coping well: implementing the principles of stress resilience
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Coping Well: Implementing the Principles of Stress Resilience. N. Lee Smith, MD Adjunct Associate Professor of Medicine University of Utah Director, Stress Medicine Lifetree Clinical Research and Pain Clinic Salt Lake City, Utah. Our purposes today- To identify:. - PowerPoint PPT PresentationTRANSCRIPT
Coping Well:Implementing the Principles
of Stress Resilience
N. Lee Smith, MD
Adjunct Associate Professor of Medicine
University of Utah
Director, Stress Medicine
Lifetree Clinical Research and Pain Clinic
Salt Lake City, Utah
Our purposes today-To identify:
• Four core principles of stress resilience– And what these have do do with mental and
physical well-being (health)
• Some specific techniques for applying these principles
INTERHEART Study: Significance of Coronary Risk Factors
(15123 MI Cases; 14820 controls; 52 countries)
0
5
10
15
20
25
30
35
40
Attributable Risk %
Smoking Depression Obesity Hypertension
Yusef S; also Rosengren A. Lancet 2004;364:937-52 and 364:953-62
Outcome Effects of Treating MI Depression with Sertraline
(SADHART Trial: n = 369)
-61
-30
-15
-30
-2
-70
-60
-50
-40
-30
-20
-10
0
Percent reduction from placebo
Mortality 2nd MI Angina CHF Stroke
Glassman AH, (SADHART) JAMA 2002;288:701-709
Many Very Common Medical Problems Involve Central Nervous
System Hypersensitivity:
• Irritable bowel syndrome
• Atypical chest pain
• Migraine and Tension Headaches
• Fibromyalgia & Myofascial Pain Syndromes
• Anxiety and depression disorders
Interventions improving chronic pain and hypersensitivity
usually require improvements
in the central function of:• Serotonin• Norepinephrine• Dopamine• Endorphins• GABA • Deep sleep• Reduced sympathetic tone
What are the effects of cognitive-behavioral interventions on
these protective mechanisms?
• Sense of internal control Serotonin• Love, cooperation Dopamine,Endorphins
• Exercise, pos. excitement NE and DA“Turned on”-purpose Endorphins
• Deep Relaxation, Sleep, Serotonin & mindfulness sympathetic tone meditation GABA (?)
Coping Styles and Health 45 year Harvard Study (Vaillant, et al)
Coping Styles
• Denial
• Blaming and victimizing – denying personal responsibility
• Repression, intellectualizing
• Mature, adaptive – Internal control, connectedness, humor
Coping Styles and Health: Outcomes
• Styles 20 years later tended to be the same (with no intervention)
• Middle age (53): % chronic illness or death:
– Mature adaptive style: 3%– The others combined: 37%
• Additional analysis: – optimism (hope) and altruism (meaning) were
important for outcome
Vaillant G, et al; also Seligman M and Peterson C Learned Optimism 1990s
Connectedness and Health
• Roseto, PA study– 1/6 the national average of MIs and CV death– Average exercise, smoking, obesity, hypertension
• Multifactorial analysis —The keys: – Strong sense of community: unconditional support —
Social and family ties —Elderly honored
• When these deteriorated: MI rates = average —Stewart Wolf, Temple Univ.
• (Compare 10000 Israeli men with CAD risk)
Stress Hardiness The Three C’s”
• Control– Internal source of power to choose responses– Refusal to be a victim
• Challenge– Sees change as opportunity– Enjoys growth– Tightly linked to hope
• Commitment– Curiosity and deep involvement– Finding meaning and purpose
Suzanne Kobasa and Salvatore Maddi
Four Principles of Stress Resilience Clearly Related toImproved Health Outcomes
• An internal locus of control
• A sense of connectedness
• A sense of purpose and meaning
• HopeKarren K, Smith NL, Hafen B, Frandsen K: Mind-Body Health… (3rd edition) 2005 (San Francisco, Benjamin Cummmings Publ)
A Sense of Connectedness:
• To one’s deepest self
• To other people• To the larger sources
of one’s power
Stress and Heart Disease
What are the
cardiotoxic components of
Type A behavior?
• Cynicism
• Hostility and anger
• Relationship problems
Anger/Hostility and Carotid DiseaseMiddle aged women- over 3 years
0
1
2
3
4
5
6
7
Percent progression on IMT
Lowest Highest
Trait Anger QuartilesRaikkonen K Psychosom Med 2004;66:903-908
Stress Reduction ReducesCarotid Atherosclerosis
• A meditation-based stress reduction program reduced carotid intimal thickening– compared with health education
in hypertensive African Americans– carotid intimal thickening = predictive of coronary disease
• The meditation group: decrease in carotid intima-media thickness of -0.098 mm
• Control group: increased of 0.054 mm Castillo-Richmond A. Stroke 2000;31(3):568-73
Comparing Stress Reductionand Exercise in CAD Patients
05
1015202530
Usual Care Exercise StressReduction
Intervention
Coro
nary
Eve
nts
(%
)
Blumenthal JA, et al Arch Int Med 1997;157:2213-2223
Creating Stress Resilience
• Is stress good or bad?
• What makes the difference?
• An important key:– How much sense of control do you feel in
dealing with it?
Animal Studies:Cancer Cell Rejection
0
10
20
30
40
50
60
70
In Control Victims No Stress
Percent immune rejection of the cancer cells
-Martin Seligman, U. of Penn
The Paradox of Control
• The more you try to take control of the world out there,
the more out of control it seems
• The more you let go trying to control the external world (and stop blaming),
and instead, respond in a way that you would deeply admire as wise,
the more personal control you feel
How to Create a Sense of Personal Control and Hope
• Conscious awareness“I can respond as I choose.”
• Relaxation skills: To let go and get focused
• Clarify deep values“How do I want to be?”
• Visualizing (experiencing) responding the new way
Creating Hope
• Visualizing (experiencing) one’s self handling the situation well,
in accord with wisdom and deepest values
A Sense of Personal Controlhas much to do with identifying
one’s deepest, wise values,
then creating ways to respond through them
Creating Connectedness:We have been highly conditioned to
see (and respond to) the world through eyes of fear and judging
Suppose instead, we saw through eyes of love
A truly great relationship
lift each other
safe, acceptance honest, authentic
kind
create hope
humor
honors needs
win-win
caring
A Philosophical Checkup:Discovering the core, wise mind:
What is life really about, anyway?– Productivity in numbers generated?– Proving oneself worthy, or right?
or– Learning to love?– Becoming wise and resilient? – Making a difference?– Joy?
} Spiritual well-being
A Philosophical Checkup:Discovering the core, wise mind:
• Why did I get into my work in the first place?– external rewards? (income, status) – or intrinsic meaning?
• What is the real purpose of my work?
Journaling for Meaning
Review your day backwards, asking:• “What surprised me today?”• “What moved or touched me today?”• “What inspired me today?”
Look for the stories.
After some time, the gap to seeing the answers will narrow, until they are seen as they happen
Remen RN. Int Med News 1/15/02, p.5
What is Health? (from: World Health Organization)
Total well-being:
Physical
Mental
Social
Spiritual
control (personal)
connectedness
meaning
hope
Summary(1)
• Depression, anxiety and associated traits of cynicism, hostility and anger are highly associated with cardiovascular disease and with many very common pain problems
• Several mechanisms of this are known
• Effectively teaching stress resilience (and treating dpression/anxiety) improves health outcomes
Summary(2)
• needs to be experiential
• needs to be directed at four core (spiritual) principles:– An internal locus of control (remember the paradox)– Enhancing connectedness (oneness)– Finding purpose and meaning (in all experience)– Creating hope
To be medically effective, stress resilience training: