Via Christi Women's Connection presentation on "Better ways to handle stress," by Connie Marsh, MD,

1. Stress:
Better Ways to Handle It
November 12, 2013

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. Stress
Reality is the leading cause of stress
among those in touch with it.
--Lily Tomlin

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. 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. Stress in America
What are the big three?
 Family
 Economy
 Health
 Work
 Money
 Relationships

7. Stress in America
Causes:
 Money
 Work
 Economy

9. Stress in America
Americans still managing stress in unhealthy
ways
 Overeating, unhealthy foods
 Alcohol/drugs
 Sedentary behaviors



music
napping
reading

10. 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.

11. 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

12. 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

13. 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

15. 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.

16. Stress
Increased stress results in increased
productivity up to a point.

17. 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**

18. To achieve great things, two things are
needed:
 a plan and not quite enough time.
--Leonard Bernstein

19. Stress
Much is known about acute stress
Less is known about chronic stress

20. Stress
If temporary, physical effects usually
temporary
 Example


Test anxiety among college students
increased severity of acne
Condition diminished after exams over

21. 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.

22. 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.

24. Nervous System
Sympathetic nervous system signals
adrenals to release norepinephrine and
cortisol
 Increased heart rate
 Increased BP
 Increase blood glucose levels

25. Stress

26. 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

27. Endocrine Response to Stress
Inflammation
Chronic exposure to stress hormones
 Weakens immune system
 Change structure of chromosomes
27

28. Chronic Stress: The Bad Stuff

29. 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

30. 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

32. 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

33. 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

35. 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

36. 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

38. 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)

39. 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

40. 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

41. 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

43. 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

44. 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)

45. 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

46. 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.

48. 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.

49. 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

50. 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

51. Stress: Better Ways to Handle It

52. 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

53. Cognitive Behavioral Therapies
 Correcting cognitive distortions
 Relaxation response
 Mindfulness
 Time Management
 Stress Management
 Meditation

54. Cognitive Behavioral Therapies
Easily accessible
 CBT manuals
 Smart phone apps
 Internet sites

56. 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

57. 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

58. The greatest weapon against stress is our
ability to choose one thought over another.
--William James

59. 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

60. 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

61. 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.

62. 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.

63. 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

64. Cognitive Behavioral Therapies
 Meditation=improved amygdala and
hippocampus structure
 Relaxation Training=dampens acute
“stress reaction”
 CBT, Tai Chi=improved immunity to
vaccines

66. 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.

67. 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

68. 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?

69. Exercise
Exercise does more to bolster thinking than
thinking.
Many people skip exercise at the time it is
needed most.

70. Electronic World
Pressures of today’s connected world
 Email
 Cell phones
 Constant internet
Increasingly difficult to switch off and
concentrate on personal priorities.

71. Management of Electronic World
TAKE A NEWS/ELECTRONIC WORLD
BREAK

73. Stress Reduction






Exercise
Meditation
Guided imagery
Nap
Massage
Yoga





Tai chi
Music
Biofeedback
Time out: short walk
Reading

74. Stress Management
Remove or alter the stressor
Change the perception of the stress
Reduce the physiologic sequelae of stress
Use alternative coping strategies

75. 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

76. 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

78. A life of being, having, and doing enough
--Wayne Muller 2010

79. Management NOW
Relax NOW
 Visualization
 Deep breathing
 Repeat word or phrase
 Change thought

80. 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)