Coping Well: Implementing the Principles of Stress Resilience

1. 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

2. 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

3. What does mental stress have to do with medical illness?

4. INTERHEART Study: Significance of Coronary Risk Factors(15123 MI Cases; 14820 controls; 52 countries) Attributable Risk % SmokingDepressionObesity Hypertension Yusef S; also Rosengren A. Lancet 2004;364:937-52 and 364:953-62

5. Outcome Effects of Treating MI Depression with Sertraline(SADHART Trial: n = 369) Mortality 2nd MI Angina CHF Stroke Percent reduction from placebo Glassman AH, (SADHART) JAMA 2002;288:701-709

6. 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

7. Inhibitory track serotonin, norepinephrine, dopamine

8. Interventions improving chronic pain and hypersensitivity usually require improvements in the central function of: • Serotonin • Norepinephrine • Dopamine • Endorphins • GABA • Deep sleep • Reduced sympathetic tone

9. 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 (?)

10. Coping Styles and Health45 year Harvard Study (Vaillant, et al) Coping Styles • Denial • Blaming and victimizing • denying personal responsibility • Repression, intellectualizing • Mature, adaptive • Internal control, connectedness, humor

11. 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

12. 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)

13. 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

14. 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 • Hope Karren K, Smith NL, Hafen B, Frandsen K: Mind-Body Health… (3rd edition) 2005 (San Francisco, Benjamin Cummmings Publ)

15. Dealing with Times of Chaos What gives a sense of control? • Hope • Loving support

16. A Sense of Connectedness: • To one’s deepest self • To other people • To the larger sources of one’s power

17. Is the way I’m handling this situation: Connecting us more deeply? or Disconnecting us?

18. Does stress reduction work? If so, what are the keys to success?

19. Stress and Heart Disease What are the cardiotoxic components of Type A behavior? • Cynicism • Hostility and anger •  Relationship problems

20. Anger/Hostility and Carotid DiseaseMiddle aged women- over 3 years Percent progression on IMT Lowest Highest Trait Anger Quartiles Raikkonen K Psychosom Med 2004;66:903-908

21. 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

22. Comparing Stress Reductionand Exercise in CAD Patients 30 25 20 Coronary Events (%) 15 10 5 0 Usual Care Exercise Stress Reduction Intervention Blumenthal JA, et al Arch Int Med 1997;157:2213-2223

23. Stress Resilience can be learned It takes practicing experientially to do so

24. 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?

25. Animal Studies:Cancer Cell Rejection Percent immune rejection of the cancer cells -Martin Seligman, U. of Penn

26. 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

27. Hindus:“You have given your power (spirit) away. Call your power back”

28. 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

29. Creating Hope • Visualizing(experiencing) one’s self handling the situation well, in accord with wisdom and deepest values

30. A Sense of Personal Controlhas much to do with identifying one’s deepest, wise values,then creating ways to respond through them

31. 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

32. lift each other safe, acceptance honest, authentic kind caring A truly great relationship honors needs create hope humor win-win

33. Example:Overwhelmed:“Have too much to do”

34. 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

35. 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?

36. 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

37. What is Health? (from: World Health Organization) Total well-being: Physical Mental Social Spiritual control (personal) connectedness meaning hope

38. 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

39. Summary(2) To be medically effective, stress resilience training: • 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