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A Harvard Medical School Special Health Report Price: $26 Stress Management Approaches for preventing and reducing stress In this report: Mini-relaxations for quick stress relief How stress affects your brain, heart, and lungs Learn meditation, breath focus, guided imagery, and other techniques SpecIal BonuS SectIon Your portable guide to stress relief This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  • Print out one copy and route this “original” to family. • You are permitted to have one copy of this publication on your computer at any time (you can’t put it on a network unless you pur- chased a license to do so). If you have paid for more copies, then you may have that many copies on computers at any time. • Copy, on an occasional basis, a couple of pages to give to friends, family members, or colleagues. • We are registered with the Copyright Clear- ance Center (CCC). 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Contents Understanding the stress response . . . . . . . . . . . . . . . . . . 2 What is stress? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The positive side of stress . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 The toll of stress on your body and mind . . . . . . . . . . . . . . . . . 4 Stress in your life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 The major life event stress scale . . . . . . . . . . . . . . . . . . . . . . . 7 Recognizing the early signals . . . . . . . . . . . . . . . . . . . . . . . . . 9 Unhealthy responses to stress . . . . . . . . . . . . . . . . . . . . . . . . 9 How to prevent and manage stress . . . . . . . . . . . . . . . . 10 Producing the relaxation response . . . . . . . . . . . . . . . . . . . . . 10 Breath focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Body scan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Guided imagery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Mindfulness meditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Proper nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Cognitive restructuring: You are what you think . . . . . . . . . . . . 20 The role of positive psychology . . . . . . . . . . . . . . . . . . . . . . . 23 Communicating better . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Social support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Nurturing yourself . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Journals: Easing stress the write way . . . . . . . . . . . . . . . . . . . 27 The different faces of stress . . . . . . . . . . . . . . . . . . . . . . 29 Gender and stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Age and stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Caregiving and stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Work and stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 How stress affects the body . . . . . . . . . . . . . . . . . . . . . . 33 Stress and cardiovascular disease . . . . . . . . . . . . . . . . . . . . 33 Stress and cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Stress and high blood pressure . . . . . . . . . . . . . . . . . . . . . . . 36 Stress and the immune system . . . . . . . . . . . . . . . . . . . . . . . 37 Stress and asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Stress and gastrointestinal disorders . . . . . . . . . . . . . . . . . . 38 Your portable guide to stress relief . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115 Dear Reader, Turn on the television and you will likely be bombarded by stories of history-making financial bailouts, terrorist threats, and natural disasters. Add to this backdrop layoffs, illness, money woes, temper tantrums, and traffic jams—challenges you are more apt to face in your own life—and you can see that stressful situations are constant and inevitable. Just as serious as the stressors themselves are the adverse effects stress can have on your emotional and physical health. Many well-respected studies link stress to heart disease and stroke—the No. 1 and No. 3 causes of death, respectively, in the United States. Stress is also implicated in a host of other ailments such as depression and anxiety, chronic lower respiratory diseases, asthma flare-ups, rheumatoid arthritis, and gastrointestinal problems. To be clear, stress is not all bad. Your perception of a real or imagined threat can spark the stress response, which prepares the body to fight or flee. That swift reflex was encoded in you for survival. Thanks to the stress response, you might suddenly jump out of the path of a speeding car or flee from a burning house. But when your stress response is evoked repeatedly, your body experiences unnecessary wear and tear—such as high blood pressure— that can lead to poor health. While you can’t avoid stress altogether, you can learn to manage stressful situations in healthier ways, enabling you to sidestep certain health problems and prevent some ailments from worsening. One important key is the connection between your mind and your body. You can learn techniques to help you avoid triggering the stress response. You can also learn how to use your mind to elicit the opposite physiological response—a calm, relaxed state called the relaxation response. This report is intended to help you learn to identify your stress warning signs and develop new resiliency tools so you can better manage stressful situations. Choose the tools that work best for you and try them. By doing so, you could ward off the harmful effects of stress on your health and develop greater peace of mind. Sincerely, Herbert Benson, M.D. Medical Editor Aggie Casey, M.S., R.N. Medical Editor This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  2 Stress Management www.health.harvard.edu W hat is stress? Does it have positive attributes? How have decades of research shaped current theories on stress? This section answers these ques- tions and touches briefly on how stress affects the body. The list titled “My stress warning signs” on page 8 will help you identify how you feel when faced with stressful situations in your own life. What is stress? You may define stress as bumper-to-bumper traffic, a deadline bearing down fast, a worrisome illness, or a contentious argument with your spouse. A friend may define it as a relationship spiraling downward, the need to care for an ailing parent, or a pile of unpaid bills. If you were a medical expert, though, you would label these scenarios stressors—that is, examples of stressful events and circumstances. Stress itself can be defined more broadly as an automatic physical response to any stimulus that requires you to adjust to change. Whether it’s a sudden car crash, a loud argu- ment, or the ache of rheumatoid arthritis, each real or perceived threat to your body triggers a cascade of stress hormones that produce well-orchestrated physio logical changes. All of us know these sensations. Your heart pounds. Muscles tense. Breathing quickens, and beads of sweat appear. But exactly how and why these reactions occur and what effects they might have over time are ques- tions that have intrigued researchers for many years. Harvard physiologist Walter B. Cannon was a pioneer in exploring the biochemistry of stress. His research nearly a century ago convinced him that fright was not all in the mind, but also stemmed from the adrenal glands, which sit atop the kidneys. By experi- menting with barking dogs and caged cats, Cannon was able to isolate a hormone secreted by the adrenal glands of the frightened cats. When he injected that hormone into a second, perfectly calm cat, it touched off a physical reaction of fear. The cat’s heartbeat and blood pressure shot up, while blood flow to the muscles increased. Cannon dubbed this occurrence the “fright, fight, or flight” response. Currently, though, it’s known as the fight-or-flight response or the stress response. the stress response The initial hormone Cannon isolated was epinephrine. It’s also called adrenaline, after the glands that manu- facture it. Next, Cannon found a second stress-response hormone called norepinephrine, or noradrenaline. Other researchers discovered cortisol, which belongs to a second class of stress hormones (known as glucocorti- coids) that play key roles in the stress response. The stress response starts with a signal from the part of your brain called the hypothalamus. Perched above the brainstem, the hypothalamus is a network of nerves wired to the rest of your body through the autonomic nervous system. The autonomic nervous system rules such involuntary body functions as breathing, blood pressure, heartbeat, and the dilation or constriction of key blood vessels and small airways in the lungs called bronchioles. Its two tributaries are the sympathetic nervous system, which revs up the body in response to perceived dangers, and the para- sympathetic nervous system, which calms the body after the danger has passed. When the hypothalamus processes certain infor- mation—perhaps the sight of your boss bearing down with an ominous expression, or the sound of screech- ing car tires behind you—it sends a chemical messen- ger called corticotropin-releasing factor (CRF) down a pathway to the nearby pituitary gland (see Figure 1). This stimulates cells in the pituitary to send their own chemical messenger, adrenocorticotropic hor- mone (ACTH), to the adrenal glands, which spill cor- tisol into the bloodstream. Surges of epinephrine and norepinephrine are also released by the adrenal glands on instructions from the brain and simultaneously Understanding the stress response This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  www.health.harvard.edu Stress Management 3 throughout the body by the sympathetic nervous sys- tem. (The powerful triumvirate of the hypothalamus, pituitary gland, and adrenal glands is dubbed the HPA axis. It governs a multitude of hormonal activities in the body and provides a feedback loop that helps switch off the stress response when levels of certain hormones are too high.) Stress hormones race through your bloodstream to different parts of your body, preparing you to fight or flee. Your breath quickens as your body takes in extra oxygen. Energy-boosting glucose and fats are released from storage sites into your bloodstream. Sharpened senses, such as sight and hearing, make you more alert. Your heart beats faster—up to two to three times as quickly as normal—and your blood pressure rises. Certain blood vessels constrict, which helps direct blood flow to your muscles and brain and away from your skin and other organs. Blood cells called platelets become stickier, so clots can form more easily to minimize bleeding from potential injuries. Immune system activity picks up. Your muscles—even tiny, hair-raising muscles beneath your skin—tighten, preparing you to spring into action. Body systems not needed for the immediate emer- gency are suppressed. The stomach and intestines cease operations. Sexual arousal lessens. Repair and growth of body tissues slows. Cannon believed the stress response was tempo- rary. Minutes after the rush triggered by epinephrine, he thought, the body would wind down to its normal balance, a physical state known as homeostasis. That meant your lungs would slow their rate of breathing. Your blood pressure would drop as your heartbeat slowed and blood flowed in normal patterns again. Your intestines would start their work again, provid- ing new fuel to replace the energy burned in the emer- gency. Bones would resume repairs or start growing again, and sex might appear more inviting. With the challenge that sparked the stress response behind you and the parasympathetic nervous system exerting its calming influence, the day-to-day business of your body would resume. Later research showed, however, that Cannon was not completely correct (see “The toll of stress on your body and mind,” page 4). The positive side of stress As many people have noted, the stress response can be enormously helpful. Surging epinephrine enables people to perform Herculean feats. Who can forget the firemen laden with lifesaving equipment who charged up flights of smoke-filled stairs in the World Trade Center after the terrorist attacks of Sept. 11, 2001? Or the ordinary citizens who carried injured and disabled people out of the towers? Fight-or-flight responses are appropriate and essen- tial in such overwhelming situations. When appropri- Figure 1 The HPA axis and the stress response ACTH released Blood pressure rises Muscles tighten Glucose and fats are released into bloodstream Senses sharpen Breath quickens and lungs take in more oxygen Heart beats faster Adrenal glands release cortisol, adrenaline, and nor­ adrenaline Hypothalamus The hypothalamus, pituitary gland, and adrenal glands make up the HPA axis, which plays a pivotal role in triggering the stress response. By releasing certain chemicals, such as adreno­ corticotropic hormone (ACTH) and cortisol, the HPA axis rouses the body for action when it’s faced with a stressor. As the illustration reveals, the effect of this release of hormones is widespread. Senses become sharper, muscles tighten, the heart beats faster, blood pressure rises, and breathing quickens. All of this prepares you to fight or flee in the face of danger. Pituitary gland This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  4 Stress Management www.health.harvard.edu ately evoked, the stress response helps us rise to many challenges. These challenges may be external forces, such as a fire or an earthquake, or internal threats, such as your circulatory system teetering on the brink of a deadly collapse. The fight-or-flight response can prove beneficial under far less dangerous circumstances, too. Physiologist Hans Selye, whose work helped shape modern stress theory, advanced the idea that physi- cal and psychosocial stressors trigger the same physio- logical response. Selye explored the line between short-term stress that stimulates people to summon the resources to hurdle obstacles (“good” stress) and ongoing or overabundant stress, which wears down the ability to adapt and cope (“bad” stress, or distress). Two Harvard researchers, Robert M. Yerkes and John D. Dodson, likewise demonstrated that a jolt of stress isn’t necessarily bad. They noted that as stress or anxi- ety levels rose, so did performance and efficiency—up to a point (see Figure 2). At this turning point, further stress and anxiety led to significant declines in perfor- mance and ability. Where that turning point falls seems to differ from person to person. For while the stress response is hard-wired into humans and other animals, the events and perceptions that set it off vary widely. What you perceive as a threatening situation, your neighbor may easily brush aside or even relish. Scientists have tackled the question of why some people appear less vulnerable to stress or even seem to thrive on regular doses of it. Some research has iden- tified characteristics common to stress-hardy folks. Exercise and social support proved essential. So did control, challenge, and commitment. Stress-hardy peo- ple seem to feel a sense of control or the ability to influ- ence events, embrace the challenge in situations others might find stressful, and describe themselves as com- mitted to something meaningful. According to one study, people with these characteristics report fewer illnesses and are less likely to be absent from work. The toll of stress on your body and mind Intuitively, the stress response makes sense. It enables us to rise to occasions and events that reward heightened awareness and abilities. You see a bus rushing toward you, and the surge of epinephrine helps you sprint out of its path far faster than you normally move. The stress hormones that spilled into your bloodstream at the sight of the bus found the perfect physical outlet. But experience tells us obvious dangers are not the only scenarios that elicit the stress response. Any situa- tion you perceive as threatening or which requires you to adjust to a change may do the same. That’s where the trouble starts. Your body does a poor job of distinguishing between life-threatening events and day-to-day stressful situations. Anger or anxiety triggered by less momen- tous sources of stress, such as financial fears or traffic jams, doesn’t find a quick physical release and tends to build up as the day rolls on. Adding to the turmoil is anticipation of potential problems, such as what you might experience in waiting for the results of a medi- cal test. Without realizing it, you might make assump- tions about what the test results will be, which sets off another cycle of physiological symptoms—such as a clenched jaw, tight neck and shoulders, and anxiety. When your body repeatedly experiences the stress response or when arousal following a terrible trauma is never fully switched off (see “Post-traumatic stress disorder,” page 5), your body’s stress response can be described as maladaptive, or unhealthy. In this situa- tion, the stress response kicks in sooner or in more situations than it otherwise would, increasing the burden your body must handle. Maladaptive stress responses can lead to worrisome health problems. A Figure 2 Yerkes-Dodson law As stress increases, performance rises to an optimal point, but if stress continues to increase, eventually performance and efficiency decline. stress or anxiety performance or efficiency low moderate high optimal This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  www.health.harvard.edu Stress Management 5 prime example of this is high blood pressure, or hyper- tension, which is a major risk factor for heart disease. Another is suppression of the immune system, which increases susceptibility to colds and other common ill- nesses (see “Stress linked to health problems,” at right, and “How stress affects the body,” page 33). It’s impossible to sidestep all sources of stress, and you wouldn’t want to. Our lives are full of physical and psychological challenges, which add zest to life and sometimes deliver satisfying rewards. But while you can’t easily erase certain sources of stress, you can learn to perceive and manage them differently. The sec- tion “How to prevent and manage stress” on page 10 describes many tools to help you accomplish this. post-traumatic stress disorder (ptSD) Traumatic experiences often scar the psyche. Many military personnel who have been in combat suffer post-traumatic stress disorder (PTSD). According to the National Center for Posttraumatic Stress Disorder, 11% to 20% of veterans of the Iraq and Afghanistan wars, 10% of Gulf War veterans, and as many as 30% of Vietnam veterans have experienced PTSD. Other traumatic events—such as rape, physical assault, accidents, natural disasters, witnessing acts of terrorism, living in a war zone or otherwise vio- lent locale, and losing a loved one suddenly—may also trigger PTSD. The risk of developing PTSD is higher among people with a family history of depression. These are its key symptoms: • recurrent flashbacks, dreams, or intrusive thoughts about a traumatic event • withdrawal from people and certain situations • avoidance of reminders of the event or difficulty recalling it • difficulty sleeping • being overly vigilant or easily startled. Not everyone who survives a traumatic event devel- ops PTSD. Even if your immediate response to a disas- ter is extreme, this is not a sign of an emotional disorder or mental illness. Reaching out to others and resuming normal life may provide solace. Relaxation therapies, physical activity, and expressing emotions while con- centrating on the future may also prove useful. Stress may contribute to or exacerbate various health problems, including these: • allergic skin reactions • anxiety • arthritis • constipation • cough • depression • diabetes • dizziness • headaches • heart problems, such as angina, heart attack, and cardiac arrhythmia • heartburn • hypertension • infectious diseases, such as colds or herpes • infertility • insomnia • irritable bowel syndrome • menopausal symptoms, such as hot flashes • “morning sickness,” the nausea and vomiting of pregnancy • nervousness • pain of any sort, including backaches, headaches, abdominal pain, muscle pain, joint aches, postoperative pain, and chronic pain caused by many conditions • periodontal disease • postoperative swelling • premenstrual syndrome • side effects of AIDS • side effects of cancer and cancer treatments • slow wound healing • trouble sleeping and resulting fatigue • ulcers. To the extent that stress worsens these ailments, the relaxation response (a state of profound rest) and other stress-relief methods can be healing (see “How to prevent and manage stress,” page 10). More in-depth information about some of the medical effects of stress appears in “How stress affects the body” (page 33). Adapted primarily from The Wellness Book, Herbert Benson, M.D., and Eileen M. Stuart, R.N., M.S. (Fireside, 1993). Stress linked to health problems This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  6 Stress Management www.health.harvard.edu However, you should seek help from a licensed mental health professional if symptoms affect you for more than a few weeks. Keep in mind, too, that some- times symptoms don’t occur until six months or more after the triggering event. anxiety and depression The buildup of stress often feeds or causes anxiety and depression, too. Adopting the strategies outlined in this report may help prevent these problems. Prac- ticing stress management techniques may also bring some relief from anxiety and symptoms of depression; however, it’s important to seek advice from a licensed health professional. He or she can evaluate you and may recommend a combination of medications and counseling, as well as a mind-body program or other stress management approaches. Seek a professional opinion if your anxiety is severe enough to interfere with your daily life. Symp- toms may include any of the following: • extreme worry or fear much of the time, or repeated panicky feelings • irrational feelings of fear, dread, or danger • frequent physical symptoms—such as agitation, shakiness and trembling, nausea, hot and cold flashes, dizziness, shortness of breath, or frequent urination—in the absence of a rational threat • recurrent distressing thoughts and uncontrollable repetitive behaviors intended to reduce the anxiety triggered by those thoughts. Likewise, it’s important to seek a professional opin- ion if you have the following symptoms of depression: • prolonged feelings of sadness or irritability • loss of interest in activities you once enjoyed • sleeping or eating markedly more or less than usual • feelings of guilt, worthlessness, or hopelessness • feeling anxious and unable to sit still • trouble concentrating and making decisions. Recurrent thoughts of death or suicide are symp- toms of depression that call for immediate profes- sional attention. It’s clear that the stress response creates physiological changes in the body, but what are the physiological effects of stress management techniques that produce the relax- ation response? As this report explains, stress management techniques can have a host of health benefits such as better mood and lower blood pressure. But a study revealed that relaxation response techniques may also alter the body at a deep, fundamental level—by influencing the expression of certain genes. Genes carry instructions for making proteins (the basic building blocks of the body) in cells. The 2008 study, pub- lished in the journal PLoS ONE, examined the effects of the relaxation response on certain sets of genes. The study was conducted by the Genomics Center at Beth Israel Deaconess Medical Center and the Benson- Henry Institute for Mind Body Medicine at Massachusetts General Hospital. One of the senior authors of the study is Dr. Herbert Benson, who is the medical editor of this Spe- cial Health Report. The study compared the activity of genes—whether the genes were being activated or suppressed—in 19 healthy adults who were long-term users of relaxation techniques and in 19 healthy adults who hadn’t used relaxation tech- niques. Those who used relaxation techniques had done so for an average of nine years and used a variety of methods— such as meditation, yoga, breath focus, or repetitive prayer. The researchers found that the activity of certain genes dif- fered between these two groups. Then the participants who hadn’t used relaxation tech- niques attended an eight-week course on evoking the relax- ation response, and their genetic activity was measured again. The researchers now found changes in the expression of those genes similar to those seen in the long-term users of relaxation techniques, but to a lesser extent. “We found differences in how certain sets of genes were being turned on and off. These genes were involved with controlling how the body handles free radicals, inflammation processes, and cell death,” explained Dr. Benson. In order for the genetic changes to persist, relaxation response techniques have to be done regularly. The researchers also found that any of the relaxation techniques produced the same genomic changes, supporting the theory that one relaxation technique is not superior to another. However, all the techniques used in the study were well- established practices. More research is needed to confirm these findings and to determine if similar changes occur in patients who use relax- ation response techniques to help treat stress-related illnesses. Relaxation response changes gene activity This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  www.health.harvard.edu Stress Management 7 I n the course of a lifetime, odds are good that you’ll survive some very stressful events. You’ll also face a gamut of far smaller day-to-day stressors. The list that appears later in this section will help you recognize the stress warning signs in your life. Once you’re aware of how stress makes you feel and act, you can use the many different tools described in “How to prevent and manage stress” on page 10, to help quell its effects. The major life event stress scale Several decades ago, two psychiatrists at the Univer- sity of Washington devised a scale for researchers that weighed the stress of major life events by asking 394 adults to rank specific situations. The subjects were told that marriage equaled 50 units out of a possible 100, and they were asked to rate other life events with that in mind. Their responses were averaged (see Table 1). Stress in your life Table 1 Major life event stress scale (out of a possible 100) EvEnT ScorE EvEnT ScorE Spouse’s death 100 Son or daughter leaving home 29 Divorce 73 Trouble with in­laws 29 Marriage separation 65 Outstanding personal achievement 28 Jail term 63 Spouse starts or stops working 26 Death of close relative 63 Start or stop school 26 Injury or illness 53 Change in living conditions 25 Marriage 50 Change in personal habits 24 Fired from job 47 Difficulty with boss 23 Marriage reconciliation 45 Shift in job hours or conditions 20 Retirement 45 Change in residence 20 Change in health of family member 44 Changing schools 20 Pregnancy 40 Change in recreation 19 Sexual difficulties 39 Change in church activities 19 New family member 39 Change in social activities 18 Business readjustment 39 Moderate debt 17 Change in finances 38 Shift in sleep habits 16 Death of close friend 37 Change in number of family get­togethers 15 Shift to different type of work 36 Shift in eating habits 15 Shift in number of arguments with spouse 35 Vacation 13 Moderate to high mortgage payments 31 Christmas 12 Foreclosure of mortgage or loan 30 Minor legal violations 11 Shift in work responsibilities 29 Adapted from The Relaxation Response, Herbert Benson, M.D., with Miriam Z. Klipper, updated and expanded edition (Avon Books, 2000). This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  8 Stress Management www.health.harvard.edu In subsequent studies, Thomas Holmes and Richard Rahe, the scale’s creators, noted that the death of a spouse—which ranks highest—appeared to have a serious impact on health. Surviving spouses were 10 times as likely to die within the subsequent year as others in their age group. Likewise, spouses who divorced were 12 times as likely to get sick in the fol- lowing year than were married people. Many researchers have used the scale in study- ing how stress affects people. However, it has limita- tions. The study’s age may limit its relevance today. In addition, it covers only major events, which represent Physical symptoms • Tight neck and shoulders • Back pain • Sleep difficulties • Tiredness or fatigue • Racing heartbeat or palpitations • Shakiness or tremors • Sweating • Ringing in ears • Dizziness or fainting • Choking sensation • Difficulty swallowing • Stomachache • Indigestion • Diarrhea or constipation • Frequent, urgent need to urinate • Loss of interest in sex • Restlessness Behavioral symptoms • Grinding of teeth • Inability to complete tasks • Overly critical attitude • Bossiness • Fidgeting • Overuse of alcohol • Emotional eating or overeating • Fist clenching • Changes in the amount of alcohol or food you consume • Taking up smoking or smoking more than usual • Increased desire to be with or withdraw from others • Rumination (frequent talking or brooding about stressful situations) Emotional symptoms • Crying • Irritability • Edginess • Anger • Feeling powerless to change things • Nervousness • Feeling anxious • Quick temper • Lack of meaning in life and pursuits • Boredom • Loneliness • Unhappiness with no clear cause • Depression Cognitive symptoms • Continual worry • Poor concentration • Trouble remembering things • Loss of sense of humor • Indecisiveness • Lack of creativity • Trouble thinking clearly Other symptoms _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________ Adapted primarily from The Wellness Book, Herbert Benson, M.D., and Eileen M. Stuart, R.N., M.S. (Fireside, 1993). My stress warning signs Being able to recognize when you’re feeling stressed can help you quickly counteract the stress response. A good first step is to look over the list below and circle all the symptoms you recognize. This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  www.health.harvard.edu Stress Management 9 a small fraction of daily stressors. Simple everyday stressors—waiting in long lines, sitting in traffic, or coping with the demands of a job—can also accumu- late and endanger your physical and emotional health. While primarily a tool for researchers, the scale can be helpful for those outside the field, too. You may find it useful to know that others have catego- rized an event that you may be facing—such as a change in your finances—as particularly stressful. It’s intriguing that many of the events on the scale aren’t obviously negative. An outstanding personal achieve- ment, a new baby, or a marriage may seem like cause for celebration. But many changes can be construed as uplifting or upsetting—or perhaps a bit of both. Truly, the perception of stress is specific to the person experiencing it. The scale can also serve as a reminder. If you’re coping with one or more of the stressors listed in the major life event stress scale, you may want to spend extra time practicing stress management techniques and other self-help strategies. recognizing the early signals Most likely, you intuitively know how you react to stressful situations. Certainly big events and obvi- ous distress are easy to spot. But smaller ripples may slip by your radar. Noting exactly how you’re affected by stress will make you more aware of your personal stress warning signs early so you can try to put the brakes on unnecessary stress responses (see “My stress warning signs,” page 8). Unhealthy responses to stress You probably have your own ways of dealing with stress- ful times. Some may be healthy, such as calling a friend, cooking a comforting dinner, or curling up in bed ear- lier than usual. Others may not be as benign. All too often, people self-medicate or turn to other unhealthy behaviors in an attempt to relieve pressure they feel. They may do so in a variety of ways. For example: • watching endless hours of TV • withdrawing from friends or partners or, conversely, jumping into a frenzied social life to avoid facing problems • overeating or weight gain • undereating or weight loss • sleeping too much • drinking too much alcohol • lashing out at others in emotionally or physically violent outbursts • taking up smoking or smoking more than usual • taking prescription or over-the-counter drugs that promise some form of relief, such as sleeping pills, muscle relaxants, or anti-anxiety pills • taking illegal or unsafe drugs. Becoming aware of how you typically handle stress can help you make healthy choices. If you nor- mally reach for a sugary snack, for example, you might instead call a friend. Choosing to connect rather than consume can relieve your stress. Studies suggest that emphasizing social ties can provide definite health benefits—with no calories! This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  10 Stress Management www.health.harvard.edu I n the late 1970s, working in the same room at Harvard Medical School where Cannon had labored years before, a cardiologist named Herbert Benson launched landmark research into the dam- aging effects of stress and the body’s potential for self- healing. In the years since, he and many other researchers have investigated the stress response and its antidotes—the relaxation response and other stress-relieving strategies. Dr. Benson is the medical editor of this report and the president of the Benson-Henry Institute for Mind Body Medicine at Massachusetts General Hos- pital in Boston, which advises using a combination of approaches for stress management. Among them: • learning various techniques that elicit the relaxation response, such as breath focus and guided imagery • using cognitive restructuring, a method of helping you reframe negative thoughts in order to cope more effectively with a difficult situation • doing regular exercise • eating healthy foods • nurturing yourself by setting aside time for socializ- ing, relaxing, connecting with others, and pursuing activities that add joy to your life. Such self-care is an essential ingredient for good health. The example of cardiovascular disease illus- trates how it can make a difference. Currently, millions of Americans take medication to lower blood pressure and unhealthy cholesterol levels, two risk factors for heart disease. Surgical procedures, such as angioplasty and coronary artery bypass, can reopen blocked ves- sels or divert the flow of blood to healthier vessels. These two approaches—medication and medical pro- cedures—are invaluable. Yet when used alone, they form only two legs of a sturdy three-legged stool that represents the best of modern health care. The third leg is self-care approaches of proven worth. Research shows that regularly evoking the relax- ation response leads to lasting declines in high blood pressure. Stress management techniques that short-circuit the stress response, such as cogni- tive restructuring, can also reduce blood pressure. Good nutrition and regular exercise can improve levels of cholesterol, as well as blood pressure. And social support also has a strong protective effect on health. Over time, the combination of these self-care approaches may ward off serious consequences and reduce or possibly even eliminate the need for cer- tain medications. Producing the relaxation response The relaxation response—which is the opposite of the stress response—can be elicited at will to create a state of profound peace and rest. The relaxation response is a physiologic shift that puts the brakes on the runaway biological changes that first put us into overdrive. By regularly practicing techniques that evoke the relax- ation response, you can help your body reduce the cumulative effects of stress. A number of physiological changes occur dur- ing the relaxation response. When a person practices relaxation response techniques, for example, heartbeat How to prevent and manage stress relaxing the brain A small study of five subjects used functional magnetic reso- nance imaging (fMRI) to map the parts of the brain that are active during meditation sessions that induce the relaxation response. Although global brain activity declined, signals increased in areas of the brain involved in attention as well as arousal and control of the autonomic nervous system. This suggests that meditation induces deep relaxation, yet sparks intense neural activity because of the vigilance required to keep the mind from wandering. By shining light on observ- able biological changes triggered by the relaxation response, this study helps bolster the concept that it is a distinct state and may also build support for its use in modern health care. This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  www.health.harvard.edu Stress Management 11 and breathing slow down. The body uses less oxygen, and blood flows more easily throughout the body. Blood lactate levels, which some researchers believe are linked with anxiety attacks, decline markedly. You can elicit the relaxation response in many dif- ferent ways, including these (see Table 2): • breath focus (see page 12) • body scanning (see page 14) • guided imagery or visualization (see page 14) • mindfulness meditation (see page 15) • yoga, tai chi, or qi gong (see “Choosing exercise with relaxation in mind,” page 19) • repetitive prayer (see Table 1, page 7, and “Power of prayer,” page 26). These are not the only techniques that can elicit the relaxation response. You may find that others are quite effective. What’s crucial is that the method you choose interrupts everyday thoughts by letting you focus on a word, phrase, prayer, or repetitive mus- cular activity. Once learned, these techniques can be practiced regularly almost anywhere. No special equipment or expert trainer is required, although many people find mind-body programs and medita- tion or yoga classes helpful as they learn a new tech- nique (see “Resources,” page 46). Rather than choosing just one technique to elicit the relaxation response, you can benefit from sam- pling many. You’ll also be able to decide which meth- ods work well for you. And if your favorite fails to engage you sometimes, you will have an alternative. In fact, many people get the best results from combining several techniques. creating a routine Whether you are trying to lose weight, exercise more, or teach your body to relax, establishing new behav- iors can be a challenge at first. Developing a routine can help you make these new behaviors stick. You may find it helpful to follow these tips: • Find a quiet, peaceful place to sit or lie down. Table 2 Which technique is right for you? By regularly practicing techniques that elicit the relaxation response, you create a well of calm to dip into as the need arises. As this chart details, these techniques can be especially beneficial under certain circumstances, but may not be suitable under others. METHod WHaT iS iT? ESPEciaLLY bEnEficiaL MaY noT bE SUiTabLE Breath focus Focusing on slow, deep breathing and gently disengaging the mind from distracting thoughts and sensations If you have an eating disorder or tend to hold in your stomach; may help you focus on your body in healthier ways If you have health problems that make breathing difficult, such as respiratory ailments, heart failure, or panic attacks Body scan Focusing on one part of the body or group of muscles at a time and mentally releasing any physical tension you feel there For increasing your awareness of the mind­body connection If you have had a recent surgery that affects body image or other difficulties with body image Guided imagery Using pleasing mental images to help you relax and focus When you want to reinforce a positive vision of yourself or a goal you wish to reach If you have intrusive thoughts that make imagery difficult; if you have difficulty with visualizations Mindfulness meditation Breathing deeply while staying in the moment by deliberately focusing on thoughts and sensations that arise during the meditation session If racing thoughts make other forms of meditation difficult If you find it too hard to commit the needed time Yoga, tai chi, and qi gong Three ancient arts that combine rhythmic breathing with a series of postures or flowing movements At times when your mind is racing; whenever you find it especially hard to settle down and focus; if you wish to enhance flexibility and balance If you are not normally active or have health problems or a painful or disabling condition; if so, speak with your doctor before starting any program of exercise Repetitive prayer Using a short prayer or phrase from a prayer to help enhance breath focus If religion or spirituality is meaningful to you If you are not religious This Harvard Health Publication was prepared exclusively for Verane Braissand - Purchased at http://www.health.harvard.edu/  12 Stress Management www.health.harvard.edu • Focus. Choose something simple to focus on: your breath, a sound, or a word or phrase that you repeat aloud or silently. • Learn to “let go” and relax. Accept any thoughts, feel- ings, or sensations that arise. • Practice regularly—aim for once or twice a day. Sti...