life event in the past year u Results: “People with MI reported higher prevalence of all 4 stress factors. ” u Across age, gender, SES, culture, geography u Adjusted for other cardiovascular risk factors u Mechanism not yet determined u (Rosengren 2004 Lancet)

Heart Health Education u “The way we live is breaking our hearts. ” u

Heart Health Education u “The way we live is breaking our hearts. ” u “Anger rips up the insides of your arteries, making little tears. ” u “The health of your heart is all in your mind. ” u [PNI] u Michael Rotman, MD u Austin Heart, Austin’s largest cardiology group

PNI: Personality and Health u Type “A” Personality u workaholic, multi-tasking u hurried, impatient

PNI: Personality and Health u Type “A” Personality u workaholic, multi-tasking u hurried, impatient u irritable, explosive u punctual, demanding u high energy, hyperactive u no fun, can’t relax u self-absorbed, feels superior u materialistic, obsessed with $ u (Rosenman 1958 and Friedman 1969)

Personality (continued) u Type “B” Personality u. Opposite of Type A traits u Who

Personality (continued) u Type “B” Personality u. Opposite of Type A traits u Who is more successful? u Makes more $? u Probably equal, or may even favor Type B u Type A has double the risk of CHD

Type “H” Personality u “Hostile” u cynical, suspicious u hyper-critical u angry, aggressive u

Type “H” Personality u “Hostile” u cynical, suspicious u hyper-critical u angry, aggressive u low self-esteem u High risk u accidents u sick days u premature death u (Cortis 1997)

Type H and Heart Risks u Actually subcategory of Type “A” but higher risk

Type H and Heart Risks u Actually subcategory of Type “A” but higher risk u Cardiovascular disease, especially MI u Sudden death u Outbursts of anger and aggression activate: u 1. Epinephrine and norepinephrine: Constrict blood vessels u 2. Cortisol: clogs arteries, causes chronic inflammation u (Williams 1997)

PNI and CVA u “People who had strokes were more likely to have experienced

PNI and CVA u “People who had strokes were more likely to have experienced uanger or negative emotions uin the 2 hours prior to the stroke” u(Koton 2004 Neurology)

PNI and Cancer u “Evidence suggests that stress and depression result in impairment of

PNI and Cancer u “Evidence suggests that stress and depression result in impairment of the immune response, u “And might promote initiation and progression of some types of cancer. ” u (Reiche 2004 Lancet)

PNI and Chronic Kidney Disease u Optimistic u 40% patients greater survival than the

PNI and Chronic Kidney Disease u Optimistic u 40% patients greater survival than the average patient u Pessimistic u 40% patients greater mortality than the average patient u “Assessing patients’ emotional health umight help doctors treat illness. ” (NIH 2002)

Gender Stress: Women u Report feelings of stress more often u React to a

Gender Stress: Women u Report feelings of stress more often u React to a wider range of stressors, Including community problems u Often have 2 jobs: Wage earner and (unpaid) homemaker [and mother] u Tend to “internalize” stress, resulting in: u Sleep disturbance, GI distress, Depression

Gender Stress: Men u Tend to “externalize” stress u Anger, blaming, violence u Men

Gender Stress: Men u Tend to “externalize” stress u Anger, blaming, violence u Men with explosive anger episodes u Sharper rise in BP when stressed u Increased risk of CVA u But suppressing anger also increases BP. u So what’s a fella to do?

Gender, Occupation and Heart Disease u House-husbands had higher mortality u 82% higher than

Gender, Occupation and Heart Disease u House-husbands had higher mortality u 82% higher than men employed outside home u Higher than housewives u Executive males u Lower-than-average risk of heart disease u Executive females? u “Unusually high risk”: 3 x other women u (Eaker 2002 N=3600)

SES and Health u SES is one of the most powerful health predictors u

SES and Health u SES is one of the most powerful health predictors u More powerful predictor than smoking, genetics, exposure to carcinogens u Including cardiovascular disease, diabetes, arthritis, infant mortality, many infectious diseases, some types of cancer u Direct linear correlation u The lower the SES, the greater the risk of poor health

SES (continued) u Childhood u (Poulton SES affects your adult health. 2002 Lancet) u

SES (continued) u Childhood u (Poulton SES affects your adult health. 2002 Lancet) u “SES is viewed as a determinant of health rather than a mere correlate. ” u What is the mediating factor between SES and morbidity/mortality? u. Stress (Anderson 2002)

SES and Health: Example u High Blood Pressure u. People from all SES u.

SES and Health: Example u High Blood Pressure u. People from all SES u. Have about the same BP readings at work. u However, those lower on the social scale u. Have higher blood pressure at home. (Evans 1994)

Work Stress u Workplace stress is increasing “every day” u 62% say workload increased

Work Stress u Workplace stress is increasing “every day” u 62% say workload increased over last 6 months u Costs the U. S. $300 billion/year u Stressed workers incur 46% higher med. costs u White collar workers particularly at risk u Tend to “take our work home” u (Standing, UN International Labor Office 2004)

PNI: Race, Stress and Health u Example: Study with African-Americans u Coped better with

PNI: Race, Stress and Health u Example: Study with African-Americans u Coped better with stress than whites u But higher rate of disease/death than whites u “Everyday discrimination” was implicated u Discourteous treatment, harassment, poor service offered, feeling threatened, etc. u More damaging than major discrimination u. Employment, housing, etc. u (Williams 1997)

PNI: Marital Stress u Marital stress is as good a predictor of health u

PNI: Marital Stress u Marital stress is as good a predictor of health u as any of the usual major prognostic indicators, u increasing the risk for everything from chronic pain to a heart attack u (Keicolt-Glaser u Example: u Job 2002) Thickening of heart’s left ventricle stress did not have same effect u (Harvard Men’s Health Watch newsletter 2004)

Marital stress (cont. ) u Appears to be a “bigger hazard” than other types

Marital stress (cont. ) u Appears to be a “bigger hazard” than other types of stress, such as work life u. Can’t escape it, no safe haven. u Expectation: Should be your comfort zone. u. Primary support becomes primary stressor. u (Parker-Pope 2004)

Childhood Stress and Health u Kids who are neglected u have higher levels of

Childhood Stress and Health u Kids who are neglected u have higher levels of stress hormones u become “hot reactors” u have worse health (including depression) u Kids raised in chaotic, unstable, non-cohesive, resentful households u have higher blood pressure as adults. u (Mc. Ewen 1999)

Adverse Childhood Events (ACE) u Abuse, neglect, household dysfunction u Increased risk of ischemic

Adverse Childhood Events (ACE) u Abuse, neglect, household dysfunction u Increased risk of ischemic heart disease in adulthood u N=17, 337 (54% female) u Psychological factors u Especially depression and anger u “Appear to be more important than traditional risk factors” u (Dong 2004 Circulation)

ACE’s (continued) u “Abundant evidence that ACEs are major determinants of health problems in

ACE’s (continued) u “Abundant evidence that ACEs are major determinants of health problems in adulthood” u Many of the leading causes of death in adults u (Felitti 1998) u “Considerable evidence to suggest that adverse early-life experiences have a profound effect on the developing brain” u Increased CRF activity u Lifelong reactivity to even mild stress u (Nemeroff 2004)

Childhood Stress: Maternal Deprivation u Early contact experiences of rat pups u Such as

Childhood Stress: Maternal Deprivation u Early contact experiences of rat pups u Such as amount of maternal grooming u Set the level of stress reactivity as adult rats u Early maternal deprivation u Increased stress reactivity u Lifelong (Mc Ewen 1999)

Gestational & Neonatal Stress u Rat pups u. Maternal glucocorticoid crosses placenta u. Alters

Gestational & Neonatal Stress u Rat pups u. Maternal glucocorticoid crosses placenta u. Alters structure and function of fetus’ hippocampus in adulthood u Maternal separation at birth u. Leads to increased CRH as adults u (Sapolsky 2003 Scientific American)

Gestational Stress: Humans u Babies born to stressed mothers have u Higher incidence of

Gestational Stress: Humans u Babies born to stressed mothers have u Higher incidence of chronic diseases as adults u Heart disease, hypertension, stroke, Type II diabetes (and gestational diabetes) u (Reviewed in Couzin 2002 Science) u Maternal anxiety during pregnancy u Adversely affects developing humans. u (Dingfelder 2004)

Gestational Stress Mechanism u H-P-A axis is “reset” in the womb u Becoming hypersensitive

Gestational Stress Mechanism u H-P-A axis is “reset” in the womb u Becoming hypersensitive u And overactive lifelong u Churning out excess, damaging glucose, cortisol, and other toxic stress hormones u (Reviewed in Couzin 2002 Science)

Psycho-neuro-immunology: Summary u “What goes on in your head can affect how well your

Psycho-neuro-immunology: Summary u “What goes on in your head can affect how well your immune system functions. ” u (Sapolsky 1998) u “The hottest and most promising area of medical research today” u (Berry 1999)

Summary of Part I: Research u Stress can damage our physiology, make us sick,

Summary of Part I: Research u Stress can damage our physiology, make us sick, and shorten our lives. u Psychological traits, social factors, gender, and lifestyle can affect our immune system. u Childhood stress can permanently alter physiology and cause health problems as adults [implications for SES and health? ]

Recommendation Learn how to manage your own stress. u At work u. Especially overload

Recommendation Learn how to manage your own stress. u At work u. Especially overload u. Time pressures u. Unrealistic self-expectations u At home: Especially in your relationships (Part II: Stress Management)

End of Part I: Stress Research u Please turn in your evaluations.

End of Part I: Stress Research u Please turn in your evaluations.

Stress, Part II: Stress Management Anita Webb, Ph. D. John Peter Smith Family Medicine

Stress, Part II: Stress Management Anita Webb, Ph. D. John Peter Smith Family Medicine Residency

Part II: Objectives u Learn simple stress busters u. For yourself, for your patients

Part II: Objectives u Learn simple stress busters u. For yourself, for your patients u Consider resilience as a goal

Key Points u Our usual response to stress is automatic. u You can learn

Key Points u Our usual response to stress is automatic. u You can learn to take control and change this automatic response. u The bio-psycho-social-spiritual model offers abundant stress-busting strategies. u Controlling your reaction to stress can improve your health.

Highest Risk Stress Profile u Childhood: chaos, abuse, neglect u Low SES: an independent

Highest Risk Stress Profile u Childhood: chaos, abuse, neglect u Low SES: an independent health risk factor u Targets of discrimination u Personality style: hostility, poor coping u Cognitive: depression, pessimism u Deficient life skills: vocational, ed. , etc. u Low social support u Long-term major stress u Multiple contiguous losses

Psycho-neuro-immunology Example of early PNI studies u Participants: Medical students u Decreased immune function

Psycho-neuro-immunology Example of early PNI studies u Participants: Medical students u Decreased immune function before and during exams for first 2 years of medical school u “Robust immune response” during first week of third year u Significant drop one month later (Kiecolt-Glaser 1984, multiple replications)

More Recent PNI Research u Example: Stress and Aging u Mothers with chronically ill

More Recent PNI Research u Example: Stress and Aging u Mothers with chronically ill child u Mothers’ cells aged the equivalent of 9 -17 years more than control group u Dose-response: duration and severity of stress u Cells of self-described “stressed out” controls u Also aged more quickly u (Continued)

Mom Study: Conclusions u 1. Stress “accelerates the aging process” u Stress hormones cause

Mom Study: Conclusions u 1. Stress “accelerates the aging process” u Stress hormones cause damage, esp. cortisol u Shortens the life span of cells u “Opens the door to disease” u 2. “It may be more or equally important” u How you view your life u How you cope with demands u What kind of support you have u (Epel 2004)

Stress and Aging: Mechanism Stress accelerates cognitive decline and aging via a “feedforward cascade”:

Stress and Aging: Mechanism Stress accelerates cognitive decline and aging via a “feedforward cascade”: u 1. stress triggers glucocorticoid (GC) u 2. which shrinks the hippocampus (HC) u 3. and inhibits neurogenesis in HC u 4. which inhibits de-activation of GC u 5. and further damages HC, etc. (Sapolsky 1998)

Modern Stress u Why do we feel so stressed in spite of vast improvements

Modern Stress u Why do we feel so stressed in spite of vast improvements in our society? u More affluent than ever u Better educated than ever u Better health care than ever u Stronger human rights for minorities, religions, children, women, seniors, sexual preference, etc.

20 th Century Advances 1900 -1920 1995 -98 u Infant mortality (1, 000) 100

20 th Century Advances 1900 -1920 1995 -98 u Infant mortality (1, 000) 100 7 u Infectious deaths* 700 50 u Heart disease* (1950) 307 126 u Pollution (lead) (1977) 135 4 u Poverty rate 40% 13% u High school diploma 22% 88% u Life expectancy 47 yrs 77

Modern Job Stress most stressful jobs in United States? u. President u. Firefighter u.

Modern Job Stress most stressful jobs in United States? u. President u. Firefighter u. Senior corporate executive u. Race car driver u. Taxi driver u Five u Where would you rank “Physician” (out of 250)? u Physician (GP) = 32 (Jobs Rated Almanac 2001)

Physician Stress: Personal Consequences u Doctors have “alarmingly high rates” of u drug abuse,

Physician Stress: Personal Consequences u Doctors have “alarmingly high rates” of u drug abuse, suicide, failed marriages u “Hardly making them worthy prophets of healthy living. ” u “Healing is more than technology. ” u “It is very much about listening, being more open, and u healing yourself before you attempt to heal others. ” u (Miller 2002)

“The Unhealthy Doctor”? u Actually: Physicians have decreased risk for u cancer u heart

“The Unhealthy Doctor”? u Actually: Physicians have decreased risk for u cancer u heart disease u other major cause of death (AFSP 2002) u “As a group, physicians are healthy and have healthy lifestyles. ” u “It’s time to erase the myth of the unhealthy doctor” (Frank 2004)

Physician Life Expectancy u Physicians (males) have lower mortality rates u general population =

Physician Life Expectancy u Physicians (males) have lower mortality rates u general population = 70 u professionals = 71 u lawyers = 72 u physicians = 73 u (1984 -95) u (Frank 2000)

[FYI: Lesser Job Stress] u Five least stressful jobs in U. S. ? u.

[FYI: Lesser Job Stress] u Five least stressful jobs in U. S. ? u. Medical records technician u. Janitor u. Forklift operator u. Musical instrument repairer u. Florist (Source: Jobs Rated Almanac 2001)

Stress Management Strategies u. I. Biological u. II. Psychological u. III. Social u. IV.

Stress Management Strategies u. I. Biological u. II. Psychological u. III. Social u. IV. Spiritual

I. Biological Strategies For stress management u Eat, drink (preferably something nutritional) u Deep

I. Biological Strategies For stress management u Eat, drink (preferably something nutritional) u Deep muscle relaxation u Medication, “herbs” u Bubble bath, aromatherapy u Dance, tai chi, yoga, exercise, fitness u Massage, stretch, hugs u Sleep, power-naps, “good cry” u Sing, play an instrument, listen to music u Slow Breathing!!!

Breathing Example Hypertension treatment: “Controlled breathing is effective, and tests have shown that the

Breathing Example Hypertension treatment: “Controlled breathing is effective, and tests have shown that the effect lasts” u However, for those who need extra help: u “RESPe. RATE”: To decrease blood pressure u“Medical device” to decrease respiration rate u. Audiotaped breathing exercise u 15 minutes per day, 4 times per week u. Effective within 2 months, no side effects u$299. 00 (FDA approved) (Elliot 2002)

Another Biological Example: Exercise u 30 minutes of (almost) daily brisk walking u Protected

Another Biological Example: Exercise u 30 minutes of (almost) daily brisk walking u Protected against URIs u 20% decrease annually u 32% during cold season (Matthews 2002)

Another Biological Example: Oxytocin (vs. Catecholamines) u Well known “fight-or-flight” stress response u Releases

Another Biological Example: Oxytocin (vs. Catecholamines) u Well known “fight-or-flight” stress response u Releases a cascade of toxic catecholamines u 5 decades of stress research u Almost 90% of the studies with males only u But: Oxytocin is also released in stress response u Calming, buffers the fight-or-flight response u Inhibited by testosterone, enhanced by estrogen u (Taylor 2002)

Oxytocin: “Cuddle Hormone” u Lactation as an indirect measure u. Nursing women produce large

Oxytocin: “Cuddle Hormone” u Lactation as an indirect measure u. Nursing women produce large amounts u “Breast-feeding appears to buffer women’s stress response” u. Physical and social stress u. Supported by results of animal research u(Carter 2002)

Oxytocin and Friendship u Rodents injected with oxytocin u. Increased sociability in males and

Oxytocin and Friendship u Rodents injected with oxytocin u. Increased sociability in males and females u Oxytocin encourages women to utend to children and gather with other women uinstead of fighting or fleeing u(Taylor 2002)

“Tend-&-Befriend” Response u Conclusion: u Women tend to respond to stress differently u Goal:

“Tend-&-Befriend” Response u Conclusion: u Women tend to respond to stress differently u Goal: Decreasing distress u Oxytocin encourages nurturing and gathering u which in turn releases more oxytocin u which is even more calming u Contributes to longer life? u e. g. friendship, social support u (Fight-or-flight also still available) (Ibid)

Extra Oxytocin? u Exposing research animals to extra oxytocin during early life u Permanently

Extra Oxytocin? u Exposing research animals to extra oxytocin during early life u Permanently reduced their stress reactivity u Lowered their baseline blood pressure u (Uvnas-Moberg) u Long-term effects of pitocin? u Synthetic form of oxytocin u 73% of mothers in U. S. get pitocin u (Witt 2002)

A Third Type of Stress Reaction u Withdrawal from the environment u. Pulling back

A Third Type of Stress Reaction u Withdrawal from the environment u. Pulling back to conserve energy u. Depression as an adaptive response to excessive stress? u (Kemeny 2002)

II. Social Strategies For stress management u Good communication skills u Social skills, manners

II. Social Strategies For stress management u Good communication skills u Social skills, manners u Appropriate venting u Assertiveness training u Laughter clubs u Emotional intelligence u Talking, companionship, intimacy u Social activities, fun u PETS!!

Social Example: Talking u Simply talking to someone helps to u fight off colds

Social Example: Talking u Simply talking to someone helps to u fight off colds and infections u heal faster from illness and wounds u Implications for physicians? (Cohen 1991 NEJM)

Physician Communication Large body of research demonstrating that physician communication skills can increase: u

Physician Communication Large body of research demonstrating that physician communication skills can increase: u Efficiency: Accuracy/completeness of data u with fewer tests and procedures u Patient compliance u Patient satisfaction u Physician satisfaction u Health outcome measures u (Lipkin 1997)

Communication (continued) u Physicians were briefly trained to u Listen, convey warmth, provide feedback

Communication (continued) u Physicians were briefly trained to u Listen, convey warmth, provide feedback u Results: Their patients reported u Decreased anxiety and depression u Increased satisfaction u Increased sense of control over their health (Andersen 2002)

Example of PNI Social Treatment Application u Women with breast cancer who attended support

Example of PNI Social Treatment Application u Women with breast cancer who attended support group lived twice as long as control group. u Subsequently widespread adoption u (Spiegel 1989 LANCET) u However, not supported by recent research u But other benefits of support group u (Goodwin 2001 NEJM)

Another Social Example: Laughter Clubs u To improve physical and mental health u Through

Another Social Example: Laughter Clubs u To improve physical and mental health u Through SYSTEMATIC laughter u Simulated laughter u e. g “Vowel Movements” u Most popular in nursing homes (Kataria 1995, India)

Health Benefits of Laughter u Favorable brain and stress hormone changes u Produces endorphins

Health Benefits of Laughter u Favorable brain and stress hormone changes u Produces endorphins u Optimizes immune system u (Berk) u May help fight heart disease u Cardiovascular u (Miller workout (“internal jogging”) 2002) u Relaxes muscles, u (Stitch 2002) decreases tension pain

Another Social Example: PETS! u “Pet owners repeatedly told us that u. They talk

Another Social Example: PETS! u “Pet owners repeatedly told us that u. They talk to and confide in their pets. u “Pets lower stress by providing u. Nonjudgmental companionship. u “People see their pets as important sources of u. Social support. ” u (Blascovich 2002)

Pets and Health u Elderly: fewer visits to doctor u AIDS: lower depression u

Pets and Health u Elderly: fewer visits to doctor u AIDS: lower depression u Post MI: increased survival u Kids: reduced blood pressure while reading u Sig. cardiovascular and behavioral benefits u Cats or dogs more effective? (Reviewed in Blascovich 2002)

III. Spiritual De-stress strategies u Prayer, ritual u Hymns, chants u Meditation, mantras u

III. Spiritual De-stress strategies u Prayer, ritual u Hymns, chants u Meditation, mantras u Inspirational readings u Visiting a house of worship u Attending services, functions u Forgiveness, universal love u Faith, meaning, purpose, coherence u Belief that there is order to the universe

Spirituality Research: Review Article Summaries u “There is a persistent predictive relationship u between

Spirituality Research: Review Article Summaries u “There is a persistent predictive relationship u between religious variables and health. u Substantial empirical evidence” (Miller 2003) u “Religiosity/spirituality is linked to health related physiological processes including u cardiovascular, neuroendocrine, and u immune function” (Seeman 2003) u Mediators: faith, social, lifestyle/health behaviors

Spirituality: Brain Imaging u Parietal lobe activity during prayer and meditation (Newberg 2001) u

Spirituality: Brain Imaging u Parietal lobe activity during prayer and meditation (Newberg 2001) u Increased theta activity (slowing) in PL u (Gregg 2001) u Religious experiences during temporal lobe epileptic attacks u “God module” in the brain? u (Ramachandran 1997)

Spirituality and the Brain u “Hardwired to connect”? u “The need for meaning is

Spirituality and the Brain u “Hardwired to connect”? u “The need for meaning is increasingly discernible in the basic structure of the brain. ” u The emotions of religious experience may have neurobiological origins. u Infant attachment imprints into the right brain u Creating either resilience or vulnerability to psychological disorder (Kline 2003)

Prayer Research “Research validating the role of prayer in healing … has already taken

Prayer Research “Research validating the role of prayer in healing … has already taken place in abundance” (Dossey 1994) u Example: Patients hospitalized for MI’s (N=393) u Intervention: Church prayer groups (offsite) u Control group, randomized, double-blind u Results (compared to controls): u Less CHF, antibiotics, pneumonia, CPR u No intubation (Byrd 1988) u “Meticulous study” (Dossey 1994)

Another Spiritual Stress-buster u “The Relaxation Response” u. To de-activate the stress signal u.

Another Spiritual Stress-buster u “The Relaxation Response” u. To de-activate the stress signal u. Activate parasympathetic nervous system u Activates 3 seconds after stress signal ends Herbert Benson, MD (1975) Mind/Body Institute, Harvard Medical School

“Relaxation Response”: Technique 1. Repetition -a sound, sight, prayer, action 2. Passive ignoring -of

“Relaxation Response”: Technique 1. Repetition -a sound, sight, prayer, action 2. Passive ignoring -of other stimuli, external and internal 3. 10 -20 minutes: B. I. D. -e. g. awakening and bedtime [Why is this considered a spiritual technique? ]

“Relaxation Response”: Research u The Relaxation Response technique has been successfully used for treatment

“Relaxation Response”: Research u The Relaxation Response technique has been successfully used for treatment of: u HTN u arrhythmias u chronic pain u insomnia u chemo nausea/vomiting u depression (with cancer, AIDS) u infertility (Reviewed in Oxton 1996)

Spirituality: Physician’s Role? u “To encourage whatever gives the patient comfort and hope” u

Spirituality: Physician’s Role? u “To encourage whatever gives the patient comfort and hope” u Caution: uwithout imposing your personal values or beliefs on the patient (Koenig 1999)

IV. Psychological Stress management strategies u Visualization, daydreaming u Music, media, entertainment, reading u

IV. Psychological Stress management strategies u Visualization, daydreaming u Music, media, entertainment, reading u Expressive writing, journaling, diary u Self “hypnosis”, self-talk u Attitude adjustment, hemi-synch u Anger management, “hate letters” u Organizational/problem solving skills u Draw/paint/arts and crafts, hobbies u Self-confidence, self-esteem u Psychotherapy

Psychological Example: Cognitive Psychotherapy u Our thoughts create our emotions u Therefore we can

Psychological Example: Cognitive Psychotherapy u Our thoughts create our emotions u Therefore we can decide our emotions. u i. e. We can decide not to feel stressed. u The mechanism is “self-talk” u The key is Self-awareness. u Guided Imagery Therapy u “Changing channels” for kids

PNI: “Mind” Your Emotions u “When we consciously [deliberately] shift into a positive emotional

PNI: “Mind” Your Emotions u “When we consciously [deliberately] shift into a positive emotional state, u the heart triggers a response in the brain, u creating a favorable cascade of neural, hormonal and biochemical effects” u Which reverses the effects of stress u “Benefits mind, body and emotions” u “Solid scientific basis, thoroughly tested” u (Rosch)

PNI Physical Evidence: Flu Shots u Brain activation imaging research showed: u Right prefrontal

PNI Physical Evidence: Flu Shots u Brain activation imaging research showed: u Right prefrontal cortex = negative emotions u Left prefrontal cortex = positive emotions u (Lit review in Rosenkranz 2003) u Study: Flu shots, 6 months follow-up measuring presence of antibodies u Activity in right prefrontal cortex (negative) u Predicted weaker immune response u Flu shot “less effective in negative people” u (Davidson 2003)

Another Psychological Strategy: Expressive Writing u Writing in a journal/diary u Improved health, Increased

Another Psychological Strategy: Expressive Writing u Writing in a journal/diary u Improved health, Increased immune function u For patients with AIDS, asthma or arthritis u (Pennebaker u 20 2002) minutes of directed writing x 3 days u Patients with asthma or rheumatoid arthritis u “Improved more, deteriorated less” u (Smith 1999 JAMA)

Another De-stress Strategy: Time Management skills: Lists u Prioritizing, Ordering tasks u Preparation, Advance

Another De-stress Strategy: Time Management skills: Lists u Prioritizing, Ordering tasks u Preparation, Advance planning u Clarify your values. u Learn to say “No” nicely. u (Assertiveness Training) u Organizational

PNI and “Coping Style” u Definition: the way you respond to stress u Mentally,

PNI and “Coping Style” u Definition: the way you respond to stress u Mentally, emotionally, and behaviorally u “It is well documented that the manner in which individuals cope with negative or stressful life events u affects their physical and psychological well-being. ” u (Mac. Mahon 2002)

Positive Coping u There are three ways to cope with a stressful situation. u

Positive Coping u There are three ways to cope with a stressful situation. u Accept it u Change it u Leave it u You do have choices. u [Sense of control] u (Stuart and Lieberman 1983)

TIP: u. We experience the most stress uwhen we try to change things uthat

TIP: u. We experience the most stress uwhen we try to change things uthat we cannot change!

Beyond Coping: “Resilience” u When faced with stress, don’t just u “cope” with it,

Beyond Coping: “Resilience” u When faced with stress, don’t just u “cope” with it, or u “deal” with it, or u “live” with it u Be resilient when challenged by stress u “Crisis” = danger + opportunity u Seize the opportunity! [sense of control]

APA “Road to Resilience” u Be proactive in preventing negative stress damage u Large

APA “Road to Resilience” u Be proactive in preventing negative stress damage u Large menu of “rather ordinary” behaviors u Can be learned by “most anyone” u Including kids u Bundle your own personal package of strategies for building resilience. u http: //helping. apa. org (APA: Newman 2002)

Example of “Resilience Bundle” u Biological strategy u. Breathe! u Psychological strategy u. Positive

Example of “Resilience Bundle” u Biological strategy u. Breathe! u Psychological strategy u. Positive self-talk u Social strategy u. Laugh with others u Spiritual strategy u. Attitude of gratitude

Kids and Resilience u Much of the research shows that children uare more resilient

Kids and Resilience u Much of the research shows that children uare more resilient than adults uhave an easier time adopting the concept of resilience and making it work for them uare able to apply these strategies to all aspects of their lives and development u (Kersting 2003)

Kids, Illness, and Resilience: u Cancer survivors, ages 8 -12: After treatment u “Many

Kids, Illness, and Resilience: u Cancer survivors, ages 8 -12: After treatment u “Many are just as happy and well-adjusted as those who never had the illness. ” u Sometimes even more so: u Example: “I kind of feel guarded by God now. ” (Sebastian, age 9) u (Bhatia 2005)

Recommendation: Kids & Stress Teach kids at an early age how to be resilient:

Recommendation: Kids & Stress Teach kids at an early age how to be resilient: u Have friends and be a friend. u Believe in yourself and what you know you can do. u Take charge of your behavior and actions. u Look at the bright side. u Set new goals and make a plan to reach them. (APA brochures for kids, teens, parents, teachers 2003) http: //helping. apa. org

Lifespan Stressors change with age: u Younger people? u Relationship problems u Middle-agers? u

Lifespan Stressors change with age: u Younger people? u Relationship problems u Middle-agers? u Sandwich generation u Older generation? u Health problems u(Almeida 2002)

Lifespan (continued) u What age group deals best with stress? u Older adults deal

Lifespan (continued) u What age group deals best with stress? u Older adults deal better with their stress. u “Sense of coherence” u. Ability to find meaning in stressful events u“Logical consistency” u (Lutgendorf u “Don’t 2002, Almeida 2002) sweat the small stuff. ” u And remember: u Everything is small stuff.

Psychological De-stressing (cont. ): Attitudes/Beliefs Wisdom of the Ages “Men are disturbed not by

Psychological De-stressing (cont. ): Attitudes/Beliefs Wisdom of the Ages “Men are disturbed not by things, but by the view which they take of them. ” u. Epectetus u. Stoic philosopher u. First century AD

19 th Century Update u “We are what we think about all day long.

19 th Century Update u “We are what we think about all day long. ” u Emerson

Modern Version u “It’s not so much what has happened to a person that

Modern Version u “It’s not so much what has happened to a person that is important, u but what a person tells himself about what has happened. ” u [Self-talk, self-awareness] u Cognitive Psychotherapy u (Ellis 1962)

Consider: Life is 10 % what happens to you and 90% how you react

Consider: Life is 10 % what happens to you and 90% how you react to it.

Best Said: “There’s nothing either Good or bad but Thinking makes it so. ”

Best Said: “There’s nothing either Good or bad but Thinking makes it so. ” (Hamlet)

And Finally: “Good stress” u Bell Curve of stress-health/performance u Optimal stress is midpoint

And Finally: “Good stress” u Bell Curve of stress-health/performance u Optimal stress is midpoint of bell u Distress = “bad stress” u Eustress = “good stress” u (Yerkes-Dodson Law 1908 Harvard) u For good health and/or peak athletic performance u 1. Find and maximize your optimal stress point u 2. Learn how to pull out of the danger zone u (Handout attached)

[FYI: The Breakout Principle] u How to reach your peak performance u Four steps

[FYI: The Breakout Principle] u How to reach your peak performance u Four steps when practicing/performing: u 1. Work hard 2. Tune out (“Relaxation Response”) u 3. “In the zone” (Peak experiences) u 4. Higher performance level is new-normal u u (Benson 2003)

Part I Conclusion: Stress Management Template u Stress is ameliorated when there is: u.

Part I Conclusion: Stress Management Template u Stress is ameliorated when there is: u. An outlet for frustration u. A sense of control u. Social support u. A belief that something better will follow u(Sapolsky 2003 Scientific American)

FP Practice Points Gradually teach your patients u 1. Awareness of their stress profile

FP Practice Points Gradually teach your patients u 1. Awareness of their stress profile u 2. Simple stress busters u. Over many years of contact u. One visit at a time

Summary: Key Points u Our usual response to stress is automatic. u You can

Summary: Key Points u Our usual response to stress is automatic. u You can learn to take control and change this automatic response. u The bio-psycho-social-spiritual model offers abundant stress-busting strategies. u Controlling your reaction to stress can improve your health.

The End u Please turn in your evaluations.

The End u Please turn in your evaluations.