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Stress

Highlights

Stress affects most individuals in our modern society to some degree. Recent studies on stress have focused on several issues, including the causes of stress and why some people are more vulnerable, the body’s response to stress, and the effectiveness of different stress reduction techniques.

Acute Stress

Acute stress leads to rapid changes throughout the body that affect the brain, heart, lungs, immune system, skin, and metabolism. These changes can result in immediate effects that could prove beneficial in a critical, life-or-death situation. Over time, however, repeated stressful situations put a strain on the body that may contribute to both physical and psychological problems.

Cortisol and Stress

During an acute stress response, levels of a hormone called cortisol are increased. Cortisol is therefore called a “stress hormone”, and is thought to be involved in many effects of stress. Researchers can measure cortisol levels to determine people’s physical reactions to stress and to quantitatively measure the effectiveness of stress reduction techniques. In one such study, individuals who received training in cognitive-behavior techniques and were later exposed to a stressful situation had dampened cortisol responses as a result of the training. Other studies have found that massage therapy can decrease cortisol levels in a variety of individuals. Apparently, the massage need not come from an expert: women receiving instructed shoulder-neck massages from their partners immediately before a stressful situation had dampened cortisol increases after the stressor.

Stress can affect everyone

Overall, stress continues to affect many people, from children to older adults. Chronic stress can have real health consequences, and should be addressed like any other health concern. Fortunately, research is showing that lifestyle changes and stress reduction techniques can be beneficial for learning to effectively manage stress.

Introduction

The stress response of the body is somewhat like an airplane readying for take-off. Virtually all systems (the heart and blood vessels, the immune system, the lungs, the digestive system, the sensory organs, and brain) are modified to meet the perceived danger.

External and Internal Stressors

People can experience either external or internal stressors.

• External stressors include adverse physical conditions (such as pain or hot or cold temperatures) or stressful psychological environments (such as poor working conditions or abusive relationships). Humans, like animals, can experience external stressors.
• Internal stressors can also be physical (infections, inflammation) or psychological. An example of an internal psychological stressor is intense worry about a harmful event that may or may not occur. As far as anyone can tell, internal psychological stressors are rare or absent in most animals except humans.

Acute or Chronic Stress

Stressors can also be defined as short-term (acute) or long-term (chronic).

Acute Stress. Acute stress is the reaction to an immediate threat, commonly known as the fight or flight response. The threat can be any situation that is experienced, even subconsciously or falsely, as a danger.

Common acute stressors include:

• Noise (which can trigger a stress response even during sleep).
• Crowding.
• Isolation.
• Hunger.
• Danger.
• Infection.
• High technology effects (playing video games, frequently ringing mobile phones).
• Imagining a threat or remembering a dangerous event.

Under most circumstances, once the acute threat has passed, the response becomes inactivated and levels of stress hormones return to normal, a condition called the relaxation response.

Chronic Stress. Frequently, however, modern life poses on-going stressful situations that are not short-lived and the urge to act (to fight or to flee) must be suppressed. Stress, then, becomes chronic. Common chronic stressors include:

• On-going highly pressured work.
• Long-term relationship problems.
• Loneliness.
• Persistent financial worries.

The Body's Response

The best way to envision the effect of acute stress is to imagine oneself in a primitive situation, such as being chased by a bear.

The Brain's Response to Acute Stress

In response to seeing the bear, a part of the brain called the hypothalamic-pituitary-adrenal (HPA) system is activated.

Release of Steroid Hormones and the Stress Hormone Cortisol. The HPA systems trigger the production and release of steroid hormones (glucocorticoids), including the primary stress hormone cortisol. Cortisol is very important in marshaling systems throughout the body (including the heart, lungs, circulation, metabolism, immune systems, and skin) to deal quickly with the bear.

Release of Catecholamines. The HPA system also releases certain neurotransmitters (chemical messengers) called catecholamines, particularly those known as known as dopamine, norepinephrine, and epinephrine (also called adrenaline).

Catecholamines activate an area inside the brain called the amygdala, which apparently triggers an emotional response to a stressful event. (In the case of the bear, this emotion is most likely fear.)

Effects on Long- and Short Term Memory. During the stressful event, catecholamines also suppress activity in areas at the front of the brain concerned with short-term memory, concentration, inhibition, and rational thought. This sequence of mental events allows a person to react quickly to the bear, either to fight or to flee from it. (It also hinders the ability to handle complex social or intellectual tasks and behaviors during that time.)

On the other hand, neurotransmitters at the same time signal the hippocampus (a nearby area in the brain) to store the emotionally loaded experience in long-term memory. In primitive times, this brain action would have been essential for survival, since long-lasting memories of dangerous stimuli (such as the large bear) would be critical for avoiding such threats in the future.

Response by the Heart, Lungs, and Circulation to Acute Stress

The stress response also affects the heart, lungs, and circulation:

• As the bear comes closer, the heart rate and blood pressure increase instantaneously.
• Breathing becomes rapid and the lungs take in more oxygen.
• The spleen discharges red and white blood cells, allowing the blood to transport more oxygen throughout the body. Blood flow may actually increase 300 - 400%, priming the muscles, lungs, and brain for added demands.

The Immune System's Response to Acute Stress

The effect on the immune system from confrontation with the bear is similar to marshaling a defensive line of soldiers to potentially critical areas. The steroid hormones dampen parts of the immune system, so that specific infection fighters (including important white blood cells) or other immune molecules can be redistributed. These immune-boosting troops are sent to the body's front lines where injury or infection is most likely, such as the skin and the lymph nodes.

The Acute Response in the Mouth and Throat

As the bear gets closer, fluids are diverted from nonessential locations, including the mouth. This causes dryness and difficulty in talking. In addition, stress can cause spasms of the throat muscles, making it difficult to swallow.

The Skin's Response to Acute Stress

The stress effect diverts blood flow away from the skin to support the heart and muscle tissues. (This also reduces blood loss in the event that the bear causes a wound.) The physical effect is a cool, clammy, sweaty skin. The scalp also tightens so that the hair seems to stand up.

Metabolic Response to Acute Stress

Stress shuts down digestive activity, a nonessential body function during short-term periods of physical exertion or crisis.

The Relaxation Response: the Resolution of Acute Stress

Once the threat has passed and the effect has not been harmful (for example, the bear has not  wounded the human), the stress hormones return to normal. This is known as the relaxation response. In turn, the body's systems also normalize.

Complications

In prehistoric times, the physical changes in response to stress were an essential adaptation for meeting natural threats. Even in the modern world, the stress response can be an asset for raising levels of performance during critical events such as a sports activity, an important meeting, or in situations of actual danger or crisis.

If stress becomes persistent and low-level, however, all parts of the body's stress apparatus (the brain, heart, lungs, vessels, and muscles) become chronically over- or under-activated. Such chronic stress may produce physical or psychologic damage over time. Acute stress can also be harmful in certain situations, particularly in individuals with preexisting cardiac conditions.

Psychologic Effects of Stress

Studies suggest that the inability to adapt to stress is associated with the onset of depression or anxiety. In one study, two-thirds of subjects who experienced a stressful situation had nearly six times the risk of developing depression within that month.

Some evidence suggests that repeated release of stress hormone produces hyperactivity in the hypothalamus-pituitary-adrenal axis and disrupts normal levels of serotonin, the nerve chemical that is critical for feelings of well-being. Certainly, on a more obvious level, stress diminishes the quality of life by reducing feelings of pleasure and accomplishment, and relationships are often threatened.

Nevertheless, some stress may be beneficial. For example, although some research has suggested that stress may be a risk factor for suicide, a 2003 study found a higher risk for suicide in women reporting both low and very high stress. Those with moderate stress levels, however, had the lowest risk.

Heart Disease

The effects of mental stress on heart disease are controversial. Stress can certainly influence the activity of the heart when it activates the sympathetic nervous system (the automatic part of the nervous system that affects many organs, including the heart). Such actions and others could theoretically negatively affect the heart in several ways:

• Sudden stress increases the pumping action and rate of the heart while at the same time causing the arteries to constrict, thereby restricting blood flow to the heart. A 2002 study suggested that such actions may be responsible for some incidences of acute stress that have been associated with a higher risk for serious cardiac events, such as heart rhythm abnormalities and heart attacks, and even death in people with heart disease.
• Emotional effects of stress alter the heart rhythms, which could pose a risk for serious arrhythmias in people with existing heart rhythm disturbances.
• Stress causes blood to become stickier (possibly in preparation of potential injury), increasing the likelihood of an artery-clogging blood clot.
• Stress appears to impair the clearance of fat molecules in the body, raising blood-cholesterol levels, at least temporarily.
• Chronic stress may lead to the production of certain immune factors called cytokines that produce a damaging inflammatory response, which is now believed to be responsible for injuries in the arteries that contribute to heart disease.
• Studies have reported an association between stress and hypertension (high blood pressure), which may be more pronounced in men than in women. According to some evidence, people who regularly experience sudden spikes in blood pressure caused by mental stress may, over time, developed injuries in the inner lining of their blood vessels. In one 20-year study, for example, men who periodically measured highest on the stress scale were twice as likely to have high blood pressure as those with normal stress.

Nevertheless, evidence is still needed to confirm any clear cut relationship between stress and heart disease. For example, a 2002 study in Scotland found no greater risk for actual heart disease or heart events even in men who reported higher mental stress. In fact, higher stress was associated with fewer heart events. (Men with high stress levels did tend to complain of chest pain and to go to the hospital for it more often than those with lower stress. They also went to the hospital more often.)

Evidence has linked stress to heart disease in men, particularly in work situations where they lack control. The association between stress and heart problems in women is weaker and there is some evidence that the ways women cope with stress may be more heart-protective. In one study, for example, men were more apt than women to use alcohol or eat less healthily in response to stress than women, which might account for their higher heart risks from stress. Different stressors may affect genders differently. In one study, work stress was associated with a higher risk for heart disease in men, but marital stress-- not work stress--was associated with more severe heart disease in women with existing heart problems.

Stress Reduction and Heart Disease. Studies in 2001 and 2002 suggest that treatments that reduce psychological distress improve long-term outlook in people with heart disease, including after a heart attack. Some evidence exists that stress management programs may reduce the risk of heart events (e.g., heart attack) by up to 75% in people with heart disease. Specific stress management techniques may help some problems but not others. For example, acupuncture in one study helped people with heart failure but had no effect on blood pressure. Relaxation methods, on the other hand, may help hypertensive individuals.

Stroke

One survey revealed that men who had a more intense response to stressful situations, such as waiting in line or problems at work, were more likely to have strokes than those who did not report such distress. In some people prolonged or frequent mental stress causes an exaggerated increase in blood pressure. In fact, a 2001 study has linked for the first time a higher risk for stroke in adult Caucasian men and elevated blood pressure during times of stress.

Effect on the Immune System

Chronic stress affects the immune system in complex ways, which may have various effects.

Susceptibility to Infections. Chronic stress appears to blunt the immune system's response to infections and may even impair a person's response to immunizations. A number of studies have shown that subjects under chronic stress have low white blood cell counts and are vulnerable to colds. And once any person catches a cold or flu, stress can exacerbate symptoms. People who harbor herpes virus or HIV may be more susceptible to viral activation following exposure to stress. Even more serious, some research has found that HIV-infected men with high stress levels progress more rapidly to AIDS when compared to those with lower stress levels.

Inflammatory Response. Some evidence suggests that chronic stress triggers an over-production of certain immune factors called cytokines, which in excess levels can have very damaging effects. In fact, such findings may partly explain the association between chronic stress and a number of diseases, including heart disease and asthma.

Cancer

Current evidence does not support the idea that stress causes cancer or recurrence in cancer survivors. For example, a 2002 study reported no association between stressful life events and recurrence in women who had been treated for breast cancer. Nevertheless, some animal studies suggest that lack of control over stress (not simply stress itself) had negative effects on immune function and contributed to tumor growth. Although stress reduction techniques have no effect on survival rates, studies show that they are very helpful in improving a cancer patient's quality of life.

Gastrointestinal Problems

The brain and the intestine are strongly related and mediated by many of the same hormones and nervous system. (Indeed, some research suggests that the gut itself has features of a primitive brain.) It is not surprising then that prolonged stress can disrupt the digestive system, irritating the large intestine and causing diarrhea, constipation, cramping, and bloating. Excessive production of digestive acids in the stomach may cause a painful burning.

Irritable Bowel Syndrome. Irritable bowel syndrome (or spastic colon) is strongly related to stress. With this condition, the large intestine becomes irritated, and its muscular contractions are spastic rather than smooth and wave like. The abdomen is bloated and the patient experiences cramping and alternating periods of constipation and diarrhea. Sleep disturbances due to stress can further exacerbate irritable bowel syndrome.

Peptic Ulcers. It is now well established that most peptic ulcers are either caused by the H. pylori bacteria or by the use of nonsteroidal anti-inflammatory (NSAID) medications (such as aspirin and ibuprofen). Nevertheless, studies still suggest that stress may predispose someone to ulcers or sustain existing ulcers. Some experts, in fact, estimate that social and psychologic factors play some contributing role in 30% to 60% of peptic ulcer cases, whether they are caused by H. pylori or NSAIDs. In any case, some experts believe that the anecdotal relationship between stress and ulcers is so strong that attention to psychological factors is still warranted.

Inflammatory Bowel Disease. Although stress is not a cause of inflammatory bowel disease (Crohn's disease or ulcerative colitis), there are reports of an association between stress and symptom flare-ups. One study, for example, found that while short term (past month) stress did not significantly exacerbate ulcerative colitis symptoms, long term perceived stress tripled the rate of flare-ups compared to patients who did not report feelings of stress.

Eating Problems

Stress can have varying effects on eating problems and weight.

Weight Gain. Often stress is related to weight gain and obesity. Many people develop cravings for salt, fat, and sugar to counteract tension and, thus, gain weight. Weight gain can occur even with a healthy diet, however, in some people exposed to stress. And the weight gained is often abdominal fat, a predictor of diabetes and heart problems. The release of cortisol, a major stress hormone, appears to promote abdominal fat and may be the primary connection between stress and weight gain. Cortisol is a glucocorticoid, and glucocorticoids, along with insulin, appear to be responsible for stress-related food cravings. A 2005 study showed that such hormonally induced cravings for “comfort foods” may have a biological benefit for managing stress. Ingestion of comfort foods appears to reduce the negative hormonal and behavioral changes associated with stress, which might lessen the impact of stress on an individual. However, the long-term health risks of carrying excess abdominal fat are significant.

Weight Loss. Some people suffer a loss of appetite and lose weight during periods of stress. In rare cases, stress may trigger hyperactivity of the thyroid gland, stimulating appetite but causing the body to burn up calories at a faster than normal rate.

Eating Disorders. Chronically elevated levels of stress chemicals have been observed in patients with anorexia and bulimia. (Some studies, however, have not found any strong link between stress and eating disorders.) More work is needed to determine if changes in stress hormones are a cause or result of eating disorders.

Diabetes

Chronic stress has been associated with the development of insulin-resistance, a condition in which the body is unable to use insulin effectively to regulate glucose (blood sugar). Insulin-resistance is a primary factor in diabetes. Stress can also exacerbate existing diabetes by impairing the patient's ability to manage the disease effectively.

Pain

Researchers are attempting to find the relationship between pain and emotion, but the area is complicated by many factors, including effects of personality types, fear of pain, and stress itself.

Muscular and Joint Pain. Chronic pain caused by arthritis and other conditions may be intensified by stress. (According to a study on patients with rheumatoid arthritis, however, stress management techniques do not appear to have much effect on arthritic pain.) Psychologic distress also plays a significant role in the severity of back pain. Some studies have clearly associated job dissatisfaction and depression to back problems, although it is still unclear if stress is a direct cause of the back pain.

Headaches. Tension-type headache episodes are highly associated with stress and stressful events. (Sometimes the headache doesn't even start until long after a stressful event is over.) Some research suggests that tension-type headache sufferers may actually have some biological predisposition for translating stress into muscle contractions. Among the wide range of possible migraine triggers is emotional stress (although the headaches often erupt after the stress has eased). One study suggested that women with migraines tend to have personalities that over-respond to stressful situations.

Sleep Disturbances

The tensions of unresolved stress frequently cause insomnia, generally keeping the stressed person awake or causing awakening in the middle of the night or early morning. In fact, evidence suggests that stress hormones can increase during sleep in anticipation of a specific waking time.

Sexual and Reproductive Dysfunction

Sexual Function. Stress can lead to diminished sexual desire and an inability to achieve orgasm in women. Stress response can also cause temporary impotence in men. Part of the stress response involves the release of brain chemicals that constrict the smooth muscles of the penis and its arteries. This constriction reduces the blood flow into and increases the blood flow out of the penis, which can prevent erection.

Premenstrual Syndrome. Some studies indicate that the stress response in women with premenstrual syndrome may be more intense than in those without the syndrome.

Fertility. Stress may even affect fertility. Stress hormones have an impact on the hypothalamus gland, which produces reproductive hormones. Severely elevated cortisol levels can even shut down menstruation. One interesting small study reported a significantly higher incidence of pregnancy loss in women who experienced both high stress and prolonged menstrual cycles. Another reported that women with stressful jobs had shorter periods than women with low-stress jobs.

Effects on Pregnancy. Old wives' tales about a pregnant woman's emotions affecting her baby may have some credence. Stress may cause physiologic alterations, such as increased adrenal hormone levels or resistance in the arteries, which may interfere with normal blood flow to the placenta. Maternal stress during pregnancy has been linked to a higher risk for miscarriage, lower birth weights, and increased incidence of premature births. Some evidence also suggests that stress experienced by expectant mothers can even influence the way in which the baby's brain and nervous system will react to stressful events. Indeed, one study found a higher rate of crying and low attention in infants of mothers who had been stressed during pregnancy.

Memory, Concentration, and Learning

Stress affects the brain, particularly memory, but the effects differ significantly depending on whether the stress is acute or chronic.

Effect of Acute Stress on Memory and Concentration. Studies indicate that the immediate effect of acute stress impairs short-term memory, particularly verbal memory. On the plus side, high levels of stress hormone during acute stress have been associated with enhanced memory storage and greater concentration on immediate events.

Effect of Chronic Stress on Memory. If stress becomes chronic, sufferers often experience loss of concentration at work and at home, and they may become inefficient and accident-prone. In children, the physiologic responses to chronic stress can clearly inhibit learning. Chronic stress in older people may play an even more important role in memory loss than the aging process. In one study, for example, older adults with low stress hormone levels tested as well as younger adults in cognitive tests: those with higher stress levels tested between 20% and 50% lower.

Studies have associated prolonged exposure to cortisol (the major stress hormone) to shrinkage in the hippocampus, the center of memory. For example, two studies reported that groups who suffered from post-traumatic stress disorder (Vietnam veterans and women who suffered from sexual abuse) displayed up to 8% shrinkage in the hippocampus. It is not yet known if this shrinkage is reversible.

Other Disorders

Allergies. Stress has been related to skin allergies. In fact, some research suggests that stress, not indoor pollutants, may actually be a cause of the so-called sick-building syndrome, which produces allergy-like symptoms, such as eczema, headaches, asthma, and sinus problems, in office workers.

Skin Disorders. Stress plays a role in exacerbating a number of skin conditions, including hives, psoriasis, acne, rosacea, and eczema. Unexplained itching may also be caused by stress.

Unexplained Hair Loss (Alopecia Areata). Alopecia areata is hair loss that occurs in localized (or discrete) patches. The cause is unknown but stress is suspected as a player in this condition. For example, hair loss often occurs during periods of intense stress, such as mourning.

Teeth and Gums. Stress has now been implicated in increasing the risk for periodontal disease, which is disease in the gums that can cause tooth loss.

Substance Abuse

Alcohol affects receptors in the brain that reduce stress. Deprivation of nicotine increases stress in smokers, which creates a cycle of dependency. One study further indicated that nicotine has calming effects in women but not in men. (In fact, in the study, smoking increased aggression in men.) People under chronic stress, then, frequently seek relief through alcohol abuse or tobacco use. Many also resort to abnormal eating patterns, or passive activities, such as watching television.

The damage these self-destructive habits cause under ordinary circumstances is compounded by the physiologic effects of stress itself. And the cycle is self-perpetuating; a sedentary routine, an unhealthy diet, alcohol abuse, and smoking promote heart disease, interfere with sleep patterns, and lead to increased rather than reduced tension levels. Drinking four or five cups of coffee, for example, can cause changes in blood pressure and stress hormone levels similar to those produced by chronic stress. Animal fats, simple sugars, and salt are known contributors to health problems.

Conditions with Similar Symptoms

The physical symptoms of anxiety disorders mirror many of those of stress, including a fast heart rate; rapid, shallow breathing; and increased muscle tension. Anxiety is an emotional disorder, however, and is characterized by feelings of apprehension, uncertainty, fear, or panic. Unlike stress, the triggers for anxiety are not necessarily or even usually associated with specific stressful or threatening conditions. Some individuals with anxiety disorders have numerous physical complaints, such as headaches, gastrointestinal disturbances, dizziness, and chest pain. Severe cases of anxiety disorders are debilitating, and interfere with career, family, and social spheres.

Depression

Depression can be a disabling condition, and, like anxiety disorders, may result from chronic stress. can be a disabling condition, and, like anxiety disorders, may result from chronic stress. A 2005 study of Canadian workers found that individuals with a high level of work-related stress are more than twice as likely to experience a major depressive episode as individuals under less stress. (Evidence also suggests that certain people may be genetically susceptible to depression after stressful life events.)

Depression also mimics some of the symptoms of stress, including changes in appetite, sleep patterns, and concentration. Serious depression, however, is distinguished from stress by feelings of sadness, hopelessness, loss of interest in life, and, sometimes, thoughts of suicide. Acute depression is also accompanied by significant changes in the patient's functioning. Professional therapy may be needed in order to determine if depression is caused by stress or if it is the primary problem.

Post-Traumatic Stress Disorder Symptoms

Post-traumatic stress disorder (PTSD) is a reaction to a very traumatic event: it is actually classified as an anxiety disorder. The event that precipitates PTSD is usually outside the norm of human experience, such as intense combat or sexual assault. The patient struggles to forget the traumatic event and frequently develops emotional numbness and event-related amnesia. Often, however, there is a mental flashback, and the patient re-experiences the painful circumstance in the form of intrusive dreams and disturbing thoughts and memories, which resemble or recall the trauma. Other symptoms may include lack of pleasure in formerly enjoyed activities, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle-response to noise.

Treatment

Perhaps the best general approach for treating stress can be found in the elegant passage by Reinhold Niebuhr, "Grant me the courage to change the things I can change, the serenity to accept the things I can't change, and the wisdom to know the difference." The process of learning to control stress is life-long, and will not only contribute to better health, but a greater ability to succeed in one's own agenda.

When to Seek Professional Help for Stress

Stress can be a factor in a variety of physical and emotional illnesses, which should be professionally treated. Many stress symptoms are mild and can be managed by over the counter medications (e.g., aspirin, acetaminophen, or ibuprofen for tension headache and antacids and anti-diarrhea medications or laxatives for mild stomach distress). A physician should be consulted, however, for physical symptoms that are out of the ordinary, particularly those which progress in severity or awaken one at night. A mental health professional should be consulted for unmanageable acute stress or for severe anxiety or depression. Often short-term therapy can resolve stress-related emotional problems.

Considerations for Choosing a Strategy for Reducing Stress

In choosing specific strategies for treating stress, several factors should be considered.

• First, no single method is uniformly successful: a combination of approaches is generally most effective.
• Second, what works for one person does not necessarily work for someone else.
• Third, stress can be positive as well as negative. Appropriate and controllable stress provides interest and excitement and motivates the individual to greater achievement, while a lack of stress may lead to boredom and depression.
• Finally, stress may play a part in making people vulnerable to illness. A physician or psychologist should be consulted if there are any indications of accompanying medical or psychologic conditions, such as cardiac symptoms, significant pain, anxiety, or depression.

Overcoming Obstacles to Treatment

Often people succeed in relieving stress for the short-term but resort to previous ways of stressful thinking and behaving because of outside pressure or entrenched beliefs or habits. Some obstacles to managing stress are the following:

• One major obstacle to reducing stress is the strong biologic urge for fight or flight itself. The very idea of relaxation can feel threatening, because it is perceived as letting down one's guard. For example, an over-demanding boss may put a subordinate into a psychologic state of fighting-readiness, even though there is no safe opportunity for the subordinate to fight back, or even express anger. Stress builds up, but the worker has the illusion, even subconsciously, that the stress itself is providing safety or preparedness, so does nothing to correct the condition.
• Many people are afraid of being perceived as selfish if they engage in stress-reducing activities that benefit only themselves. The truth is that self-sacrifice may be inappropriate and even damaging if the person making the sacrifice is unhappy, angry, or physically unwell.
• Some people believe that certain emotional responses to stress, such as anger, are innate and unchangeable features of personality. Research has shown, however, that with cognitive behavioral therapy, individuals can be taught to change their emotional reactions to stressful events.

It is essential to remember that reducing stress and staying relaxed clears the mind so it can initiate appropriate actions to get rid of the stress-ridden conditions.

Stress Reduction and Effects on Health

It should be strongly noted that although treating stress cannot cure medical problems, stress management can be a very important component in a medical regimen. Specific stress reduction approaches, may benefit different medical problems. For example, acupuncture in one study helped reduce harmful heart muscle actions in people with heart failure but it had no effect on blood pressure. Relaxation methods, on the other hand, may help hypertensive individuals. They also may improve well being and quality of life for many patients who are experiencing stress because of severe or chronic medical conditions.

Important Note: Stress reduction techniques should never be used as sole treatment or to replace proven therapies for any medical condition.

Risk Factors

At some point in their lives virtually everyone will experience stressful events or situations that overwhelm their natural coping mechanisms. In one poll, 89% of respondents indicated that they had experienced serious stress in their lives. Some people are simply biologically prone to stress; many outside factors influence susceptibility as well.

Conditions Most Likely To Produce Stress-Related Health Problems. Conditions that are most likely to be associated with stress and negative physical effects include the following:

• An accumulation of persistent stressful situations, particularly those that a person cannot easily control (for example, high-pressured work plus an unhappy relationship).
• Persistent stress following a severe acute response to a traumatic event (such as an automobile accident).
• Acute stress accompanying serious illness, such as heart disease.

Factors That Influence the Response to Stress. People respond to stress differently depending on different factors:

• Early nurturing. (Abusive behavior towards children may cause long-term abnormalities in the hypothalamus-pituitary system, which regulates stress.)
• Personality traits. Certain people have personality traits that cause them to over-respond to stressful events.
• Genetic factors. Some people have genetic factors that affect stress, such as having more or less efficient relaxation response. One 2001 study found a genetic abnormality in serotonin regulation that was associated with a heightened reactivity of the heart rates and blood pressure in response to stress. (Serotonin is a brain chemical involved with feelings of well being.)
• Immune regulated diseases. Certain diseases that are associated with immune abnormalities (such as rheumatoid arthritis or eczema) may actual impair a response to stress.
• The length and quality of stressors. Naturally the longer the duration and more intense the stressors, the more harmful the effects.

Individuals at Higher Risk for Stress. Studies indicate that the following people are more vulnerable to the effects of stress than others:

• Older adults. As people age, the ability to achieve a relaxation response after a stressful event becomes more difficult. Aging may simply wear out the systems in the brain that respond to stress, so that they become inefficient. The elderly, too, are very often exposed to major stressors such as medical problems, the loss of a spouse and friends, a change in a living situation, and financial worries. No one is immune to stress, however, and it may simply go unnoticed in the very young and old.
• Women in general and working mothers specifically. Working mothers, regardless of whether they are married or single, face higher stress levels and possibly adverse health effects, most likely because they bear a greater and more diffuse work load than men or other women. This has been observed in women in the US and in Europe. Such stress may also have a domino and harmful effect on their children. (It is not clear, however, if stress has the same adverse effects on women's hearts as it does on men's.)
• Less educated individuals.
• Divorced or widowed individuals. (A number of studies indicate that unmarried people generally do not live as long as their married contemporaries.)
• Anyone experiencing financial strain, particularly long-term unemployed and those without health insurance.
• Isolated individuals.
• People who are targets of racial or sexual discrimination.
• People who live in cities.

Childhood Factors

Children are frequent victims of stress because they are often unable to communicate their feelings accurately or their responses to events over which they have no control. (Certain physical symptoms, notably recurrent abdominal pain without a known cause, may be indicators of stress in children.)

Various conditions can affect their susceptibility to stress.

Low Birth Weight. A 2002 study reported that low birth weight plus slow growth up until age seven was related to stress in adulthood. It appears that children who compensated for the low birth weight with higher weight gain after birth did not have as high risk for stress later on.

Parental Stress. Parental stress, particularly in mothers, is a particularly powerful source of stress in children, even more important than poverty or overcrowding. In a 2002 study, for example, young children of mothers who were highly stressed (particularly if they were depressed) tended to be at high risk for developing stress-related problem, particularly if the mothers were stressed during both the child's infancy and early years. There is even some evidence to support the old idea that stress during pregnancy can have adverse effects on the infant's mood and behavior. Older children with stressed mothers may become aggressive and anti-social. One study suggested that stress-reduction techniques in parents may improve their children's behavior.

Gender Differences in Adolescent Stress. Adolescent boys and girls experience equal amounts of stress, but the source and effects may differ. Girls tend to become stressed from interpersonal situations, and stress is more likely to lead to depression in girls than in boys. For boys, however, specific events, such as changing schools or poor grades, appear to be the major sources of stress.

Work and Stress

In a 1999 study of 46,000 workers, health care costs were 147% higher in workers who were stressed or depressed than in others who were not. Furthermore, according to one survey, 40% of American workers describe their jobs as very stressful, making job-related stress an important and preventable health hazard. In fact, a number of studies are now suggesting that job-related stress is as great a threat to health as smoking or not exercising. Stress impairs concentration, causes sleeplessness, and increases the risk for illness, back problems, accidents, and lost time. Work stress can lead to harassment or even violence while on the job. At its most extreme, chronic stress places a burden on the heart and circulation that in extreme cases may be fatal. The Japanese even have a word for sudden death due to overwork, karoushi.

Not all work stress is harmful. Studies suggest the following job-related stressors may put people--particularly men--for health risks:

• Having no participation in decisions that affect one's responsibilities.
• Unrelenting and unreasonable demands for performance.
• Lack of effective communication and conflict-resolution methods among workers and employers.
• Lack of job security.
• Night-shift work, long hours, or both.
• Excessive time spent away from home and family.
• Wages not commensurate with levels of responsibility.

Reducing Stress on the Job. Still, many institutions within the current culture, while paying lip service to stress reduction, put intense pressure on individuals to behave in ways that increase tension. Yet, there are a number of effective management tools and techniques available to reduce stress. Furthermore treatment for work-related stress has proven benefits for both the employee and employer. In one study, at the end of two years, a company that instituted a stress management program saved nearly $150,000 in workmen's compensations costs. (The cost of the program was only $6,000.) Other studies in 2002 and 2003 reported specific health benefits resulting from workplace stress-management programs. In one of the studies, workers with hypertension experienced reduced blood pressure after even a brief (16-hour) program that helped them manage stress behaviorally.

In general, however, few workplaces offer stress management programs, and it is usually up to the employee to find their own ways to reduce stress. Here are some suggestions:

• Seek out someone in the Human Resources department or a sympathetic manager and communicate concerns about job stress. Work with them in a non-confrontational way to improve working conditions, letting them know that productivity can be improved if some of the pressure is off.
• Establish or reinforce a network of friends at work and at home.
• Restructure priorities and eliminate unnecessary tasks.
• Learn to focus on positive outcomes.
• If the job is unendurable, plan and execute a career change. Send out resumes or work on transfers within the company.
• If this isn't possible, be sure to schedule daily pleasant activities and physical exercise during free time.

It may be helpful to keep in mind that bosses are also victimized by the same stressful conditions they are imposing. For example, in a 2001 study of male managers in three Swedish companies, those who worked in a bureaucracy had greater stress-related heart risks than those who worked in companies with social supports.

Caregiving

Caregivers of Family Members. Studies show that caregivers of physically or mentally disabled family members are at risk for chronic stress. Furthermore, a 1999 study reported that over-all mortality rates were over 60% higher in caregivers who were under constant stress. Spouses caring for a disabled partner are particularly vulnerable to a range of stress-related health threats including influenza, depression, heart disease, and even poorer survival rates. Caring for a spouse with even minor disabilities can induce severe stress.

Specific risk factors that put caregivers at higher risk for severe stress or stress-related illnesses include the following:

• Caregiving wives. Some studies suggest that wives experience significantly greater stress from caregiving than husbands do. In fact, in a 2000 study, caregiving wives tended to feel more negative about their husbands than caregiving husbands felt about their wives.
• Having a low income.
• Being African American. African Americans tend to be in poorer physical health and have lower incomes than Caucasians and so face greater stress as caregivers to their spouses than their Caucasian counterparts.
• Living alone with the patient.
• Helping a highly dependent patient.
• Having a difficult relationship with the patient.

Intervention programs that are aimed at helping the caregiver approach the situation positively can be very helpful at reducing stress and helping the caregiver maintain a positive attitude. A 2002 program also demonstrated that moderate-intensity exercise was very helpful in reducing stress and improving sleep in caregivers.

Health Professional Caregivers. Caregiving among the health professionals is also a high risk factor for stress. One 2000 study, for example, found that registered nurses with low job control, high job demands, and low work-related social support experienced very dramatic health declines, both physically and emotionally.

Anxiety Disorders

People who are less emotionally stable or have high anxiety levels tend to experience specific events as more stressful than others. Some experts describe an exaggerated negative response to stress as "catastrophizing" the event (turning it into a catastrophe). Nevertheless, a 2003 study of patients with anxiety disorder did not find any differences in actual physical response to stress (heart rate, blood pressure, release of stress hormones) compared to people without anxiety.

Lacking a Social Network

The lack of an established network of family and friends predisposes one to stress disorders and stress-related health problems, including heart disease and infections. And, a 2000 study reported that older people who maintain active relationships with their adult children are buffered against the adverse health effects of chronic stress-inducing situations, such as low income or lower social class. One study suggested this may be because people who live alone are unable to discuss negative feelings and so relieve their stress.

Studies of people who remain happy and healthy despite many life stresses conclude that most have very good networks of social support. One study indicated that support even from strangers reduced blood pressure surges in people undergoing a stressful event. Many studies suggest that having a pet helps reduce medical problems aggravated by stress, including heart disease and high blood pressure.

Lifestyle Changes

A healthy lifestyle is an essential companion to any stress-reduction program. General health and stress resistance can be enhanced by regular exercise, a diet rich in a variety of whole grains, vegetables, and fruits, and by avoiding excessive alcohol, caffeine, and tobacco.

Of interest, a 2003 study suggested that fish oil, which has been associated with a lower risk for heart disease and stroke, may blunt some of the harmful effects of mental stress on the heart.

In one 2002 study, high doses of vitamin C reduced stress levels and blood pressure. The doses given were higher than the recommended upper limit of 2000 mg/day. High doses may cause headaches and diarrhea. Long-term use increases risk for kidney stones and has other adverse effects in specific individuals.

Exercise

Exercise in combination with stress management techniques is extremely important for many reasons, including the following:

• Exercise is an effective distraction from stressful events.
• Exercise may directly blunt the harmful effects of stress on blood pressure and the heart. (Exercise protects the heart in any case.)

Usually, a varied exercise regime is more interesting, and thus easier to stick to. Start slowly. Strenuous exercise in people who are not used to it can be very dangerous and any exercise program should be discussed with a physician. In addition, half of all people who begin a vigorous training regime drop out within a year. The key is to find activities that are exciting, challenging, and satisfying. The following are some suggestions:

• Sign up for aerobics classes at a gym.
• Brisk walking is an excellent aerobic exercise that is free and available to nearly anyone. Even short brisk walks can relieve bouts of stress.
• Swimming is an ideal exercise for many stressed people including pregnant women, individuals with musculoskeletal problems, and those who suffer exercise-induced asthma.
• Yoga or Tai Chi can be very effective, combining many of the benefits of breathing, muscle relaxation, and meditation while toning and stretching the muscles. The benefits of yoga may be considerable. Numerous studies have found it beneficial for many conditions in which stress is an important factor, such as anxiety, headaches, high blood pressure, and asthma. It also elevates mood and improves concentration and ability to focus.

As in other areas of stress management, making a plan and executing it successfully develops feelings of mastery and control, which are very beneficial in and of themselves. Start small. Just 10 minutes of exercise three times a week can build a good base for novices. Gradually build up the length of these every-other-day sessions to 30 minutes or more.

Cognitive-Behavioral Techniques

Cognitive-behavioral techniques (CBTs) are among the most effective ways of reducing stress. A 2005 study found that CBT training can have a long-term impact one’s ability to cope with stress. In the study, participants received CBT training and were exposed to a stressful situation 4 months later. The participants who had received CBT training had significantly less stress-induced cortisol responses compared with individuals who had received no stress management training. This effect was observed in both men and women, although the CBTs had a greater effect on men. CBT may be particularly helpful when the source of stress is chronic pain or a chronic disease. In fact, in a study of patients with HIV, CBT was more helpful than support groups for improving well-being and quality-of-life.

A CBT typical approach includes identifying sources of stress, restructuring priorities, changing one's response to stress, and finding methods for managing and reducing stress.

Identifying Sources of Stress. One key component in most CBT approaches is a diary that keeps an informal inventory of daily events and activities. While this exercise might itself seem stress producing (and yet one more chore), it need not be done in painstaking detail. A few words accompanying a time and date are usually enough to serve as reminders of significant events or activities.

The first step is to note activities that put a strain on energy and time, trigger anger or anxiety, or precipitate a negative physical response (such as a sour stomach or headache).

Also note positive experiences, such as those that are mentally or physically refreshing or produce a sense of accomplishment.

After a week or two, try to identify two or three events or activities that have been significantly upsetting or overwhelming.

Questioning the Sources of Stress. Individuals should then ask themselves the following questions:

• Do these stressful activities meet their own goals or someone else's?
• Have they taken on tasks that they can reasonably accomplish?
• Which tasks are in their control and which ones aren't?

Restructuring Priorities: Adding Stress Reducing Activities. The next step is to attempt to shift the balance from stress-producing to stress-reducing activities. Eliminating stress is rarely practical or feasible, but there are many ways to reduce its impact.

Consider as many relief options as possible. Examples include the following:

• Listen to music. Music an effective stress reducer in both healthy individuals and people with health problems. In a 2001 study, for example, students who listened to a well-known gentle classical piece of music during a stressful task had reduced feelings of anxiety, heart rate, and blood pressure.
• Take long weekends or, ideally, vacations.
• If the source of stress is in the home, plan times away, even if it is only an hour or two a week.
• Replace unnecessary time-consuming chores with pleasurable or interesting activities.
• Make time for recreation. (This is as essential as paying bills or shopping for groceries.)
• Own a pet. In a 2001 study of people with high blood pressure, pet owners had much lower blood pressure increase in response to stress than non-owners. (Pet owning was beneficial only for people who like animals to begin with.)

Discuss Feelings. The concept of communication and letting your feelings out has been so excessively promoted and parodied that it has nearly lost its value as good psychologic advice. Nevertheless, feelings of anger or frustration that are not expressed in an acceptable way may lead to hostility, a sense of helplessness, and depression.

Expressing feelings does not mean venting frustration on waiters and subordinates, boring friends with emotional minutia, or wallowing in self-pity. In fact, because blood pressure may spike when certain chronically hostile individuals become angry, some therapists strongly advise that just talking, not simply venting anger, is the best approach, especially for these people.

The primary goal is to explain and assert one's needs to a trusted individual in as positive a way as possible. Direct communication may not even be necessary. Writing in a journal, writing a poem, or composing a letter that is never mailed may be sufficient.

Expressing one's feelings solves only half of the communication puzzle. Learning to listen, empathize, and respond to others with understanding is just as important for maintaining the strong relationships necessary for emotional fulfillment and reduced stress.

Keep Perspective and Look for the Positive. Reversing negative ideas and learning to focus on positive outcomes helps reduce tension and achieve goals. The following steps using an example of a person who is alarmed at the prospect of giving a speech may be useful:

• First, identify the worst possible outcomes (forgetting the speech, stumbling over words, humiliation, audience contempt).
• Rate the likelihood of these bad outcomes happening (probably very low or that speaker wouldn't have been selected in the first place).
• Envision a favorable result (a well-rounded, articulate presentation with rewarding applause).
• Develop a specific plan to achieve the positive outcome (preparing in front of a mirror, using a video camera or tape recorder, relaxation exercises).
• Try to recall previous situations that initially seemed negative but ended well.

Use Humor. Research has shown that humor is a very effective mechanism for coping with acute stress. Keeping a sense of humor during difficult situations is a common recommendation from stress management experts. Laughter not only releases the tension of pent-up feelings and helps keep perspective, but it appears to have actual physical effects that reduce stress hormone levels. It is not uncommon for people to recall laughing intensely even during tragic events, such as the death of a loved one, and to remember this laughter as helping them to endure the emotional pain.

Relaxation and Other Alternative Techniques

Relaxation Methods. Since stress is here to stay, everyone needs to develop methods for invoking the relaxation response, the natural unwinding of the stress response. Relaxation lowers blood pressure, respiration, and pulse rates, releases muscle tension, and eases emotional strains. This response is highly individualized, but there are certain approaches that seem to work.

Combinations are probably best. For example, in a study of children and adolescents with adjustment disorder and depression, a combination of yoga, a brief massage, and progressive muscle relaxation effectively reduced both feelings of anxiety and stress hormone levels. A 2005 study of organ transplant recipients showed that training in meditation and gentle yoga led to significant improvements in quality of sleep and lessened anxiety and depression.

No one should expect a total resolution of stress from these approaches, but if done regularly, these programs can be very effective.

Acupuncture. Some evidence suggests that acupuncture may also be helpful. It might even improve some physical factors associated with stress and health problems. For example, in a study of heart failure patients acupuncture improved stress-related heart muscle activity, which could be an important benefit in these patients. (Acupuncture had no effect on stress-related blood pressure or heart rate.)

Hypnosis. Hypnosis may also benefit some people with severe stress. In one study of patients with irritable bowel, stress reduction by hypnosis correlated with improvement in many IBD symptoms.

Herbal and Natural Remedies

Some people who experience chronic stress seek herbal or natural remedies. It should be strongly noted, however, that just as with standard drugs, so-called natural remedies can cause problems, sometimes serious ones.

Probiotics. Probiotics are helpful bacterial strains that by themselves may provide a barrier against harmful bacteria, possibly through various mechanisms, such as by excreting certain acids (e.g., lactate, acetate) that inhibit harmful bacteria or competing with them for nutrients. Stress reduces levels of these bacteria, and it has been suggested that probiotics may help maintain remission in patients with IBD. In one small 2002 study, at the end of six months people suffering from stress and exhaustion who took a probiotic supplement experienced significant reductions in stress symptoms and gastrointestinal complaints. The specific bacterial strains that might be beneficial, however, are not fully known. The most well-known probiotics are the lactobacilli strains, such as acidophilus, which is found in yogurt and other fermented milk products. Others, however, may prove to be more important, such as bifidobacteria and GG lactobacilli. Other probiotics include the lactobacilli rhamnosus, casel, plantarium, bulgaricus, and salivarius, and also Enterococcus faecium and Streptococcus thermophilus.

Aromatherapy. The smell of lavender has long been associated with a calming effect. In a Japanese study, 14 women who were put in a room with a lavender scent experienced reduced mental stress. A number of aromatherapies are now used for relaxation. It should be strongly noted that some of exotic plant extracts in these formulas have been associated with a wide range of skin allergies.

Valerian. Valerian is an herb that has sedative qualities and may reduce stress and associated physical effects. This herb is listed on the FDA's list of generally safe products. Of note, however, its effects could be dangerously increased if it is used with standard sedatives. Other interactions and long-term side effects are unknown. Side effects include vivid dreams. It should be noted that high doses of valerian can cause blurred vision, excitability, and changes in heart rhythm.

Resources

• www.nimh.nih.gov -- National Institute of Mental Health
• www.nami.org -- National Alliance for the Mentally Ill (800-950-6264)
• www.nmha.org -- National Mental Health Association (800-969-6642)
• www.amtamassage.org -- American Massage Therapy Association (877-905-2700)
• www.cognitivetherapynyc.com -- American Institute for Cognitive Therapy
• www.aabt.org -- Association for the Advancement of Behavior Therapy (800-685-AABT)
• www.healthyminds.org -- The American Psychiatric Association (888-357-7924)
• www.naswdc.org -- The National Association of Social Workers
• www.aacap.org -- American Academy of Child and Adolescent Psychiatry
• www.stress.org -- The American Institute of Stress (914-963-1200)

References

Dallman MF, Pecoraro NC, la Fleur SE. Chronic stress and comfort foods: self-medication and abdominal obesity. Brain Behav Immun. 2005;19:275-280.

Wang J. Work stress as a risk factor for major depressive episode(s). Psychol Med. 2005;35:865-871.

Hammerfald K, Grau M, et al. Persistent effects of cognitive-behavioral stress management on cortisol responses to acute stress in healthy subjects-A randomized controlled trial. Psychoneuroendocrinology. 2005 Sep 22; epub ahead of print.

Kreitzer MJ, Gross CR, Ye X, et al. Longitudinal impact of mindfulness meditation on illness burden in solid-organ transplant recipients. Prog Transplant. 2005;15:166-172.

Field T, Hernandez-Reif M, Diego M, et al. Cortisol decreases and serotonin and dopamine increase following massage therapy. Int J Neurosci. 2005;115:1397-1413.

Ditzen B, Neumann I, Bodenmann G, et al. Romantic Partner Interaction Reduces Endocrine and Autonomic Stress Responses in Women. New Research Abstracts, Annual Meeting of the American Psychiatric Association. Washington, D.C. 2005. Abstract NR140.

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