Stress Management

1. Stress Management Jennifer Peel, PhD Director of Education, GME Office Assistant Professor, Anesthesiology

2. Objectives By the end of this session, participants will be able to: define stress, discuss the physiological effects of stress, and describe and practice stress reduction strategies.

3. General Competences Medical Knowledge Professionalism

4. “The only person without stress is a dead person.” -Hans Selye (Father of stress research)

5. What is “stress?” Any stimulus, event or demand impacting on the sensory nervous system Events (environmental or internal) that tax or exceed the adaptive resources of the individual When an imbalance exists between a perceived demand (that is, the stimulus) and our perceived ability to meet that demand, we will experience a state of stress. When an imbalance exists between a perceived demand (that is, the stimulus) and our perceived ability to meet that demand, we will experience a state of stress.

6. Yerkes-Dodson Law In order to perform well in a challenging situation, you must be psychologically and physically alert. Stress is essential for optimal performance. We need a certain degree of stress (or arousal) in order to perform, but accept in excess and it can cause job burnout. Likewise, “rust-out” can occur when medical practitioners feel that their skills and abilities are not being utilized to their satisfaction, or the work environment is perceived as boring. In order to perform well in a challenging situation, you must be psychologically and physically alert. Stress is essential for optimal performance. We need a certain degree of stress (or arousal) in order to perform, but accept in excess and it can cause job burnout. Likewise, “rust-out” can occur when medical practitioners feel that their skills and abilities are not being utilized to their satisfaction, or the work environment is perceived as boring.

7. If stress becomes chronic, cortisol induces the locus caeruleus to release norepinephrine that communicates with the amygdala, leading to the production of more CRH and to ongoing reactivation of the stress pathwaysIf stress becomes chronic, cortisol induces the locus caeruleus to release norepinephrine that communicates with the amygdala, leading to the production of more CRH and to ongoing reactivation of the stress pathways

8. The Continuum of Stress

9. Burnout A syndrome of depersonalization, emotional exhaustion and perceived low personal accomplishment that leads to decreased effectiveness at work.

10. Symptoms of Stress and Burnout Psychological Anxiety Depression Irritability Loss of energy

11. The Toll of Unmanaged Stress and Burnout Professional Dysfunction Work dissatisfaction Error Cynicism Loss of compassion Loss of hope

12. The Toll of Unmanaged Stress and Burnout Addictive Behavior Alcohol abuse Drug abuse

13. Rates of True Impairment 10-15% of physicians will become impaired by drugs and/or alcohol during their career 20-25% of physicians will become impaired by mental illness during their career

14. Burnout and self-reported patient care in an internal medicine residency program (Shanafelt, et al., 2002) Cross-sectional, anonymous study Survey mailed to 151 IM residents in 2001 115 (76%) responders 87 (76%) met criteria for burnout Burned out residents more likely to self report providing suboptimal patient care 50% of these residents also had depressive symptoms

15. Greatest Stresses in Training Inadequate sleep Shifts greater than 24 hours Inadequate leisure time Financial stress Emotional stress

16. What personality traits make physicians susceptible to stress and burnout?

17. Common Defense Mechanisms Reaction formation Denial Minimization Rationalization Work becomes the ultimate defense

18. Intellect as a Defense “Intelligence is a little bit like four wheel drive; it just enables you to get lost in more remote places.” Garrison Keillor

19. 12 Point Personal Plan Identify the sources of pressure in your life & learn to recognize your stress reactions. Keep a stress log or diary Can you bring about change? Tackle the cause of your stress.

20. Clarify and set personal and career (SMART) goals. Specific Measurable Achievable Realistic Time-bounded Prioritize Monitor progress Reward success and examine failures

21. 4. Identify your strategy & learn stress-control skills. Assertiveness Relaxation Venting Avoid faulty thinking Build and develop social support networks Conflict management Time management 5. Plan your activities.

22. 6. Evaluate progress—reward success. 7. Understand your preferred coping style. Maintain positive interactions with other people. Stay fit & healthy. Get professional help & seek social support.

23. Stay in control—life is stress—don’t let stress control you! Stress is a dynamic process.

24. Relaxation Techniques Progressive, deep-muscle techniques Meditation Affirmations Momentary mental and/or physical relaxation

25. Progressive, deep-muscle technique Sit in a comfortable position in a chair that supports your back and neck, or lay down on the floor with your head supported by a cushion. Close your eyes. Begin by taking a few deep breaths through the nose and exhale to push the air out of the lungs through the mouth. Continue to breath deeply and slowly while tensing groups of muscles for 10 seconds, and then relaxing each group for 30 seconds using the following order: Clench fists and relax Bend arms to flex the biceps and then straighten Straighten arms tightly to flex the triceps then relax. Shrug shoulders up towards the ears and then drop them to relax. Press head back to tense the neck muscles and relax. Purse lips and relax. Press the tongue against the back of the teeth and relax. Clench teeth to tense the jaw and relax. Squeeze eyes tightly shut, frown and then relax Breathe in deeply and hold to tense the chest—exhale deeply and relax. Tense the stomach muscles as if preparing them for a blow and relax. Clench the buttock muscles together tightly and relax. Keep legs straight without locking the knees—point the toes downwards and relax. Make a commitment to practice each day for 1 month to assess the benefits. Remember this 13-point schedule and keep to the routine. Always end your relaxation session with several deep breaths. Then after slowly opening your eyes, maintain your relaxation position for a few minutes before resuming your next activity. Play music to help you relax.Sit in a comfortable position in a chair that supports your back and neck, or lay down on the floor with your head supported by a cushion. Close your eyes. Begin by taking a few deep breaths through the nose and exhale to push the air out of the lungs through the mouth. Continue to breath deeply and slowly while tensing groups of muscles for 10 seconds, and then relaxing each group for 30 seconds using the following order: Clench fists and relax Bend arms to flex the biceps and then straighten Straighten arms tightly to flex the triceps then relax. Shrug shoulders up towards the ears and then drop them to relax. Press head back to tense the neck muscles and relax. Purse lips and relax. Press the tongue against the back of the teeth and relax. Clench teeth to tense the jaw and relax. Squeeze eyes tightly shut, frown and then relax Breathe in deeply and hold to tense the chest—exhale deeply and relax. Tense the stomach muscles as if preparing them for a blow and relax. Clench the buttock muscles together tightly and relax. Keep legs straight without locking the knees—point the toes downwards and relax. Make a commitment to practice each day for 1 month to assess the benefits. Remember this 13-point schedule and keep to the routine. Always end your relaxation session with several deep breaths. Then after slowly opening your eyes, maintain your relaxation position for a few minutes before resuming your next activity. Play music to help you relax.

26. Meditation Meditation helps quiet your mind and puts a stop to the voice-over or commentary that sometimes threatens to take over. The simplest meditation technique is to focus your attention on an object or spot in the room. Gaze at the object, concentrating your attention on it ofr a few minutes and breathing slowly and deeply. If your mind wanders, gently bring your attention back to the object or spot. You may want to choose a word to repeat as you breathe deeply and focus on the object or spot. Meditation helps quiet your mind and puts a stop to the voice-over or commentary that sometimes threatens to take over. The simplest meditation technique is to focus your attention on an object or spot in the room. Gaze at the object, concentrating your attention on it ofr a few minutes and breathing slowly and deeply. If your mind wanders, gently bring your attention back to the object or spot. You may want to choose a word to repeat as you breathe deeply and focus on the object or spot.

27. Affirmations An affirmation is a positive statement that you say to yourself several times each day. Many people who use affirmations make a list of 5 to 10 statements and write them on a card. They repeat the affirmations to themselves regularly. Incorporating these positive thoughts into your day is a way to reduce any anxiety that you may feel, because the positive thoughts replace the negative thoughts. An affirmation is a positive statement that you say to yourself several times each day. Many people who use affirmations make a list of 5 to 10 statements and write them on a card. They repeat the affirmations to themselves regularly. Incorporating these positive thoughts into your day is a way to reduce any anxiety that you may feel, because the positive thoughts replace the negative thoughts.

28. Four-Step Approach Constructive self-talk Quick recovery Thought stopping Mental diversion Constructive self-talk can be used as an effective stress-control strategy. By focusing on the positive aspects of a situation, holding realistic expectations, and keeping things in perspective, it is possible to avoid damage caused by negative thoughts. This is the ability to bounce back from an upsetting experience. We sometimes prolong or exacerbate a negative experience because we continually revisit it in our mind to try and justify our position or rehash the event. You stop the negative and damaging circular loop by becoming more rational and less conscious of the need to win on every occasion. Recognizing non-constructive thoughts, attitudes and behaviors, and stopping them immediately by visualizing, for example, a large STOP sigh. Divert your thoughts to a topic that is more comfortable and manageable, or until you are ready to cope with the stress event. This can stop the negative train of thought and subsequent drain on the recovery process.Constructive self-talk can be used as an effective stress-control strategy. By focusing on the positive aspects of a situation, holding realistic expectations, and keeping things in perspective, it is possible to avoid damage caused by negative thoughts. This is the ability to bounce back from an upsetting experience. We sometimes prolong or exacerbate a negative experience because we continually revisit it in our mind to try and justify our position or rehash the event. You stop the negative and damaging circular loop by becoming more rational and less conscious of the need to win on every occasion. Recognizing non-constructive thoughts, attitudes and behaviors, and stopping them immediately by visualizing, for example, a large STOP sigh. Divert your thoughts to a topic that is more comfortable and manageable, or until you are ready to cope with the stress event. This can stop the negative train of thought and subsequent drain on the recovery process.

29. Examples I am calm and relaxed. I am free of all worry and stress. I meet stressful situations with calm and determination. I take good care of my mind and body.

30. Short relaxation exercises Select a comfortable sitting or reclining position. Close your eyes and think about a place that you have been before that represents your ideal place for physical and mental relaxation. Now imagine tat you are actually in your ideal relaxation place. Imagine that you are seeing all the colors, hearing the sounds and able to taste and smell the aromas. Just relax, enjoying your soothing, rejuvenating environmnet. Feel the peacefulness, the calmness, and imagine your whole body and mine being renewed and refreshed. After 5-10 minutes, slowly open your eyes and stretch. You have the realization that you may instantly return to your relaxation place whenever you desire, and experience a peacefulness and calmness in body and mind.Select a comfortable sitting or reclining position. Close your eyes and think about a place that you have been before that represents your ideal place for physical and mental relaxation. Now imagine tat you are actually in your ideal relaxation place. Imagine that you are seeing all the colors, hearing the sounds and able to taste and smell the aromas. Just relax, enjoying your soothing, rejuvenating environmnet. Feel the peacefulness, the calmness, and imagine your whole body and mine being renewed and refreshed. After 5-10 minutes, slowly open your eyes and stretch. You have the realization that you may instantly return to your relaxation place whenever you desire, and experience a peacefulness and calmness in body and mind.

31. EXERCISE Exercise is one of the simplest, most effective ways to respond to stress. Activity provides a natural release fro the body during its fight or flight state of arousal. After exercising, the body returns to its normal state of equilibrium, and one feels relaxed and refreshed.Exercise is one of the simplest, most effective ways to respond to stress. Activity provides a natural release fro the body during its fight or flight state of arousal. After exercising, the body returns to its normal state of equilibrium, and one feels relaxed and refreshed.

32. EAT RIGHT Exercise is one of the simplest, most effective ways to respond to stress. Activity provides a natural release fro the body during its fight or flight state of arousal. After exercising, the body returns to its normal state of equilibrium, and one feels relaxed and refreshed.Exercise is one of the simplest, most effective ways to respond to stress. Activity provides a natural release fro the body during its fight or flight state of arousal. After exercising, the body returns to its normal state of equilibrium, and one feels relaxed and refreshed.

33. TIME MANAGEMENT

34. GET A THERAPIST

35. GET A DOG!