Stress: The difference Stress: The difference between Wellness and between Wellness and

IllnessIllness

Stephen Amos, PhDStephen Amos, PhD

KUSM-W Dept of PediatricsKUSM-W Dept of Pediatrics

DefinitionsDefinitions

►Stress: Stress: The body’s non specific response to any The body’s non specific response to any

demand made on it.demand made on it.

►Better:Better: Stress is what happens when the Stress is what happens when the

perceived demands of a situation are perceived demands of a situation are greater than the perceived coping skills greater than the perceived coping skills we believe we have to deal with the we believe we have to deal with the situation.situation.

A.A. StressStress = The way we = The way we feelfeel

B.B. StressorStressor = what makes = what makes us feel that wayus feel that way

C.C. Personal InterpretationPersonal Interpretation = The critical point = The critical point between A and Bbetween A and B

Definitions Definitions (Continued)(Continued)

The Stress ResponseThe Stress ResponseFirst known scientific research conducted by First known scientific research conducted by

Walter Cannon. His study of shell shocked Walter Cannon. His study of shell shocked soldiers in WWI created the name “ Fight – soldiers in WWI created the name “ Fight – Flight – Fright” response.Flight – Fright” response.

This response is governed by the This response is governed by the

Autonomic Nervous SystemAutonomic Nervous System (rules involuntary body functions)(rules involuntary body functions)

SympatheticSympathetic

ActivationActivation

Para SympatheticPara Sympathetic

De-activationDe-activation

Stress begins in the BrainStress begins in the Brain

► The primary Stress hormone corticotropin The primary Stress hormone corticotropin releasing factor (CRF).releasing factor (CRF).

► Two major pathways in the brain for CRF.Two major pathways in the brain for CRF.

amygdalaamygdala

(crucial early warning (crucial early warning systemsystem

& emotional regulation)& emotional regulation)

hypothalamushypothalamus

(major command center(major command center

for hormone activation)for hormone activation)

Inside the Stress ResponseInside the Stress Response

Inside the Stress ResponseInside the Stress Response► What Happens?What Happens?

1.1. Senses SharpenSenses Sharpen

2.2. Blood pressure risesBlood pressure rises

3.3. Breath quickens and we take in more oxygenBreath quickens and we take in more oxygen

4.4. Heart beats fasterHeart beats faster

5.5. Muscles tightenMuscles tighten

6.6. Glucose & Fats are released into the bloodstreamGlucose & Fats are released into the bloodstream

7.7. Adrenal Glands release Cortisol, adrenaline and Adrenal Glands release Cortisol, adrenaline and noradrenalinenoradrenaline

8.8. Pituitary releases adrenocorticotropin (ACTH)Pituitary releases adrenocorticotropin (ACTH)

9.9. Reproductive, digestive and other growth systems are shut Reproductive, digestive and other growth systems are shut down. (energy conservation in the face of crisis)down. (energy conservation in the face of crisis)

10.10. Energy resources are redirected to the elimination of the Energy resources are redirected to the elimination of the stressorstressor

Another Look Another Look ► Metabolism is activatedMetabolism is activated► Stress – Brought to you by Stress – Brought to you by CRF CRF► CRF – two major pathways: amygdala & hypothalamus.CRF – two major pathways: amygdala & hypothalamus.

Amygdala – warnsAmygdala – warns Hypothalamus – command center – connected to pituitaryHypothalamus – command center – connected to pituitary

► Pituitary – releases stress hormones including ACTHPituitary – releases stress hormones including ACTH ACTH – activates the adrenals producing:ACTH – activates the adrenals producing:

► AdrenalineAdrenaline► NoradrenalineNoradrenaline► CortisolCortisol

► All of this results in the release of glucocorticoids and All of this results in the release of glucocorticoids and catecholamines increasing metabolism to send fuel in the form catecholamines increasing metabolism to send fuel in the form of glucose, triglycerides, and free fatty acids via the blood of glucose, triglycerides, and free fatty acids via the blood stream.stream.

► But it doesn’t end here.But it doesn’t end here.► All this activity causes some systems to shut down most All this activity causes some systems to shut down most

notably: notably: ReproductionReproduction DigestionDigestion

The Positive Side of StressThe Positive Side of Stress

►The increased energy allows people to The increased energy allows people to accomplish things they never thought accomplish things they never thought possible.possible.

►Fight or Flight helps us to rise to the Fight or Flight helps us to rise to the challenge before us.challenge before us.

►Stress actually enhances performance Stress actually enhances performance to a degree.to a degree.

Yerkes-Dodson LawYerkes-Dodson Law

Performance or efficiency

Stress or anxiety

As stress increases, performance initially rises and then declines.

PerformancPerformancee

However, it is important to remember the However, it is important to remember the ability to generate a fear response is a ability to generate a fear response is a critical though unpleasant experience. critical though unpleasant experience.

It can mean the difference betweenIt can mean the difference between

life or death.life or death.

Factors Affecting the Stress Factors Affecting the Stress ResponseResponse

►ControlControl

►Certainty / predictabilityCertainty / predictability

►PerceptionPerception

Distress vs. EustressDistress vs. Eustress► Some stressors actually increase our quality of life Some stressors actually increase our quality of life

(Health), while others detract from it (Illness).(Health), while others detract from it (Illness).

► And not all stressors are created equal.And not all stressors are created equal.

EVENT SCORE

Spouse’s death 100

Divorce 73

Marriage separation 65

Jail term 63

Injury or illness 53

Pregnancy 40

Retirement 45

Change in finances 38

EVENT SCORE

Trouble with in-laws 29

Difficulty with boss 23

Shift in job hours or conditions 20

Change in residence 20

Change in recreation 19

Shift in sleep habits 16

Vacation 13

Christmas 12

Personality and StressPersonality and Stress

► Stress Vulnerable –Stress Vulnerable – Pessimistic with poor problem solving skillsPessimistic with poor problem solving skills Early life trauma – pre-setting the amygdala for Early life trauma – pre-setting the amygdala for

threatthreat Hot wired for Fight or FlightHot wired for Fight or Flight

► Stress Hardy –Stress Hardy – Regular exerciseRegular exercise Social supportSocial support Perception of control, challenge, commitmentPerception of control, challenge, commitment PredictabilityPredictability

Individual DifferencesIndividual Differences

► Personality Traits – Shyness vs. Sociability, Personality Traits – Shyness vs. Sociability, Curiosity vs. TimidityCuriosity vs. Timidity More timid/shy = increased levels of stress More timid/shy = increased levels of stress

hormoneshormones Many forms of chronic illnessMany forms of chronic illness Higher in shy peopleHigher in shy people

► Perceived Resources – high vs. low self esteemPerceived Resources – high vs. low self esteem Low self esteem – high reactivity to stressLow self esteem – high reactivity to stress

►Magnitude of Response – “hot wired” vs. “cool Magnitude of Response – “hot wired” vs. “cool wired”, wired”, Seems moderated by early life events & Seems moderated by early life events & geneticsgenetics

The Physical Difference between The Physical Difference between Anxiety Anxiety (Irrational Fear)(Irrational Fear) and Fear itself. and Fear itself.

► NONENONE

Both anxiety and fear are normal responses to a Both anxiety and fear are normal responses to a perceived threat but they exist at opposite perceived threat but they exist at opposite ends of a spectrum.ends of a spectrum.

Anxiety Fear

Unknown or ill defined threat. Well defined threat.

► The body does a poor job distinguishing between The body does a poor job distinguishing between a real life threatening event and anxiety a real life threatening event and anxiety triggered by less momentous sources (difficult triggered by less momentous sources (difficult boss or co-worker, traffic jams, financial fears).boss or co-worker, traffic jams, financial fears).

Anxiety vs. FearAnxiety vs. Fear

When Stress is ChronicWhen Stress is Chronic► Physical CostsPhysical Costs

AllergiesAllergies DermatitisDermatitis DiabetesDiabetes Heart BurnHeart Burn HypertensionHypertension Infectious DiseaseInfectious Disease Irritable Bowel SyndromeIrritable Bowel Syndrome PainPain Side effectsSide effects UlcersUlcers

When Stress is ChronicWhen Stress is Chronic

►Psychological CostPsychological Cost DepressionDepression AnxietyAnxiety Sleep disturbanceSleep disturbance AngerAnger ResentmentResentment ObsessionsObsessions CompulsionsCompulsions

Another way to Assess StressAnother way to Assess Stress

Stress and SleepStress and Sleep

► Chronic stress impairs sleepChronic stress impairs sleep Rumination over slings and arrowsRumination over slings and arrows Activation of stress responseActivation of stress response Inhibition of brain hormone systems that activate Inhibition of brain hormone systems that activate

sleepsleep Sleep deprivation renders us irritable and more Sleep deprivation renders us irritable and more

sensitive to threatsensitive to threat We increase reactivity to stressors leading to We increase reactivity to stressors leading to

increased anger and anxietyincreased anger and anxiety Increased sleep deprivationIncreased sleep deprivation Cycle inevitably worsensCycle inevitably worsens

Chronic Disease StatusChronic Disease Status

►Development – Development – Slow and steady processSlow and steady process Cumulative – Doesn’t happen overnightCumulative – Doesn’t happen overnight

►Homeostasis –Homeostasis – Regulation of the body to a balance point and the Regulation of the body to a balance point and the

subtle ebb and flow of the bodysubtle ebb and flow of the body

► Allostasis –Allostasis – Movement to balance thru challenge Movement to balance thru challenge

►Both involve the body’s attempt to achieve stability but Both involve the body’s attempt to achieve stability but allostasis is a more dynamic process best reserved for allostasis is a more dynamic process best reserved for the short termthe short term

Chronic Disease StatusChronic Disease Status

► Long term allostatic load = Chronic Stress.Long term allostatic load = Chronic Stress. Continuous activation of stress hormones.Continuous activation of stress hormones. Insulin efficiency decreases.Insulin efficiency decreases. Wear and tear on physiology increases.Wear and tear on physiology increases. Quality of sleep declines.Quality of sleep declines. We eat more & crave more high fat diets.We eat more & crave more high fat diets. We are more easily fatigued and less active.We are more easily fatigued and less active. Blood pressure rises.Blood pressure rises. Increased levels of triglyceride and cholesterol Increased levels of triglyceride and cholesterol

leading to diabetes, heart disease, and sometimes leading to diabetes, heart disease, and sometimes to behaviors that maintain the vicious cycle.to behaviors that maintain the vicious cycle.

How do we participate?How do we participate?►Making a Stressful World more Stress Full.Making a Stressful World more Stress Full.

Activating Event (A)

Consequent Feeling/Behavior (C)

We Believe that

Belief system(Personal Perspective)

(B)

Causes

There is a living organism between A-(Activating Event) and C-(Consequent Feeling/Behavior). This “living organism” is an information processor governed by a complex system of attitudes, beliefs, and expectations

concerning how life does and should work. So it is the perceptual experience of the individual that predetermines psychological (Cognitive/Behavioral)

outcomes.

REALITY = To get form A to C, A must go through B.

A BEHAVIORAL COGNITIVE DISPLAY (ABCD’S)A BEHAVIORAL COGNITIVE DISPLAY (ABCD’S)AA BB CC DD

ACTIVATING EVENT:ACTIVATING EVENT: BELIEF SYSTEMBELIEF SYSTEM CONSEQUENT CONSEQUENT FEELINGS/BEHAVIORSFEELINGS/BEHAVIORS

DECISION POINTDECISION POINT(Deal with it/Do it right)(Deal with it/Do it right)

(Antecedent i.e. comes (Antecedent i.e. comes before) before) Something happens Something happens representing some triggering representing some triggering event to an emotional stateevent to an emotional state

Personal Perspective:Personal Perspective:Private ideas and attitudes Private ideas and attitudes that occur spontaneously that occur spontaneously and seem more like and seem more like automatic thinkingautomatic thinking

Negative Emotional State Negative Emotional State (and resultant negative (and resultant negative behavioral actions) which tend behavioral actions) which tend to lead to self-fulfilling negative to lead to self-fulfilling negative personal positionspersonal positions

To overcome the negative effects of To overcome the negative effects of “B” (Belief System) we must engage “B” (Belief System) we must engage in a cognitive/behavioral (thoughtful in a cognitive/behavioral (thoughtful and active) shift in our personal and active) shift in our personal perspectives.perspectives.

THE FOUR WAYS THINGS THE FOUR WAYS THINGS GO WRONG:GO WRONG:Distorted ThinkingDistorted ThinkingIrrational BeliefsIrrational BeliefsUnrealistic ExpectationsUnrealistic ExpectationsFamily ScriptingFamily Scripting

Problem Feedings:Problem Feedings:DepressionDepressionAnxietyAnxietyPanicPanicAngerAngerResentmentResentmentPhobias, etc.Phobias, etc.

DEVICES FOR PERSPECTIVE DEVICES FOR PERSPECTIVE SHIFTING=SHIFTING=Meditation and/or visualization, Meditation and/or visualization, thought stopping, relaxation, thought stopping, relaxation, Prayer, etc.Prayer, etc.

& BEHAVIORS:& BEHAVIORS:Acting out Acting out AvoidanceAvoidanceWithdrawalWithdrawalSubstance abuseSubstance abuseUnfair fightingUnfair fightingVerbal abuse, etc.Verbal abuse, etc.

DISTRACT:DISTRACT:Do a different physical activity Do a different physical activity such as gardening, playing an such as gardening, playing an instrument, cleaning house, instrument, cleaning house, begin a painting, etc.begin a painting, etc.

DIVERT:DIVERT:Do a different mental activity such Do a different mental activity such as listen to tapes, do crossword as listen to tapes, do crossword puzzle, write a poem/song. Etc.puzzle, write a poem/song. Etc.

DISPUTE/DEBATE:DISPUTE/DEBATE:Challenge the “enemy” within i.e. Challenge the “enemy” within i.e. the gremlin/negative self talk by the gremlin/negative self talk by using the scientific method of the using the scientific method of the friend within (the “baker of your friend within (the “baker of your own cake metaphor”). Remember own cake metaphor”). Remember that the language of the self talk of that the language of the self talk of the friend within is logical, the friend within is logical, objective, practical, realistic, objective, practical, realistic, common sense, beneficial, common sense, beneficial, adult/adult conversation.adult/adult conversation.

Lets Look at AngerLets Look at Anger2 X 2 Table of Anger

Appropriate Expression

Inappropriate Expression

Appropriate Anger

Inappropriate Anger

100 %

Lets Look at AngerLets Look at Anger

25 %

25 % 25%

25%

2 X 2 Table of Anger

Appropriate Expression

Inappropriate Expression

Appropriate Anger

Inappropriate Anger

100 %

Note the Four Cells – Leaving only one cell

(25%) appropriate both

for anger and expression of

anger

But its even more But its even more complicatedcomplicated

►Perception is at the root of all stress.Perception is at the root of all stress.

►And our perceptions are moderated by And our perceptions are moderated by our brain/mind.our brain/mind.

Four Ways Things Go WrongFour Ways Things Go Wrong

1.1. Distorted Thinking.Distorted Thinking.

2.2. Irrational Beliefs.Irrational Beliefs.

3.3. Unrealistic Expectations.Unrealistic Expectations.

4.4. Family Scripting.Family Scripting.

When these are active, the appropriate When these are active, the appropriate expressionexpression of appropriate anger cell is depleted. of appropriate anger cell is depleted.

?

? 25%

25%

Appropriate Expression

Inappropriate Expression

Appropriate Anger

Inappropriate Anger

100 %

So what to do?So what to do?

Managing StressManaging Stress

1.1. Learning ways to relaxLearning ways to relax The relaxation responseThe relaxation response Progressive muscle relaxationProgressive muscle relaxation Meditation techniquesMeditation techniques

1.1. Learning ways to relaxLearning ways to relax The relaxation responseThe relaxation response Progressive muscle relaxationProgressive muscle relaxation Meditation techniquesMeditation techniques YogaYoga VisualizationVisualization PrayerPrayer Guided ImageryGuided Imagery Relaxation or Serenity Tapes/ CDsRelaxation or Serenity Tapes/ CDs

Managing StressManaging Stress

Managing Stress Managing Stress (continued)(continued)

2.2. Setting Aside Personal Time.Setting Aside Personal Time.► Journaling.Journaling.► Exercise.Exercise.

Managing Stress Managing Stress (continued)(continued)

2.2. Setting Aside Personal TimeSetting Aside Personal Time► JournalingJournaling► ExerciseExercise► Social SupportSocial Support

“My wife left me for health reasons.She was sick of me.”

Managing Stress Managing Stress (continued)(continued)

2.2. Setting Aside Personal TimeSetting Aside Personal Time► JournalingJournaling► ExerciseExercise► Social SupportSocial Support► Pursuing joyful activitiesPursuing joyful activities► Eating wellEating well► Time managementTime management

Managing Stress Managing Stress (continued)(continued)

2.2. Setting Aside Personal TimeSetting Aside Personal Time► JournalingJournaling► ExerciseExercise► Social SupportSocial Support► Pursuing joyful activitiesPursuing joyful activities► Eating wellEating well► Time managementTime management► 10 – 2 - 410 – 2 - 4

Stress Over Time

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Stress Over Time

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Stress Over Time

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Stress over time with Meditation

Managing Stress Managing Stress (continued)(continued)

3.3. Cognitive RestructuringCognitive Restructuring Reframing automatic negative thoughts Reframing automatic negative thoughts

with more rational responses that with more rational responses that promote coping.promote coping.

Learned Optimism.Learned Optimism.

Questions ?Questions ?