08 stress

7/27/2019 08 Stress

1/27

Overview: Mind-Body Medicine

The biopsychosocial model

7/27/2019 08 Stress

2/27



Effects of stress on the immune and cardiovascular systems

7/27/2019 08 Stress

3/27




Stress management techniques: Types and effectiveness in

relieving stress and stress-related disorders

7/27/2019 08 Stress

4/27




Stress management techniques: Types and effectiveness in

relieving stress and stress-related disorders

Application of stress management techniques to headache,hypertension, immune function, and chronic disease

7/27/2019 08 Stress

5/27


Biological and cellular processes

Psychologicalprocesses Social processesand contexts

7/27/2019 08 Stress

6/27

01234

56789

10

Chestpain

Fatigue

Dizziness

Headache

Edem

a

BackPain

Dyspnea

Insomnia

AbdominalPain

Numbness

Organic cause Unexplained cause

3-year incidence of 10 common symptoms in primary care

7/27/2019 08 Stress

7/27

Stress and the immune system

Medical school examinations associated with decreases incellularimmunity and increases in proinflammatory and

humoral immunitythis pattern is associated with increases in

vulnerability to infectious disease as well as allergy and other

autotoxic processes.

Life stress is associated with 2-fold increase in susceptibility to

the common cold virus above and beyond medical risk factors.

Severe life stress is associated with a 4-fold increase in risk ofHIV progression and 2.6-fold increase in mortality above and

beyond medical risk factors (viral load, initial CD4 count).

7/27/2019 08 Stress

8/27

Stress and the cardiovascular system

The incidence of major depression is ~20% after MI;

cardiovascularmortality is tripled in this group (15%)

compared to nondepressed patients (5%) in the next 6 months.

Risk equals that of poor left ventricular function.

0

20

4060

80

100

120

140

14 15 16 17 18 19 20

January

LA

Co

untyDeaths

1993

1994

7/27/2019 08 Stress

9/27

Is it magic? The mind-body connection

Autonomic nervous system

Sympathetic innervation (red)

Parasympathetic (blue)

Regulates physiology to

prepare for short-term vs. long-

term projects

7/27/2019 08 Stress

10/27

0

10

20

30

40

50

60

70

80

Total

volume

(x1000

ml/min)

Brain Heart Muscle Skin Kidney Viscera

Percentv

olume

At rest Sympathetic activation

Blood flow changes with sympathetic activation

7/27/2019 08 Stress

11/27

Is it magic? The mind-body connection

CRH

ACTHcortisol

Short-term effect of cortisol

Glucose release from liver and

muscles

Long-term effects

Immune changes

Loss of muscle and bone mass

Loss of insulin sensitivity

Hippocampus neuronal death

7/27/2019 08 Stress

12/27

Stress

Sympathetic activation

Cortisol release

among others

Hypertension

Immunosuppression

Insulin resistance

among others

Clinical health

ACE INHIBITORS

BETA-BLOCKERS

STRESS MANAGEMENT

7/27/2019 08 Stress

13/27

Relieving stress: Relaxation techniques

Forms of relaxation practice include progressive musclerelaxation, autogenic relaxation, stretch-based relaxation, the

relaxation response, meditation, some kinds of yoga and other

exercises coming from Eastern traditions (e.g., tai chi)

Relaxation is often used in treatments for anxiety as a way for

patients to control sympathetic activation and to provide a

coping strategy

Biofeedbackinvolves direct visual or aural feedback regardingphysiological states and can target muscle tension, skin

temperature, or vasoconstriction (e.g., of the temporal artery)

7/27/2019 08 Stress

14/27

Relieving stress: Relaxation techniques

40

42

44

46

48

50

52

54

56

Pre Post 4 weeks 6 months

Relaxation effectively treated generalized anxiety disorderin 45 patients. 44% achieved recovery levels of trait anxiety

post-treatment, 50% at 4 weeks post-treatment, and 53% at 6

months post-treatment

7/27/2019 08 Stress

15/27

Relieving stress: Exercise

Typical prescriptionin most studies is 20-30 minutes of exercise,

usually aerobic, 3-4 times weekly

Physiological effects of exercise are diverse and include

improvement in cardiac function and insulin sensitivity

Psychological effects of exercise are potentially robust and include

decreases in stress and depression (mean7 points on the Beck

Depression Inventory)

Potential biological mechanisms for psychological effects include

increased endorphins and NE in the brain (NE is also increased by

tricyclic antidepressants such as amitryptaline); potential social

effects include increased social contact in exercise groups

7/27/2019 08 Stress

16/27

Relieving stress: Exercise

Exercise was equally effective as SSRI medication (sertraline)in alleviating depression in 156 adults > 50 years old with major

depressive disorder after 16 weeks of treatment, although

medication had a somewhat larger response in the first 8 weeks

7/27/2019 08 Stress

17/27

Relieving stress: Cognitive-behavioral therapy

Stress management therapies usually have several targets

of action within the biopsychosocial model

Social: Provide social support from group therapies;

maximize support from existing social networks; teachassertion as a coping skill to resolve conflict

Psycho: Teach adaptive interpretation of stressful events

challenge rather than threat; encourage active engagement

rather than passive avoidance

Bio: Teach relaxation, self-hypnosis, healthy behavior

7/27/2019 08 Stress

18/27

Relieving stress: Cognitive-behavioral therapy

0

2

4

6

8

10

12

14

16

Depression (control) Anxiety (control)

Depression (CBSM) Anxiety (CBSM)

Stress management decreased depressive and anxiousresponses to positive HIV serostatus notification in 47 gay

men who attended group sessions twice weekly for 5 weeks

before blood draw, while waiting for notification, and 5 weeks

afterward. Change is from 1 week before to 1 after notification.

7/27/2019 08 Stress

19/27

Evidence: Benign headache

Relaxation training (such as progressive muscle relaxation),EMG biofeedback from frontal or forehead sites, and thermal

biofeedback are now well accepted in the larger headache

treatment community . . . They are a typical part of the

armamentarium of comprehensive headache centers or clinics

. . . These treatments are clearly superior to headache

monitoring while on a waiting list.

Progressive muscle relaxation or EMG biofeedback are

typically attempted first fortension headache because theyfocus on muscle tension, whereas autogenic relaxation or

thermal biofeedback are typically attempted first formigraine

headache because they focus on vasodilation.

7/27/2019 08 Stress

20/27

Issues with the Evidence: Benign headache

The placebo effect may be responsible for some of the effects;similarly, the gain in coping efficacy may be responsible.

Several treatments, however, have been shown to be more

effective than placebo.

Combination treatments may be more effective than pure

treatments. Relaxation, biofeedback, and cognitive therapy

can be combined in any configuration.

In trials that compared behavioral treatments with medications(propanolol, diazepam, amitryptaline), behavioral treatments

seem generally as effective as medications.

7/27/2019 08 Stress

21/27

Evidence: Hypertension

Blood pressure (SBP or DBP) biofeedback, thermalbiofeedback, stress management, meditation, various forms of

relaxation, and autogenic training have all been used in

controlled trials to decrease blood pressure. Single component

interventions show little effect, but combination therapies on

average decrease SBP 13.5 mm Hg, and DBP 3.4 mm Hg.

As with headache treatments, relaxation, biofeedback, and

cognitive-behavioral approaches are combined.

Other behavioral remedies include exercise, which is effectiveat reducing blood pressure mostly to the extent that it reduces

weight. Weight loss of 15-20 pounds typically reduces SBP

by 6-10 mm Hg and DBP by 3-7 mm Hg.

7/27/2019 08 Stress

22/27

Issues with the Evidence: Hypertension

Even small reductions in blood pressure may have largeclinical effects. Reduction in DBP of 5-6 mm Hg resulted in

42% decrease in stroke, 14% decrease in heart disease, and

21% decrease in vascular mortality in drug trials; mean

reduction of only 2 mm Hg lowers stroke risk by 15% and

heart disease risk by 6%.

Behavioral interventions may reduce or eliminate the need

for drug therapy in some patients.

There are few randomized, controlled trials in this area, and

more methodologically rigorous research is needed.

7/27/2019 08 Stress

23/27

Evidence and Issues: Immune function

If stress suppresses immunity, can interventions improve it?

Stress management in general has no effect, but very few

studies actually enrolled stressed populations. Those studies

found increases in immune cell functions and helper T cell

counts.

Relaxation has few effects on the immune system, but it does

reliably increase salivary IgA. Again, very few studies

actually enrolled stressed populations.

Hypnotic suggestion to increase or decrease immune

reactions is effective only for decreases and only for

suggestible people.

7/27/2019 08 Stress

24/27

Evidence: Chronic disease

Several studies with HIV and cancer suggest that stressmanagement interventions may benefit physiological

functioning and prolong life:

Cognitive-behavioral stress management

Michael Antoni and colleagues, University of Miami

HIV

Breast cancer

Cognitive-behavioral therapyFawzy Fawzy and colleagues, UCLA

Malignant melanoma

7/27/2019 08 Stress

25/27

CBSM with HIV:

Effects on immunity

In addition to buffering the

psychological impact of

HIV notification, CBSMbuffered negative

immunological changes;

these changes may be

prognostic in HIV.

7/27/2019 08 Stress

26/27

CBSM with Breast

Cancer: Effects on

cortisol

CBSM reduced serum

cortisol; this changes may

be prognostic in cancer, as

dysregulated cortisol

predicts breast cancer

survival.

This effect was most

pronounced in women whofound some benefit in their

cancer experience during

the group.

0

1

2

3

4

5

6

7

CBSM Control

Baseline Post

7/27/2019 08 Stress

27/27

CBT with Malignant

Melanoma: Effects

on recurrence and

survival

CBT reduced rates of

cancer recurrence and

death 5-6 years after

participating in a 6-weekstructured intervention.

This effect was most

pronounced in people whoincreased the amount of

active coping with cancer

stresses.

0

5

10

15

20

25

30

35

40

CBT Control

Recurrence

Cancer death

08 stress

Documents