Stress and Psychiatry

Introduction

Life without stress cannot be imagined.  Psychological stress forms an inseparable part of life.  Up to some degree, it may be essential for normal personality development.  However if these stresses become too severe may become a cause of major psychopathology, a precipitator or trigger of psychiatric illness, a contributor to considerable mental anguish.  It is reported that there is good evidence on the importance of stress on psychopathology in general, although less known about the specific risk and protective mechanisms. Negative or stressful life events more generally have been implicated in the development of a range of disorders, including mood and anxiety disorder. Maltreatment in childhood and in adulthood, including sexual abuse, physical abuse,emotional abuse, domestic violence and bullying, has been linked to the development of mental disorders, through a complex interaction of societal, family, psychological and biological factors. The main risks appear to be from a cumulative combination of such experiences over time, although exposure to a single major trauma can sometimes lead to psychopathology, like PTSD.  Resilience to such experiences varies, and a person may be resistant to some forms of experience but susceptible to others. Features associated with variations in resilience include genetic vulnerability, temperamental characteristics, cognitive set, coping patterns, and other experiences.

What is Stress?

Stress may be considered as any physical, chemical, or emotional factor that causes bodily or mental unrest and that may be a factor in disease causation.  Physical and chemical factors that can cause stress include trauma, infections, toxins, illnesses, and injuries of any sort. Emotional causes of stress and tension are numerous and varied. While many people associate the term "stress" with psychological stress, scientists and physicians use this term to denote any force that impairs the stability and balance of bodily function. When people feel stressed by something going on around them, their bodies react by releasing chemicals into the blood.  These chemicals give people more energy and strength.  A mild degree of stress and tension can sometimes be beneficial.  For example, feeling mildly stressed when carrying out a project or assignment often compels us to do a good job, focus better, and work energetically.  There are two types of stress: eustress ("positive stress") and distress ("negative stress"), roughly meaning challenge and overload.  When stress is overwhelming or poorly managed, then it causes negative effects

Common sources of stress

Survival Stress

When a person fears that someone or something may physically hurt him, the body naturally responds with a burst of energy so that he will be better able to survive the dangerous situation (fight) or escape it all together (flight). This is survival stress.

Internal Stress

Internal stress is one where people make themselves stressed. This often happens when we worry about things we can't control or put ourselves in situations that cause stress.  Some people become addicted to the kind of hurried, tense, lifestyle that results from being under stress.  They even look for stressful situations and feel stress about things that aren't stressful.

Environmental Stress

This is a response to things around us that cause stress, such as noise, crowding, and pressure from work or family. Identifying these environmental stresses and learning to avoid them or deal with them will help to lower stress level.

Fatigue and Overwork

This kind of stress builds up over a long time and can take a hard toll on your body.  It can be caused by working too much or too hard at your job(s), school, or home. It can also be caused by not knowing how to manage time or how to take time out for rest and relaxation. This can be one of the hardest kinds of stress to avoid because many people feel this is out of their control. This kind of stress builds up over a long time and can take a hard toll on your body.  It can be caused by working too much or too hard at your job(s), school, or home. It can also be caused by not knowing how to manage time or how to take time out for rest and relaxation. This can be one of the hardest kinds of stress to avoid because many people feel this is out of their control.

• Short-term 'acute' stress is the reaction to immediate threat, also known as the fight or flight response. This is when the primitive part of the brain and certain chemicals within the brain cause a reaction to potentially harmful stressors or warnings.
• Long-term 'chronic' stressors are those pressures which are ongoing and continuous, when the urge to fight or flight has been suppressed. Examples of chronic stressors include: ongoing pressurized work, ongoing relationship problems, isolation, and persistent financial worries.

Factors influencing the effects of stress and stress susceptibility

A person's susceptibility to stress can be affected by any or all of these factors, which means that everyone has a different tolerance to stressors. And in respect of certain of these factors, stress susceptibility is not fixed, so each person's stress tolerance level changes over time:

• Childhood experience (abuse can increase stress susceptibility)
• Personality (certain personalities are more stress-prone than others)
• Genetics (particularly inherited 'relaxation response', connected with serotonin levels, the brain's 'well-being chemical')
• Immunity abnormality (as might cause certain diseases such as arthritis and eczema, which weaken stress resilience)
• Lifestyle (principally poor diet and lack of exercise)
• Duration and intensity of stressors

Indicators to prompt investigation for the presence of stress

• sleep difficulties
• loss of appetite
• poor concentration or poor memory retention
• performance dip
• uncharacteristic errors or missed deadlines
• anger or tantrums
• violent or anti-social behavior
• emotional outbursts
• alcohol or drug abuse
• nervous habits

Effects of Stress

Physical Effects

Physical effects of stress occur mainly through the neuro-endocrino-immunological pathways. Whatever be the nature of the stressor, the basic responses of the body to these are similar. Following are some of the physical effects of stress on our body

• Palpitation: increased heart beat
• Increased, shallow breathing
• Tremors
• Cold, clammy extremities/sweating
• Moist eyebrows
• Tightening of muscles, showing tightening of abdominal muscles, tense arms and legs, clenched jaw causing gritting of teeth.
• Dyspepsia/bowel disturbances
• Increased frequency of urine
• Hair loss

Mental Effects

Mental effects of stress can manifest in many ways unless recognized and rectified in the proper manner. It is well known that unresolved emotional stress can translate into mental miseries and then into physical illnesses (known as psychosomatic illnesses). Other common mental effects of stress are:

• Inability to concentrate
• Difficulty with coming to decisions
• Loss of self-confidence
• Irritability or frequent anger
• Insatiable cravings
• Unnecessary worry, uneasiness and anxiety
• Irrational fear
• Panic attacks
• Compelling emotions and mood swings

Behavioural Effects

Behavioural effects of stress showcases the way in which a person acts and behaves when under the influence of stress Following are some of the behavioural effects of stress:

• Excessive smoking
• Nervous tics
• Increased use of alcohol or drug(s)
• Mannerisms like nail biting, hair puling etc.
• Increased or decreased eating
• Absent mindedness
• Excessive smoking
• Accident-proneness
• Aggressiveness on least provocation

It is evident that behavioral effects of stress are very dangerous and can affect interpersonal and social relationships Certain types of chronic and more insidious stress due to loneliness, poverty, bereavement, depression and frustration due to discrimination are associated with impaired immune system resistance to viral linked disorders ranging from the common cold and herpes to AIDS and cancer. Stress can have effects on other hormones, brain neurotransmitters, additional small chemical messengers elsewhere, prostaglandins, as well as crucial enzyme systems, and metabolic activities that are still unknown.

Few stress related diseases

Behavioral effects of stress showcases the way in which a person acts and behaves when under the influence of stress Following are some of the behavioral effects of stress:

• Acid Peptic Disease
• Alcoholism
• Asthma
• Fatigue
• Tension Headache
• Hypertension
• Insomnia
• Irritable Bowel Syndrome
• Ischemic Heart Disease
• Psychiatric disorders
• Sexual Dysfunction
• Skin diseases like Psoriasis, Lichen planus, Urticaria, Pruritus, Neurodermatitis etc. the list is not complete.

Understanding the above concepts are very important in understanding the diseases caused by stress and to create a plan of action for the management of stress and stress induced diseases. At a clinical level, stress in individuals can be assessed scientifically by measuring the levels of two hormones produced by the adrenal glands: cortisol and DHEA (dehydroepiandrosterone). To measure stress according to the Holmes and Rahe Stress Scale, the number of "Life Change Units" that apply to events in the past year of an individual's life are added and the final score will be given. For example death of spouse gives a score of hundred.

• Score of 300+: At risk of illness.
• Score of 150-299+: Risk of illness is moderate (reduced by 30% from the above risk).
• Score 150-: Only has a slight risk of illness

Stress Management

Physical Effects

A stress journal can help to identify the regular stressors in the life and the way one deals with them. One should keep track of stress whenever he/she feels stressed in the journal. As one keeps a daily log, he/she will begin to see patterns and common themes. Write down:

• What caused your stress (make a guess if you’re unsure)?
• How you felt, both physically and emotionally.
• How you acted in response.
• What you did to make yourself feel better.

Think about the ways you currently manage and cope with stress in your life. Your stress journal can help you identify them. Are your coping strategies healthy or unhealthy, helpful or unproductive? Unfortunately, many people cope with stress in ways that compound the problem.

Unhealthy ways of coping with stress

These coping strategies may temporarily reduce stress, but they cause more damage in the long run:

• Smoking
• Drinking too much
• Over eating or under eating
• Zoning out for hours in front of the TV or computer
• Withdrawing from friends, family, and activities
• Using pills or drugs to relax
• Sleeping too much
• Procrastinating
• Filling up every minute of the day to avoid facing problems
• Taking out your stress on others (lashing out, angry outbursts, physical violence)
• There are many healthy ways to manage and cope with stress, but they all require change. We can either change the situation or change the reaction. Think really seriously about and talk with others, to identify the causes of the stress and take steps to remove, reduce them or remove the stressed person from the situation that causes the stress.
• Understand the type(s) of stressors affecting the stressed person and the contributors to the stress susceptibility - knowing what you're dealing with is essential to developing the stress management approach.

Change the situation

• Avoid the stressor.

• Alter the stressor

Change your reaction

• Adapt to the stressor.
• Accept the stressor.

Avoid unnecessary stress

• Learn how to say “no”: Know your limits and stick to them. Whether in your personal or professional life, refuse to accept added responsibilities. Taking on more than you can handle is a surefire recipe for stress.
• Avoid people who stress you out: If someone consistently causes stress in your life and you can’t turn the relationship around, limit the amount of time you spend with that person or end the relationship entirely.
• Take control of your environment: If the evening news makes you anxious, turn the TV off. If traffic’s got you tense, take a longer but less-traveled route. If going to the market is an unpleasant chore, do your grocery shopping online.
• Avoid hot-button topics: If you get upset over religion or politics, cross them off your conversation list. If you repeatedly argue about the same subject with the same people, stop bringing it up or excuse yourself when it’s the topic of discussion.
• Pare down your to-do list: Analyze your schedule, responsibilities, and daily tasks. If you’ve got too much on your plate, distinguish between the “should” and the “musts.” Drop tasks that aren’t truly necessary to the bottom of the list or eliminate them entirely.

Alter the situation

• Express your feelings instead of bottling them up: If something or someone is bothering you, communicate your concerns in an open and respectful way. If you don’t voice your feelings, resentment will build and the situation will likely remain the same.

• Be willing to compromise: When you ask someone to change their behavior, be willing to do the same. If you both are willing to bend at least a little, you’ll have a good chance of finding a happy middle ground.

• Be more assertive: Don’t take a backseat in your own life. Deal with problems head on, doing your best to anticipate and prevent them. If you’ve got an exam to study for and your chatty roommate just got home, say up front that you only have five minutes to talk.

• Manage your time better: Poor time management can cause a lot of stress. When you’re stretched too thin and running behind, it’s hard to stay calm and focused. But if you plan ahead and make sure you don’t overextend yourself, you can alter the amount of stress you’re under.

Adapt to the stressor

• Reframe problems: Try to view stressful situations from a more positive perspective. Rather than fuming about a traffic jam, look at it as an opportunity to pause and regroup, listen to your favorite radio station, or enjoy some alone time.
• Look at the big picture: Take perspective of the stressful situation. Ask yourself how important it will be in the long run. Will it matter in a month? A year? Is it really worth getting upset over? If the answer is no, focus your time and energy elsewhere.
• Adjust your standards: Perfectionism is a major source of avoidable stress. Stop setting yourself up for failure by demanding perfection. Set reasonable standards for yourself and others, and learn to be okay with “good enough.”
• Focus on the positive: When stress is getting you down, take a moment to reflect on all the things you appreciate in your life, including your own positive qualities and gifts. This simple strategy can help you keep things in perspective.

Accept the things you can’t change

Some sources of stress are unavoidable. You can’t prevent or change stressors such as the death of a loved one, a serious illness, or a national recession. In such cases, the best way to cope with stress is to accept things as they are. Acceptance may be difficult, but in the long run, it’s easier than railing against a situation you can’t change.

• Don’t try to control the uncontrollable: Many things in life are beyond our control— particularly the behavior of other people. Rather than stressing out over them, focus on the things you can control such as the way you choose to react to problems.
• Look for the upside: As the saying goes, “What doesn’t kill us makes us stronger.” When facing major challenges, try to look at them as opportunities for personal growth. If your own poor choices contributed to a stressful situation, reflect on them and learn from your mistakes.
• Share your feelings: Talk to a trusted friend or make an appointment with a therapist. Expressing what you’re going through can be very cathartic, even if there’s nothing you can do to alter the stressful situation.
• Learn to forgive: Accept the fact that we live in an imperfect world and that people make mistakes. Let go of anger and resentments. Free yourself from negative energy by forgiving and moving on.

Healthy ways to relax and recharge

• Go for a walk.
• Spend time in nature.
• Call a good friend.
• Sweat out tension with a good workout.
• Write in your journal.
• Take a long bath.
• Light scented candles. Savor a warm cup of coffee or tea.
• Play with a pet.
• Work in your garden.
• Get a massage.
• Curl up with a good book.
• Listen to music.
• Watch a comedy.
• Set aside relaxation time: Include rest and relaxation in your daily schedule. Don’t allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries.
• Connect with others: Spend time with positive people who enhance your life. A strong support system will buffer you from the negative effects of stress.
• Do something you enjoy every day: Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike.
• Keep your sense of humor: This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways

Healthy way of life

Improve diet: Group B vitamins and magnesium are important, but potentially so are all the other vitamins. Vitamin C is essential to protect against stress. Vitamin D helps maintain healthy body condition, particularly bones. Adequate intake of minerals are also essential for a healthy body and brain, and so for reducing stress susceptibility Assess the current diet and identify where improvements should be made and commit to those improvements. Avoid baked, canned food ,too much salt, pills and tablets.

Reduce toxin intake: Obviously tobacco, alcohol especially - they might seem to provide temporary relief but they are working against the balance of the body and contributing to stress susceptibility, and therefore increasing stress itself.

Take more exercise: Generally, and at times when feeling very stressed:

1. Exercise burns up adrenaline and produces helpful chemicals and positive feelings.
2. Exercise distracts us from the causes of stress.
3. Exercise warms and relaxes cold, tight muscles and tissues which contribute to stress feelings.
4. Exercise increases blood flow to the brain which is good for us
5. Exercise develops and maintains a healthy body which directly reduces stress susceptibility

Increase self-awareness of personal moods and feelings: Anticipate and take steps to avoid stress build-up before it becomes more serious. Explore and use relaxation methods: They do work if given a chance - yoga, meditation, self-hypnosis, massage, a breath of fresh air, anything that works and can be done in the particular situation

Sleep and rest are essential for a healthy life-balance. Napping during the day is also healthy. It recharges and energizes, relaxes, and helps to wipe the brain of pressures and unpleasant feelings

Anger in the workplace is a symptom of stress: Management of anger (and any other unreasonable emotional behavior for that matter) and the stress that causes it, can only be improved if the person wants to change - acceptance, cognizance, commitment. Awareness is the first requirement. Some angry people take pride in their anger and don't want to change; others fail to appreciate the effect on self and others. Anger management is only possible when the angry person accepts and commits to the need to change. Counseling is required to get to the root causes. A person should look objectively and sensitively with the other person at the consequences (for themselves and others) of their anger. Helping angry people to realize that their behavior is destructive and negative is an important first step. Discuss the effects on their health and their family. Get the person to see things from outside themselves. The next anger management step to understand the cause of their angry tendency, which will be a combination of stressors and stress susceptibility factors. The counselor may need several sessions in order to build sufficient trust and rapport.

Source: Dr Sudha Rani, Assistant Professor of Psychiatry, Institute of Mental Health, Hyderabad