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What Is Stress?

Second article in the series. See May issue of Interventions for the first.

How Serious Is Long-Term Stress?

In prehistoric times, the physical changes in response to stress were an essential adaptation for meeting natural threats. Even in the modern world, the stress response can be an asset for raising levels of performance during critical events such as a sports activity, an important meeting, or in situations of actual danger or crisis. But if the acute event is traumatic, if the body has an inefficient relaxation response, or if stressors accumulate over time, all parts of the body's stress apparatus -- the brain, heart, lungs, vessels, and muscles -- become chronically over- or underactivated, causing physical or psychological damage.

Psychologic Effects

Certainly, stress diminishes the quality of life by reducing feelings of pleasure and accomplishment. Relationships are often threatened, and there is always the danger that chronic stress might develop into more serious psychologic problems, such as an anxiety disorder or depression. One study suggested that stress is responsible for an increased incidence of death in a spouse whose partner has died within the previous six months. Suicide, accidents, or alcohol-related events were likely causes of death in these cases; men were more at risk than women.

Heart Disease

Mental stress is as important a trigger for angina as physical stress and may even pose a higher risk for serious cardiac events-such as heart attacks. Incidents of acute stress often precede sudden heart-related deaths. A good example of this was the significantly increased incidence in sudden cardiac death during the 1996 Los Angeles earthquake; only a few of the deaths were related to physical exertion.

Stress can affect the heart in several ways. Sudden stress increases the pumping action and rate of the heart and causes the arteries to constrict, thereby posing a risk for blocking blood flow to the heart. The combination of these factors also increases the risk for rhythm disturbances. Stress causes blood to become stickier (possibly in preparation of potential injury), increasing the likelihood of an artery-clogging blood clot. Stress may signal the body to release fat into the bloodstream, raising blood-cholesterol levels, at least temporarily. In women, chronic stress may reduce estrogen levels, which are important for cardiac health. One study indicated that people who experience sudden increases in blood pressure caused by mental stress may, over time, be vulnerable to damage the inner lining of blood vessels, contributing to atherosclerosis. In one study, young adult children of parents with hypertension who were undergoing a mental stress test, showed significantly increased blood levels of the adrenaline and endothelin-chemicals known to constrict blood vessels. Another study measured stress levels and blood pressure periodically in people over 20 years. At the end of that period, men who measured highest on the stress scale were twice as likely to have high blood pressure as those with normal stress. The effects of stress on blood pressure in women were less clear.

Stroke

In some people prolonged or frequent mental stress causes an exaggerated increase in blood pressure. Over time, this effect has been linked to thickening of the carotid arteries, which carry blood to the front half of the brain. Blockage and injury in these arteries are primary causes of stroke. (Thickening of these arteries is also an indication of atherosclerosis -- or hardening of the arteries -- a major cause of heart disease.) One study of POWs from World War II found that their rate of stroke was more than 8 times that of other veterans, in spite of the fact that other risk factors (such as high blood pressure and diabetes) were no different. One survey revealed that men who were most bothered by stressful situations, such as waiting in line or problems at work, were more likely to have strokes than those who did not report such distress.

Susceptibility to Diseases

Some studies suggest that acute stressful events actually boost the immune system. If stress becomes chronic, however, this hypersensitive immune response becomes blunted. A number of studies have shown that subjects under chronic stress have low white blood cell counts and are vulnerable to colds. In some studies, stress that had the most negative impact on resistance to infection was from interpersonal conflicts, such as those at work or in a marriage. Recent research even suggests that stress -- not indoor pollutants -- may actually be a cause of the so-called sick-building syndrome, which produces symptoms, such as eczema, headaches, asthma, and sinus problems, in office workers. Evidence indicates, moreover, that a good deal more is at stake than just resistance to mild illnesses. Stress has been shown to affect tumor formation in laboratory animals. In a now well-known -- if still controversial -- study of women with terminal breast cancer, those who participated in programs offering emotional support and training in positive imaging lived twice as long as those who did not participate. While there is no evidence that stress causes cancer, there is some data to support the belief that emotional states influence the progression or regression of various diseases.

Digestive Problems

Over the long term, prolonged stress can disrupt the digestive system, irritating the large intestine and causing diarrhea, constipation, cramping, and bloating. Excessive production of digestive acids in the stomach may cause a painful burning. People used to believe that peptic ulcers were caused by stress, but it is now known that most peptic ulcers are either caused by the H. pylori bacteria or by the use of nonsteroidal anti-inflammatory medications-such as aspirin. However, another digestive condition, irritable bowel syndrome (or spastic colon) does appear to be strongly related to stress. With this condition, the large intestine becomes irritated, and its muscular contractions are spastic rather than smooth and wave like. The abdomen is bloated and the patient experiences cramping and alternating periods of constipation and diarrhea.

Weight Problems

Stress can have varying effects on body weight. Some people suffer a loss of appetite and lose weight. In rare cases, stress may trigger hyperactivity of the thyroid gland, stimulating appetite but causing the body to burn up calories at a faster than normal rate. Others, however, develop cravings for salt, fat, and sugar to counteract tension and, thus, may gain weight. People under stress who respond in this way are at particular risk for abdominal fat -- a predictor of diabetes and heart problems.

Diabetes

Chronic stress has been associated with the development of insulin-resistance, a condition in which the body is unable to use insulin effectively to regulate glucose (blood sugar). Insulin-resistance is a primary factor in diabetes.

Musculoskeletal Functions

Chronic pain caused by arthritis and other conditions may be intensified by stress. Stress also contributes to tension or muscle contraction headache, during which the pain is usually felt in the forehead, the back of the head and neck, or both regions; it is described as a tight feeling, as if the head were in a vise. Soreness in the shoulder or neck is common. Tension headaches can last minutes to days and may occur daily in chronic headache states. (Migraine headaches, too, occur most often when patients are experiencing increased levels of stress.) Back pain is also a common complaint. Some studies have clearly associated job dissatisfaction and depression to back problems, although it is still unclear if stress is a direct cause of the back pain.

Sleep Disturbances

It is essential for the person under stress to have a good night's sleep in order to rebuild the body's resources and gain perspective on problems that are causing trouble. The tensions of unresolved stress, however, frequently cause insomnia, generally keeping the stressed person awake or causing awakening in the middle of the night or early morning.

Sexual and Reproductive Dysfunction

Stress can lead to diminished sexual desire and an inability to achieve orgasm. Men may experience erectile dysfunction; women may develop menstrual irregularities, and stress may even affect fertility. Stress hormones also have an impact on the hypothalamus gland, which produces reproductive hormones. Severely elevated cortisol levels can even shut down menstruation.

Maternal stress during pregnancy has been linked to a 50% higher risk for miscarriage. It is also associated with lower birth weights and increased incidence of premature births -- both of which are risk factors for infant mortality. Researchers postulate that stress may cause physiologic alterations (such as increased adrenal hormone levels), that may interfere with normal blood flow to the placenta. In addition, stress is often accompanied by unhealthy behavior -- bad diet and sedentary habits -- that can harm the developing fetus.

Memory, Concentration, and Learning

The typical victim of severe stress suffers loss of concentration at work and at home and may become inefficient and accident-prone. The hippocampus, which is where memory cells in the brain are produced and stored, is highly activated during the fight or flight response. Prolonged exposure to cortisol -- the major stress hormone -- is now believed to actually damage brain cells in the hippocampus; damage may result from long term exposure. Although some memory loss occurs with age, stress may play an even more important role than simple aging. In one study older people with low stress hormone levels tested as well as younger people in cognitive tests: those with higher stress levels tested between 20% and 50% lower. If stress is chronic or extremely severe, memory loss may become permanent. Very severe and acute stress that causes post-traumatic stress disorder (PTSD) is associated with physical changes in the brain. Two studies reported that Vietnam veterans and women who suffered from sexual abuse, who suffered PTSD, displayed up to 8% shrinkage in the hippocampus. It is not yet known if this shrinkage is reversible. Severe stress may even break down the blood-brain barrier -- a physiological mechanism that helps protect the brain from toxins, bacteria and other potentially harmful substances that may be carried in blood.

Skin

Stress plays a role in exacerbating a number of skin conditions, including hives, psoriasis, acne, rosacea, and eczema. Unexplained itching may also be caused by stress.

Who Is Prone to Stress-Related Disorders?

At some point in their lives virtually everyone will experience stressful events or situations that overwhelm their natural coping mechanisms. In a recent poll, 89% of respondents indicated that they had experienced serious stress in their lives. Many factors influence susceptibility to stress. One study targeted people most likely to have frequent mental stress compared to the general population. They included younger adults, women (in general) and working mothers in particular, Native North Americans, divorced or widowed individuals, the unemployed, those who did not graduate from high school, and those with low incomes or no health insurance.

Biologic or Genetic Factors

Certain people, because of inherited or other physiologic factors, are more vulnerable than others to the damaging effects of stress.

Unhealthy Response to Frequent Episodes

In some people, exposure to frequent episodes of stress can cause blood pressure spikes, which over time, may lead to heart disease.

Inability to Adapt to Nondangerous Stressors

In most people, repeated exposure to a specific nondangerous stressful situation (such as public speaking) eventually reduces the level of stress that occurs with such an event. In some people, however, stress hormones become elevated to the same degree with repeated exposure to the situation as they were to the first.

An Absent or Inadequate Relaxation Response

In some people, stress hormones remain elevated instead of returning to normal levels. This may occur in highly competitive athletes or people with a history of depression.

Differences in Response Activity

In some people, parts of the stress response may be underactive, causing other parts to overreact. For example, if the brain fails to produce enough cortisol, the immune system may overproduce certain factors that would have been suppressed by this stress hormone, and that can cause harm in excessive amounts. (Such abnormal responses may play a role in autoimmune diseases).

Age

No one is immune to stress, although it may go unnoticed in the very young and old. Children are frequent victims of stress, because they are usually unable to communicate accurately their feelings or responses to events over which they have no control. As people age, the ability to achieve a relaxation response after a stressful event may slow down, although not necessarily stop. Aging may simply wear out the systems in the brain that respond to stress, so that they become inefficient. The elderly, too, very often are exposed to major stressors such as medical problems, the loss of a spouse and friends, a change in a living situation, and financial worries.

Personality

Personality may make some people more or less vulnerable to the effect of stress. Type A behavior -- aggressive, fast-paced, and angry -- has long been used as an example of a negatively stressed personality. When angry or stressed, such people -- both men and women -- often experience exaggerated increases in blood pressure, which may cause heart problems over time. Those with a sense of optimism, high self-esteem, and confidence in controlling situations are, of course, much less vulnerable to the destructive effects of stress than those with more negative personalities.

Isolation

The lack of an established network of family and friends is another important factor predisposing to stress disorders. Isolation also appears to put people at risk for heart disease and psychologic disorders, such as depression. A number of studies indicate that married people generally outlive their unmarried contemporaries. One study showed that middle-aged men under severe stress who lacked emotional support were five times more likely to die within a seven-year period than those who had the same amount of stress but had close personal ties.

Ethnic Differences

Ethnic differences in the stress response may exist. Researchers have found that under mental stress, arteries in African Americans dilate to a lesser degree than those in whites. The finding may explain why hypertension and its complications are more prevalent in blacks.

Factors at Work and at Home

A number of studies are showing that conditions in the workplace are major contributors to stress. Stress experienced as a result of the job is particularly likely to become chronic because it is such a large part of daily life. And stress in turn reduces a worker's effectiveness by impairing concentration, causing sleeplessness, and increasing the risk for illness, back problems, accidents, and lost time. Work stress can lead to harassment or even violence while on the job. At its most extreme, it can place such a burden on the heart and circulation that it may even be fatal. The Japanese even have a word for sudden death due to overwork -- karoushi.

Some studies indicate that people mostly likely to experience stress in the work place are those who feel they have no control over their circumstances. This is likely to occur in an organization that lacks effective communication and conflict-resolution methods; one that doesn't invite employees to participate in decision, or allow creativity, or where employees lack control over their responsibilities. In this age of downsizing, lack of job security is also a major cause of stress. Additional stressors include long hours, time spent away from home and family, office politics and conflicts between workers, wages that are not commensurate with levels of responsibility, and -- in this competitive society -- unrelenting and unreasonable demands for performance.

One study of people who work under demanding conditions suggested, however, that heart disease -- including high blood pressure -- attributed to work stress may be due to the way people cope with the stress, not to the direct effects of the job itself. People who are trying to deal with stress often resort to unhealthy habits including high-fat and high-salt diets, tobacco use, alcohol abuse, and a sedentary lifestyle. In one study, men were more apt to use alcohol or eat less healthily in response to stress, while women tended to have healthier ways of coping.

Working mothers, regardless of whether they are married or single, face higher stress levels -- not so much in the work place but at home. Such stress may also have a domino effect. A recent study shows that a boy's probability of childhood behavioral difficulties was increased with the number and type of family stressors encountered in the home. Depressed or aggressive mothers were particularly powerful sources of stress -- even more important than poverty or overcrowding.

What Other Conditions Have the Same Symptoms as Stress?

Anxiety Disorders

The physical symptoms of anxiety disorders mirror many of those of stress -- including a fast heart rate, rapid, shallow breathing, and increased muscle tension. Anxiety is an emotional disorder, however, and is characterized by feelings of apprehension, uncertainty, fear, or panic. Some individuals with anxiety disorders have numerous physical complaints, such as headaches, gastrointestinal disturbances, dizziness, and chest pain. Severe cases of anxiety disorders are debilitating, and interfere with career, family, and social spheres.

Depression

Depression can be a disabling condition, and, like anxiety disorders, may result from untreated chronic stress. Depression also mimics some of the symptoms of stress, including changes in appetite, sleep patterns, and concentration. Serious depression, however, is distinguished from stress by feelings of sadness, hopelessness, loss of interest in life, and, sometimes, thoughts of suicide. Acute depression is also accompanied by significant changes in the patient's functioning. Professional therapy may be needed in order to determine if depression is caused by stress or if it is the primary problem.

Post-Traumatic Stress Disorder Symptoms

Post-traumatic stress disorder (PTSD) is a reaction to a very traumatic event: it is actually classified as an anxiety disorder. The event that precipitates PTSD is usually outside the norm of human experience, such as intense combat or sexual assault. The patient struggles to forget the traumatic event and frequently develops emotional numbness and event-related amnesia. Often, however, there is a mental flashback, and the patient re-experiences the painful circumstance in the form of intrusive dreams and disturbing thoughts and memories, which resemble or recall the trauma. Other symptoms may include lack of pleasure in formerly enjoyed activities, hopelessness, irritability, mood swings, sleep problems, inability to concentrate, and an excessive startle-response to noise.

What Are Some Methods for Reducing Stress?

Perhaps the best general approach for treating stress can be found in the elegant passage by Reinhold Niebuhr, "Grant me the courage to change the things I can change, the serenity to accept the things I can't change, and the wisdom to know the difference." In choosing specific strategies for treating stress, several factors should be considered. First, no single method is uniformly successful: a combination of approaches is generally most effective. Second, what works for one person does not necessarily work for someone else. Third, stress can be positive as well as negative. Appropriate and controllable stress provides interest and excitement and motivates the individual to greater achievement, while a lack of stress may lead to boredom and depression. Finally, stress may play a part in making people vulnerable to illness. A physician or psychologist should be consulted if there are any indications of accompanying medical or psychologic conditions, such as cardiac symptoms, significant pain, anxiety, or depression.

It is very important to note that no evidence exists that treating stress can cure medical problems, although a recent study indicated that stress management programs may reduce the risk of cardiac events -- like heart attack -- by up to 75% in people with heart disease. One study found it was even more effective than exercise (although exercise also reduced the risk.) Such programs should never be used alone to treat any medical condition.

One major obstacle to reducing stress is the fight or flight response itself; the very idea of relaxation feels threatening, because it is perceived as letting down one's guard. If stress is provoked by an over-demanding boss for instance, the subordinate may feel the need to remain in a psychologic state of fighting-readiness, even though there is no safe opportunity to express anger against the boss. Stress builds up, but the victim has the illusion, even subconsciously, that it is providing safety or preparedness, so does nothing to correct the condition. Often people succeed in relieving stress for the short-term but resort to previous ways of stressful thinking and behaving because of outside pressure or entrenched habits. It is essential to remember that reducing stress and keeping relaxed not only helps maintain health but gives the mind more opportunities for clearer thinking in order to initiate appropriate actions to get rid of the conditions causing stress. The process of learning to control stress is life-long, and will not only contribute to better health, but a greater ability to succeed on one's own agenda.

Cognitive-Behavioral Techniques

Cognitive-behavioral methods are the most effective ways to reduce stress. They include identifying sources of stress, restructuring priorities, changing one's response to stress, and finding methods for managing and reducing stress.

Identifying Sources of Stress

It is useful to start the process of stress reduction with an informal inventory of daily events and activities. The first step is keep a diary noting which activities put a strain on energy and time, trigger anger or anxiety, or precipitate a negative physical response (e.g., a sour stomach or headache). Positive experiences should also be noted -- those that are mentally or physically refreshing or produce a sense of accomplishment. While this exercise might itself seem stress producing -- yet one more chore -- it need not be done in painstaking detail. A few words accompanying a time and date will usually be enough to serve as reminders of significant events or activities. After a week or two, the stressed individual should try to identify two or three events or activities that have been significantly upsetting or overwhelming. Priorities and goals should then be carefully examined. Individuals should question whether the stressful activities meet their own goals or someone else's, whether they have taken on tasks that they can reasonably accomplish, and which tasks are in their control and which ones aren't.

Restructuring Priorities

The next step is to attempt to shift the balance from stress-producing to stress-reducing activities. A recent study indicated that daily pleasant events have positive effects on the immune system. In fact, adding pleasurable events has more benefit than simply reducing stressful or negative ones. This is important to realize because many difficult stressful situations, such as unpleasant working conditions, an unhappy family situation, or a significant loss, can't simply be rescheduled or wished away. When eliminating the stress is not practical, there may be ways to reduce its impact. If the problem is work-related and it is impossible to change jobs or cut back on hours, consider as many pleasant relief options as possible. Examples include taking long weekends or vacations, sending out resumes or working on transfers within the company, and planning pleasant diversions or physical exercise during lunch hours. If stress at home is the problem, plan times away, even if it is only an hour or two a week. Learn to replace time-consuming chores that aren't really necessary with activities that are pleasurable or interesting. Making time for recreation is as essential as paying bills or shopping for groceries. Many people are afraid of being perceived as selfish if they make decisions that benefit only themselves. The truth is that self-sacrifice may be inappropriate and even damaging if the person making the sacrifice is unhappy, angry, or physically unwell. In most cases, small daily decisions for improvement can accumulate and work to reconstruct a stressed existence into a pleasant and productive one.

Adjusting Responses to Stress

Many people believe that certain emotional responses to stress, such as the negative and aggressive Type A behavior associated with heart disorders, are innate features of personality. Research has shown, however, that individuals can be taught to change their emotional reactions to stressful events. Given the fixed nature of many major stresses, such as the loss of a loved one, chronic illness, or pressures from work, cognitive behavioral therapy, which teaches new ways of responding to stress, may be the most effective method of permanently reducing its effects.

Discuss Feelings

The concept of communication and "letting your feelings out" has been so excessively promoted and parodied that it has nearly lost its value as good psychologic advice. Nevertheless, feelings of anger or frustration that are not expressed in an acceptable way may lead to hostility, a sense of helplessness, and depression. Expressing feelings does not mean venting frustration on waiters and subordinates, boring friends with emotional minutia, or wallowing in self-pity. In fact, because certain chronically hostile individuals can experience harmful spikes in blood pressure when they are angry, some therapists strongly advise that just talking -- not venting anger without any progress -- is the best approach for these people. The primary goal is to explain and assert one's needs to a trusted individual in as positive a way as possible. Direct communication with another person may not even be necessary; writing in a journal or composing a letter that is never mailed may be sufficient. Expressing ones feelings is not enough, however. Learning to listen, empathize, and respond to others with understanding is just as important for maintaining the strong relationships necessary for emotional fulfillment and reduced stress.

Keep Perspective and Look for the Positive

Reversing negative ideas and learning to focus on positive outcomes helps reduce tension and achieve goals. For example, an individual who is alarmed at the prospect of giving a speech should first identify the worst possible outcomes (forgetting the speech, stumbling over words, humiliation, audience contempt), and its likelihood (probably very low or the speech wouldn't have been assigned in the first place). Then the stressed individual should envision a favorable result (a well-rounded, articulate presentation with rewarding applause). Then a plan should be developed to achieve the positive outcome (preparing in front of a mirror, using a video camera or tape recorder, relaxation exercises). It is helpful to remember previous situations that initially seemed negative but ended well.

Use Humor

Keeping a sense of humor during difficult situations is a common recommendation from stress management experts. Laughing releases the tension of pent-up feelings and helps keep perspective. Research has shown that humor is a very effective mechanism for coping with acute stress. It is not uncommon for people to recall laughing intensely even during tragic events, such as the death of a loved one, and to remember this laughter as helping them to endure the emotional pain.

Relaxation Techniques

Since stress is here to stay, everyone needs to develop methods for invoking the relaxation response -- the natural unwinding of the stress response. Relaxation lowers blood pressure, respiration, pulse rates, releases muscle tension, and eases emotional strains. This response is highly individualized, but there are certain approaches that seem to work, including: exercise, deep breathing, muscle relaxation, and meditation. No one should expect a total resolution of stress from these approaches, but if done regularly, these programs can be very effective (see below).

Adapting Healthy Habits

Unfortunately people under stress frequently seek relief through drug or alcohol abuse, tobacco use, abnormal eating patterns, or passive activities-such as watching television. The damage these self-destructive habits cause under ordinary circumstances is compounded by the physiologic effects of stress itself. And the cycle is self-perpetuating; a sedentary routine, alcohol abuse and smoking promote heart disease, interfere with sleep patterns, and lead to increased rather than reduced tension levels. General health and stress resistance can be enhanced by eating well and by avoiding stresses such as alcohol, caffeine, tobacco and junk food. Fats, simple sugars, and salt are known contributors to health problems, including diabetes and heart disease. No evidence exists that stress has any effect on vitamin needs or that vitamins have any benefits against the effects of stress. Everyone, however, should certainly have a diet rich in vegetables and fruits.

Exercise

Exercise in combination with stress management techniques is extremely important, and -- for those with heart disease -- can even reduce significantly the risk for a heart attack. As the body attains fitness its ability to withstand stress is enhanced. The heart and circulation are able to work harder for longer stretches. The muscles, ligaments, bones, and joints become stronger and more flexible. And the mind is often better able to cope with stress and stay on an even, happier keel. Studies show that employees who follow an active lifestyle need fewer sick and disability days than sedentary workers. Usually, a varied exercise regime is more interesting -- and thus easier to stick to. Start slowly. Strenuous exercise in people who are not used to it can be very dangerous and any exercise program should be discussed with a physician. In addition, half of all people who begin a vigorous training regime drop out within a year, so the key is to find activities that are exciting, challenging, and satisfying. Signing up for aerobics classes at a gym can help prompt regular exercise. Because it is so natural and convenient, brisk walking is an excellent aerobic exercise. Even short brisk walks can relieve bouts of stress. Swimming is another ideal exercise for many people including pregnant women, individuals with musculoskeletal problems, and those who suffer exercise-induced asthma. Yoga or Tai Chi can be very effective, combining many of the benefits of breathing, muscle relaxation and meditation while toning and stretching the muscles.

As in other areas of stress management, making a plan and executing it successfully develops feelings of mastery and control -- which are very beneficial in and of themselves. Start small. Just 10 minutes of exercise three times a week can build a good base for novices. Gradually build up the length of these every-other-day aerobic sessions, to 30 minutes or more.

Strengthen or Establish a Support Network

Studies of people who remain happy and healthy despite many life stresses conclude that most have very good networks of social support. One study indicated that support even from strangers reduced blood pressure surges in people undergoing a stressful event. Many studies suggest that having a pet helps reduce medical problems aggravated by stress, including heart disease and high blood pressure.

Professional Help and Medications

Stress can be a factor in a variety of physical and emotional illnesses, which should be professionally treated. Many stress symptoms are mild and can be managed by over the counter medications, e.g., aspirin, acetaminophen or ibuprofen for tension headache and antacids, and anti-diarrhea medications or laxatives for mild stomach distress. A physician should be consulted, however, for physical symptoms that are out of the ordinary, particularly those which progress in severity or awaken one at night. A mental health professional should be consulted for unmanageable acute stress or for severe anxiety or depression. Often short-term therapy can resolve stress-related emotional problems.

Reducing Stress at Work

Many institutions within the current culture, while paying lip service to stress reduction, put intense pressure on individuals to behave in ways that promote tension. Some experts argue that employers should be held responsible for taking measures to prevent stress from work overload and should provide help to deal with work-related stress. Treating stress has a number of benefits, not only for the individual but also for the patient's employer. In one study, for example, in which a company set up a two-year stress management educational program, the savings to the company in workmen's compensations costs were nearly $150,000, compared to the cost of the program which was only $150 per participant for a total of $6,000.

Here are some tips: seek out someone in the Human Resources department or a sympathetic manager, and communicate concerns about job stress. Work with them in a non-confrontational way to improve working conditions, letting them know that productivity can be improved if some of the pressure is off. Establish or reinforce a network of friends at work and at home. Restructure priorities and eliminate unnecessary tasks. Learn to focus on positive outcomes. If the job is unendurable, plan and execute a career change. If this isn't possible, be sure to schedule daily pleasant activities and physical exercise during free time. Use stress reduction techniques described in this report. It is also helpful to keep in mind that the employers are victimized by the same stressful conditions they are imposing.

Relaxation Techniques

Deep Breathing

During stress, breathing becomes shallow and rapid. Taking a deep breath is an automatic and effective technique for winding down. Deep breathing exercises consciously intensify this natural physiologic reaction and can be very useful during a stressful situation, or for maintaining a relaxed state during the day. Inhale through the nose slowly and deeply to the count of ten, making sure that the stomach and abdomen expand but the chest does not raise up. Exhale through the nose-slowly and completely-also to the count of ten. To help quiet the mind, concentrate fully on breathing and counting through each cycle. Repeat five to ten times and make a habit of doing the exercise several times each day, even when not feeling stressed.

Muscle Relaxation

Muscle relaxation techniques, often combined with deep breathing, are simple to learn and very useful for getting to sleep. After lying down in a comfortable position without crossing the limbs, concentrate on each part of the body, beginning with the top of the head and progressing downward to focus on all the muscles in the body. Be sure to include the forehead, ears, eyes, mouth, neck, shoulders, arms and hands, fingers, chest, belly, thighs, calves and feet. (Some individuals even imagine tensing and releasing internal muscles once the external review is complete.) A slow, deep breathing pattern should be maintained throughout this exercise. Tense each muscle as tightly as possible for a count of five to ten and then release it completely; experience the muscle as totally relaxed and lead-heavy. Continue until the feet are reached. In the beginning it is useful to have a friend or partner check for tension by lifting an arm and dropping it -- the arm should fall freely. Practice makes the exercise much more effective and produces relaxation much more rapidly.

Meditation

Meditation, used for many years in Eastern cultures, is now widely accepted in this country as a relaxation technique. The goal of all meditative procedures, both religious and therapeutic, is to quiet the mind -- essentially to relax thought. The practiced meditater can achieve a reduction in heart rate, blood pressure, adrenaline levels, and skin temperature while meditating. A number of organizations, both religious and nonreligious, teach meditation. The names of these organizations, along with instructional books, can be found at public libraries. As in all relaxation exercises, the first step is to be as physically comfortable as possible in a quiet place, preferably a semidark room isolated from noise or distraction. One should be sitting up with the eyes closed concentrating on a simple image or sound. Some methods suggest imagining a point of light behind the forehead and between the eyes. Other techniques, such as transcendental mediation, assign mantras -- words that have particular chanting sounds -- which are repeated silently. Anyone can make up a word or a sound; the only condition is that the word or sound not be associated with a real thing that can divert the meditater from the internal process. When the mind begins to wander, the meditater gently brings concentration back to the central image or sound. Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. Successful meditation results in deep relaxation and can be very energizing. (One should probably not meditate before going to bed: some people who meditate before sleep wake up in the middle of the night, alert and unable to return to sleep.) A recent study showed that transcendental meditation was more effective in reducing blood pressure than muscle relaxation in both men and women.

One technique requiring little adaptation in the daily schedule has been termed mini-meditation. The method involves heightening awareness of the immediate surrounding environment, thus redirecting the stress-provoking brain activity into focusing on existing sensory input. One should first chose a routine activity when alone. For example while washing dishes concentrate on the feel of the water and dishes, allow the mind to wander to any immediate sensory experience (sounds outside the window, smells from the stove, colors in the room). If the mind begins to think about the past or future, abstractions or worries, redirect it gently back. This redirection of brain activity from your thoughts and worries to your senses disrupts the stress response and prompts relaxation. It also helps promote an emotional and sensual appreciation of simple pleasures already present in a person's life.

Biofeedback

During biofeedback, electric leads are taped to a subject's head. The person is encouraged to relax using methods such as those described above. Brain waves are measured and an auditory signal is emitted when alpha waves are detected -- a frequency which coincides with a state of deep relaxation. By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation by themselves.

Massage Therapy

Massage therapy appears to slow down the heart and relax the body. Rather than causing drowsiness, however, massage actually increases alertness. A number of massage therapies are available for relaxing muscles, including the following:

1. Shiatsu -- applies intense pressure to parts of the body and can be painful, but people report deep relaxation afterward.
2. Reflexology -- manipulates pressure points in the hands and feet.
3. Swedish Massage -- has been available for years and uses muscle manipulation.

Recent Literature

Can overwork kill? Harvard Men's Health Watch, April 1997

Heart disease: The mind-body connection. Johns Hopkins Medical Letter: Health after 50. July 1997

Is worrying bad for your heart? A prospective study of worry and coronary heart disease in the Normative Aging Study. Circulation, 2/18/97

Stress in employed women: Impact of marital status and children at home on neurohomone output and home strain. Psychosomatic Medicine, July/August 1997

Protective and damaging effects of stress mediators. The New England Journal of Medicine, 1/15/98

Edited by CMR Canada

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