GP Health & WellnessDr. Leon Massage

Common myths

1. Self-care is ‘selfish’

2. Asking for help is a sign of weakness

3. You only practice stress management when you really need it

4. Being relaxed means lower performance or lack of commitment

Outline

• The causes of stress

• The consequences of stress

• Stress, health and the mind-body connection

• Strategies for lifestyle change

• Stress management and relaxation techniques

Wellness spiral

Illness

Wellness

Demonstrablepathology

Averagewell-being

High levelwell-being

Holisticfocus

Conventionalmedical care

Stress and Performance

NOT ALL STRESS IS BAD

• No stress equals no performance– Inertia, procrastination etc

• Some stress associated with higher performance

• Too much stress leads to diminished performance– Burnout, inefficient, unable to prioritize, tense

etc

The “fight or flight response”

• A natural, necessary and appropriate physiological response to an exceptional situation

– E.g. attack by a saber- tooth

– Response is based on a clearly perceived threat– It is encoded into our physiology to preserve

life– Changes include:

The “fight or flight response”

Physiological Changes

• Elevation of blood-pressure and heart rate• Diversion of blood-flow to muscles and away

from the gut• Platelet adhesiveness (becoming ‘stickier’ to

stop bleeding)• Short-term mobilisation of white-blood cells• Effects on inflammatory hormones (e.g.

cortisol, cytokines, interleukins etc)

Stress response• ‘Fight or flight’ response is appropriate

and life protecting providing:– It is only turned on when it needs to be– It is allowed to turn off when it is no

longer needed– It is not prolonged

• Mediated primarily via sympathetic and parasympathetic systems but interacts with every system

The stress of modern life

• Tends to be chronic and prolonged

• Increasing at an alarming rate– E.g. 45% increase over the last 30 years– Could be explained by increased awareness of

stress and also more stressful and busy lives

• Stress is cumulative

• Stress reduces serotonin

The Stress Cycle

• Chemical stressors

• Emotional Stressors

• Physical Stressors StressOverload

• Social stressors

• Environmental stressors

• Family stressors

The Stress Cycle- short term effects

1. Behavioural – e.g. Over eating, excess alcohol

2. Physiological – e.g. Tachycardia, hypertension

3. Emotional – e.g. Anxiety, depression, hostility

4. Cognitive – e.g. Decreased concentration

The Stress Cycle- long term effects

1. Behavioural disorders – e.g. Obesity, alcoholism

2. Medical disorders – e.g. Hypertension, heart disease

3. Emotional disorders – e.g. Chronic anxiety, depression, phobias

4. Cognitive disorders – e.g. Memory problems, insomnia

Gender and the stress response• Men and women respond to stress differently• Men respond to stress through ‘fight or flight’

– Predominantly sympathetic arousal accentuated by testosterone

• Women experience ‘tend and befriend’ response– Fight and flight moderated through oxytocin and other

hormones– Secreted at times of bonding, nurturing, breast

feeding and relationships

• Male and female responses may have evolutionary and adaptive implications

Stress and Perception

“Man is not disturbed by events, but by the view he takes of them.”

Epictetus

Stress and perception

• Mis-perception of stress can be– Imagination

• E.g. worrying about future exams

– Rumination• E.g. going over a past mistake

– Exaggeration• E.g. blowing things out of proportion

• Stress is eased by:– Focusing on the present

• E.g. performing one action at a time

– Clarifying perception• E.g. CBT, mindfulness, relaxation, information gathering

Physiological effects of stress reduction

• Reduction in stress hormones• Reduction in blood pressure and heart rate• Reduction in cortisol levels• Reduction in serum cholesterol• EEG changes (increase in alpha and theta waves)• Reduction in epileptic seizure frequency• Changes in neurotransmitters: higher serotonin and

dopamine• Improved immune function • Reduction of inflammation• Adjunct to therapy (CVD, cancer, chronic pain,

asthma, diabetes)

PNI - Psychoneuroimmunology

• The mind communicates with the immune system through the nervous (and endocrine) systems

• 2 main methods of communication– Postal (blood-borne hormones) and cable (nerve

fibres) services

• Immune defenses include cellular (NK-lymphocytes) and humoral (immunoglobulins) immunity

PNI – clinical relevance

1. Lowered immune markers2. Increased susceptibility to infections3. An increased severity and progression of

infections4. Increased relapse rate of chronic and latent

infections5. Increased activity of inflammatory illnesses6. Increased activity of autoimmune conditions7. Poor response to immunisation8. Effects on the activity of allergic conditions

Health promoting responses to stress

1. Adaptive Behavioural responses

• Time management, Assertiveness training

2. Adaptive Physical responses

• Nutrition, Exercise

3. Adaptive Emotional responses

• Relaxation, meditation, CBT

Mind-Body interventions

• Stress management• CBT• Mindfulness therapy• Psychotherapy• Family therapy• Meditation / relaxation exercises• Humour• Conditioning• Prayer

Long term effects of health promoting lifestyle responses

• Behavioural Response Raised Self esteem, increased confidence

• Physical Response Improvement in health, improved immune

response

• Emotional Response Improved mental health, ability to cope with stress

Psychosocial factors and CHD

• “Recent studies provide clear and convincing evidence that psychosocial factors contribute significantly to the pathogenesis and expression of CAD.”

• Data relates CAD risk to 5 specific psychosocial domains– depression– anxiety– personality factors and character traits– social isolation– chronic life stress

• Rozanski et al. Circulation 1999;99(16):2192-217

Is heart disease reversible?• Heart disease is reversible given the right

conditions• Significant improvement possible in both the

disease and quality of life.• People with already well established CHD given

conventional medical management plus or minus an intervention (comprehensive lifestyle program)

• As risk factors are synergistic so too should be positive interventions.– Ornish D. et al. Lancet 1990;336:129-133.

The Ornish Program

• The program consisted of:– group support– stress management consisting of meditation

and yoga– a low fat vegetarian diet– moderate exercise– stopping smoking

• Stress was central to dealing with other risk factors

Results

Intervention Control

Progression 82% regressed

53% progressed

Symptom frequency

91 165

Duration 42 95

Severity 28 39

Lifestyle change and CHD

• 5 year follow-up of the Ornish program

• Most of the original intervention group maintained changes

• Outcome measures– angiographic changes– risk ratio for cardiac events

• JAMA 1998;280:2001-7

What else can make us feel better?

• Sunlight Increases serotonin

• Exercise Mops up stress hormones

• Dark chocolate Contains endorphins, antioxidant, anti-aging

• Fish Anticarcinogenic

• Folic Acid Suppresses dysplasia

GP Health & Wellbeing

Questions & Discussion

Dr. Leon Massage