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Rx: Reduce Stress
Stress-management programs are part of the treatment plan for a growing number of diseases and conditions. Consumer Reports, November 2005 It’s no wonder many people find it hard to relax. The “stress response” has been part of life for at least 700 million years, DNA research shows. Even bugs (fruit flies, honeybees, mosquitoes) have a gene strikingly similar to humans for the secretion of corticotrophin-releasing hormone, a key player in the body’s response to stressful situations. When a threat is perceived, this hormone powers up the endocrine system. Muscles tense, breathing and heart rate speed up, blood pressure increases, and energy-producing hormones such as adrenaline and cortisol surge into the bloodstream. Those changes fuel the “fight or flight” response, useful for escaping predators or dealing with life-or-death situations. In most modern-life situations, however, where neither fight nor flight is usually a useful response, there’s no immediate release for the excess energy built up in the body after a stressful episode. And without a release, it takes the revved-up body a while to return to its normal functioning. If this situation occurs frequently, it can take a serious toll on your health. A vast literature ties excess or chronic stress to reduced immunity, hypertension, coronary artery disease, increased risk of heart attack and stroke, and many other disorders. Stress is now considered as much of a risk factor as smoking, overweight, or lack of exercise for a variety of diseases. And stress itself can contribute to unhealthy lifestyle choices, such as overeating or alcohol abuse. On the positive side, extensive research now shows that learning techniques to help the body quickly recover from the stress response can have beneficial effects on a wide range of conditions (see the accompanying table, “Stress Management”). Such methods as measured breathing, meditation, and mindfulness exercises are designed to induce a set of physiological changes that counteract the nervous system’s stress response, including reduced heart rate and blood pressure, decreased muscle tension, and slowing of brain waves. The changes are known collectively as the “relaxation response.” Programs to teach those techniques are now widely available at hospitals, medical schools, and freestanding clinics around the country. “More and more doctors are ‘prescribing’ this program to their patients as part of their medical care for a great variety of conditions,” says Mark Abramson, D.D.S., director of the eight-week Mindfulness-Based Stress Reduction program at Stanford University Hospital in California. Those include heart disease, anxiety, insomnia, pain, and cancer treatment. Stress management is often a part of weight-loss or other lifestyle modification programs. It’s natural to think that relaxing is something you should be able to accomplish on your own, but without the help of a therapist, coach, or group-meditation sessions, relaxation is difficult for many people to achieve. It often takes more than a casual dabbling with meditation, tai chi, or relaxing music. If stress is posing a threat to your health or well-being, consider a structured program to help you cope. Group Approaches to Stress Interventions designed to reduce stress date back to the 1970s. Among the earliest structured programs is an eight-week, meditation-based course, which was founded at the University of Massachusetts Medical School and is geared toward helping people cope with stress, pain, and illness. The course centers on mindfulness, a nonjudgmental awareness of the present moment. (Mindfulness meditation varies somewhat from transcendental, or focus word, meditation, which involves concentrating on a specific word or phrase. Both are established and extensively researched forms of relaxation.) Today, at least 240 stress-reduction programs are available nationwide based on the University of Massachusetts model, called Mindfulness-Based Stress Reduction (MBSR). The curriculum includes training in seated and walking meditation and other relaxation techniques, mindful movement such as yoga or tai chi, verbal exercises, and group discussions. Common to all the lessons is a focus on breathing throughout all daily activities. The course consists of eight weekly meetings, plus a full-day Saturday retreat near the end of the program and assigned practice between sessions. Classes include 25 to 35 participants, about half usually referred by their physicians, according to Melissa Blacker, senior instructor at the University of Massachusetts program. The rest come on their own, driven by a desire to reduce the impact of stress on their lives or simply to explore the mind-body connection. The cost ranges from about $200 to $600; insurance reimbursement varies widely, so check with the program and your insurance company. Some nonreimbursable programs have sliding fee scales or offer scholarships. An extensive literature base supports the benefits, both mental and physical, of the MBSR program, as well as mindfulness training and meditation in general. But experts agree continued practice, only 10 to 15 minutes a day, is essential to maintaining the benefits.“We strongly encourage students to keep the momentum going,” says Jeffrey Brantley, M.D., director of the MBSR program at Duke University in North Carolina. Also emphasized is “informal mediation”—applying the principles of mediation to everyday situations, like standing in the grocery line. Some programs offer free continuation of “brush up” courses for graduates. Not all stress-reduction programs follow the MBSR model. Researchers at the University of Miami have developed an intervention called Cognitive-Behavioral Stress Management (CBSM) for people living with cancer, HIV, and AIDS. The 10-week course focuses on learning to replace negative thoughts with more constructive ones and “matching” appropriate coping strategies to various stressful situations, though some relaxation training is also included. The course includes active strategies (trying a new medication regimen, researching treatments on the Internet) and emotion-focused ones (such as using deep breathing to recover from an upsetting comment made by a relative). Studies have shown the course improves mood, coping skills, and certain immune parameters, among other benefits. Monthly follow-up sessions are standard after the course, according to Michael Antoni, Ph.D., professor of psychology and psychiatry and behavioral sciences at the University of Miami and director of the CBSM program. Other courses may include elements of both meditation and cognitive therapy, as well as activities such as writing and drawing. Shorter-term options and programs that combine vacations with stress reduction are also available. For example, the nonprofit Omega Institute (www.eomega.com) offers retreats and workshops in mindfulness stress reduction, yoga, and other peaceful practices in various locations. Finding the Right Group The group format of stress-management programs isn’t a matter of logistics alone. “When people work together as a group they can serve as models for one another, interact, give their 2 cents, give examples of where they’re going to apply the techniques,” Antoni says. “The group itself becomes a means of social support and a way to play out the interventions in real-world settings.” Experts advise looking for a program that meets the following criteria: • The instructor should be a professional with at least a master’s degree. • For meditation-based programs, ask how long the instructor has practiced meditation. Look for someone with at least several years of experience. • Courses marketed as “Mindfulness-Based Stress Reduction” should follow the University of Massachusetts format. • For other programs, ask what instructional materials the teacher uses and what research backs them up. They should be able to produce at least one good randomized controlled trial supporting the approach. To find a qualified program: Ask your physician; find a university in your area that has a center for integrative or mind/body medicine; check with local cardiology departments; or call the counseling center at a local university. The University of Massachusetts Center for Mindfulness provides free local referrals (508-856-2656; www.umassmed.edu/cfm/mbsr). If your workplace offers an on-site stress-management intervention—from an educational course to yoga—consider taking advantage of it. If your stress comes primarily from the workplace, it could provide a good opportunity to practice the skills you learn in real time. A large review published in 2001 concluded that workplace programs, especially cognitive-behavioral ones, reduced stress-related physical complaints and improved coping skills and perceived quality of life at work. Keep in mind that stress reduction is intended as an adjunct to, not a replacement for, your regular medical regimen. As Brantley says, “Don’t quit your medication when you start your meditation.” Individual options Group programs may not be the best option for everyone. Individual stress-management consultations or programs are offered by some hospitals and medical schools. Another option is to work one-on-one with a therapist, who can help you learn to reduce stress through cognitive methods or help you through various relaxation techniques, such as guided imagery. As an alternative to traditional therapy, there’s now “health coaching.” This approach focuses more on behavior modification and goal-setting, less on thoughts and emotions. For therapy and coaching alike, be sure to check the practitioner’s credentials carefully. If the principles of meditation appeal to you but you aren’t comfortable with a group program, look for a practitioner who offers training for individuals or couples (note that the cost may be higher). People who are interested and motivated can also teach themselves with the help of a book and/or audiotapes, including some sold through university stress-reduction programs. Be wary of any book or tape that insists a certain style or “brand” of meditation is superior. Research indicates that all forms of meditation can induce the desired response; feeling personally comfortable with and trusting a technique is what matters. Your own coping tools Whether or not you seek formal help, everyone should develop a personal portfolio of stress coping strategies, drawing from the following areas: • Exercise. People who get regular aerobic exercise have lower levels of stress hormones and smaller increases in heart rate and blood pressure under duress. Staying fit works both as a long-term antidote to chronic stress and as a quick fix, by providing a “time out” from worrisome thoughts. • Social support. Club membership, religious or civic activities, and volunteer work have all been shown to protect against the physical effects of stress. Having a few close friends, relatives, or a pet to lean on is also beneficial. For example, in a study of 38 couples published in July 2005, hugging for 20 seconds reduced blood pressure and increased levels of a “bonding” hormone. It also reduced cortisol levels in the women (but not the men). • Some form of relaxation. This can include hobbies, massage, music, meditation, deep abdominal breathing, biofeedback (see box, “Biofeedback Products”), or guided imagery (in which you visualize a pleasant scene). Yoga and tai chi offer additional physical benefits. • Cognitive-behavioral techniques. Separate the things that are causing you stress into those you can control and those you can’t. For the things you have some ability to change, create a step-by-step plan of action. For the things you can’t alter—such as being stuck in traffic—apply a relaxation method. • Work breaks. Vacations, lunch breaks, and strolls outside the building all play an important role in reducing stress in the workplace. • Write it down. Some evidence suggests that recording troubles brings as much relief as talking to a friend about them. Stress-reduction programs encourage participants to record both stressful and pleasant events in a calendar. Checklist: Stress Warning Signs While studies show that occasional bouts of stress, such as deadline pressure, can be good for you, prolonged or very intense levels can pose a major threat to your health and well-being. Some symptoms of stress overlap those of anxiety or depression. Seek help if you experience several of the following symptoms, or any one to the extreme: • Worrying about not having enough time to get everything done. • Odd aches and pains with no diagnosable origin—particularly headaches and back or joint pain. • Forgetfulness, difficulty concentrating. • Irritability: quickness to anger or overreaction to minor problems. • Frequent insomnia or oversleeping. • Feeling out of balance or generally dissatisfied. • Difficulty managing time effectively. • Not getting pleasure from activities that you used to enjoy. • Poor appetite or unhealthful diet. • Frequent conflicts in relationships. • A health condition, such as hypertension or chronic pain, that may be aggravated by stress. • Continued attempts to relax and reduce stress on your own aren’t working. Stress management: What's the evidence? Controlled clinical
trials have shown the benefits of
stress management interventions for the conditions checked (
1. Reduced cortisol levels;
improved immunity; reduced
nausea and vomiting pre-chemotherapy; increased survival length;
increased
optimism. Biofeedback Products: An Interactive Option The Journey to Wild Divine, pictured, has a mythical, new-age feel. Another product, Freeze-Framer, is more scientific in tone. Biofeedback programs are an alternative to meditation and other relaxation techniques known to reduce stress. Their advantage is that they deliver information about your current heart rate and other stress indicators and let you know how well you’re doing. We looked at two interactive products that can be used on home computers: The Journey to Wild Divine ($150; www.wilddivine.com) and Freeze-Framer ($295), sold by HeartMath (www.heartmath.com), a mind-body research institute based in California. Using sensors attached to one or more of your fingers, these programs monitor certain indicatorsof stress or relaxation and give you visual feedback. Forexample, a colorful balloon floats up on the screen as your body calms down. Both products compute heart-rate variability (more variability is healthier because it indicates a more flexible cardiovascular system). Wild Divine also assesses skin-conductance level, a measure of sweat-gland activity due to increased nervous-system activation (both positive, as in excitement, and negative, as in nervousness). Both variables are standard indicators used in professional biofeedback, a well-supported mind-body therapy. The HeartMath Institute, which developed Freeze-Framer, has published studies supporting the stress-reduction techniques they’ve patented collectively as “HeartMath.” Studies are currently under way testing The Journey to Wild Divine in various health groups. We purchased both programs and asked about a dozen staff volunteers to try them out. The programs include various tasks—such as spinning a pinwheel or creating a rainbow on the screen—that require you to manipulate your breathing and heart rate to induce a state of deep relaxation. Staff reactions were generally positive, though the slow pace of Wild Divine frustrated some users. And some found maintaining required scores in Freeze-Framer anxiety-producing. Both products connect to your computer via a USB cable and operate on Windows platforms; Wild Divine also works on a Mac (OS X or higher). They came with fairly complete installation instructions, but it takes some time to set them up. Citations: 1. van der Klimk JJL, et al. “The benefits of interventions for work-related stress,” American Journal of Public Health, February 2001, pp. 270-6. 2. Grewen KM, et al. “Effects of partner support on resting oxytocin, cortisol, norepinephrine, and blood pressure before and after warm partner contact,” Psychosomatic Medicine, July-August 2005, pp. 531-8. Other Sources: Hemingway H, et al. “Does autonomic function link social position to coronary risk?” Circulation, June 14, 2005, pp. 3071-7. Schneider RH, et al. “Long-term effects of stress reduction on mortality in persons 55 years of age or older with systemic hypertension,” American Journal of Cardiology, May 1, 2005, pp. 1060-4. Bryant RA, et al. “The additive benefit of hypnosis and cognitive-behavioral therapy in treating acute stress disorder,” Journal of Consulting and Clinical Psychology, April 2005, pp. 334-40. Epel ES, et al. “Accelerated telomere shortening in response to life stress,” Proceedings of the National Academy of Sciences, December 7, 2004, pp. 17312-5. McGregor BA, et al. “Cognitive-behavioral stress management increases benefit finding and immune function among women with early-stage breast cancer,” Journal of Psychosomatic Research, January 2004, pp. 1-8. Penedo FJ, et al. “Cognitive-behavioral stress management improves stress-management skills and quality of life in men recovering from treatment of prostate carcinoma,” Cancer, January 1, 2004, pp. 192-200. Perna FM, et al. “Cognitive behavioral stress management effects on injury and illness among competitive athletes: A randomized clinical trial,” Annals of Behavioral Medicine, Winter 2003, pp. 66-73. Antoni MH. “Stress management effects on psychological, endocrinological, and immune functioning in men with HIV infection: Empirical support for a psychoneuroimmunological model,” Stress, September 2003, pp.1-17. Davidson RJ, et al. “Alterations in brain and immune function produced by mindfulness meditation,” Psychosomatic Medicine, July-August 2003, pp. 564-70. Truelsen T, et al. “Self-reported stress and risk of stroke: The Copenhagen City Heart Study,” Stroke, April 2003, pp. 856-62. Lechner AC, et al. “Cognitive-behavioral interventions improve quality of life in women with AIDS,” Journal of Psychosomatic Research, March 2003, pp. 253-61. Hampel P. et al. “Multimodal patient education program with stress management for children and adolescent asthma,” Patient Education and Counseling, January 2003, pp. 59-66. Solomon SD, Johnson DM. “Psychosocial treatment of posttraumatic stress disorder: A practice-friendly review of outcome research,” Journal of Clinical Psychology, August 2002, pp. 947-59. Han KS. “The effect of an integrated stress management program on the psychologic and physiologic stress reactions of peptic ulcers in Korea,” International Journal of Nursing Studies, July 2002, pp. 539-48. Spiker LE, et al. “Mental stress induces prolonged endothelial dysfunction via endothelin-A receptors,” Circulation, June 18, 2002, pp. 2817-20. Reibel DK, et al. “Mindfulness-based stress reduction and health-related quality of life in a heterogeneous patient population,” General Hospital Psychiatry, July-August 2001, pp. 183-92. Keefer L, Blanchard EB. “The effects of relaxation response meditation on the symptoms of irritable bowel syndrome: Results of a controlled treatment study,” Behaviour Research and Therapy, July 2001, pp. 801-11. Holroyd KA, et al. “Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: A randomized controlled trial,” Journal of the American Medical Association, May 2, 2001, pp. 2208-15. Antoni MH, et al. “Cognitive-behavioral stress management intervention decreases the prevalence of depression and enhances benefit finding among women under treatment for early-stage breast cancer,” Health Psychology, January 2001, pp. 20-32. Mills N, Allen J. “Mindfullness of movement as a coping strategy in multiple sclerosis: A pilot study,” General Hospital Psychiatry, November-December 2000, pp. 425-31. Speca M, et al. “A randomized, wait-list controlled clinical trial: The effect of a mindfulness meditation-based stress reduction program on mood and symptoms of stress in cancer outpatients,” Psychosomatic Medicine, September-October 2000, pp. 613-22. Teasdale JD, et al. “Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy,” Journal of Counseling and Clinical Psychology, August 2000, pp. 615-23. Krantz DS, et al. “Effects of mental stress in patients with coronary artery disease: Evidence and clinical implications,” Journal of the American Medical Association, April 12, 2000, pp. 1800-2. Kiecolt-Glaser JK, Glaser R. “Chronic stress and mortality among older adults,” Journal of the American Medical Association, December 15, 1999, pp. 2259-60. Kabat-Zinn J, et al. “Influence of a mindfulness meditation-based stress reduction intervention on rates of skin clearing in patients with moderate or severe psoriasis undergoing phototherapy (UVB) and photochemotherapy (PUVA),” Psychosomatic Medicine, September-October 1998, Devine EC, Pearcy J. “Meta-analysis of the effects of psychoeducational care in adults with chronic obstructive pulmonary disease,” Patient Education and Counseling, November 1996, pp. 167-78. Devine EC. “Meta-analysis of the effects of psychoeducational care in adults with asthma,” Research in Nursing & Health, October 1996, pp. 367-76. Parker JC, et al. “Effects of stress management on clinical outcomes in rheumatoid arthritis,” Arthritis and Rheumatism, December 1995, pp. 1807-18. Miller JJ, et al. “Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders,” General Hospital Psychiatry, May 1995, pp. 192-200. Kaplan KH, et al. “The impact of a meditation-based stress reduction program on fibromyalgia,” General Hospital Psychiatry, September 1993, pp. 284-9. McGrady A, Bailey BK, Good MP. “Controlled study of biofeedback-assisted relaxation in type 1 diabetes,” Diabetes Care, May 1991, pp. 360-5. |
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) in this table. The
Quality of Life Benefits column refers to improvements in mental health
function, and stress symptoms (such as gastrointestinal discomfort).
The
Disease Benefits column refers to improvements in the symptoms,
biologic
markers, or outcomes of the disease, or (for items marked
“possibly”) in immune
parameters that might improve the course of the disease.