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Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 1

Stress Management Skills for Pharmacy Practice

Cynthia Knapp Dlugosz, BSPharm, ACCCertified Integrative Health Coach

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Accreditation Information

“Stress Management Skills for Pharmacy Practice” is accredited by ACPE for pharmacists and techniciansACPE #0154-0000-16-014-L04-P ACPE #0154-0000-16-014-L04-T

Cynthia Knapp Dlugosz has not disclosed any financial or conflicts of interest in relation to this program

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Learning Objectives At the end of this activity, participants should be able

to: Identify common sources of stress for pharmacy

professionals and possible effects on physical health, mood, and behavior

Contrast the body's stress response and relaxation response

Demonstrate practices for eliciting the relaxation response, including proper breathing, progressive muscle relaxation, and mindfulness meditation

Use simple cognitive techniques to transform stressful thoughts

Formulate a personal list of “in-the-moment” strategies that can be employed when stressful situations arise in pharmacy practice

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WHAT IS STRESS?

4Image: Shutterstock.com


What Is Stress?

Hans Selye (“Father of Stress Research”)“Non-specific response of the body to any

demand for change” (1936)“The rate of wear and tear in the human

machinery that accompanies any vital activity” (1964)“Everyone knows what stress is, but nobody

really knows”

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Stressor vs Stress

Stressor = stimulus (trigger)EnvironmentalSocialPhysiologicalCognitive

Stress = response

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The Problem With Definitions

How we experience stress depends on:Our view of the stressor Threatening: dangerous, difficult, painful, unfair? Overwhelming?

Our reaction to events/circumstances Events are not inherently stressful!

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Source: Hesson O, Stress Management for Life

Activating event (potentially stressful situation)

Beliefs, thoughts, perceptions

Consequence (stress or lack of stress)

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Source: Elkin A, Stress Management for Dummies


Yerkes-Dodson Principle

Source: Stress Management (Harvard Medical School Special Health Report)9

Stress is not inherently bad

Is It Good Stress or Bad Stress?

EustressPositive, desirable

stress

Feels exciting

Motivates, focuses energy

Short-term

Perceived as within our coping abilities

DistressNegative, undesirable

stress

Feels unpleasant

Causes anxiety or concern

Short-term or long-term

Perceived as outside of our coping abilities

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Stress Management Action Plan

What are your stress triggers?


THE STRESS RESPONSE



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The stress response is designed to help us survive physical danger

Fight Flight

Source: Hesson O, Stress Management for Life

Freeze

RecognitionAppraisal

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Sympathetic nervous system

Adrenal medulla

EpinephrineNorepinephrine

Pituitary gland

Hypothalamus

ACTH

Adrenal cortex

Cortisol

Fight or flight effects

CRH

Fight or Flight Effects

heart rate cardiac output blood pressure respiratory rate pulse rate O2 consumption muscle tension coagulation metabolic activity

Hepatic release of:Glucose

Free fatty acids

Cholesterol

Vasoconstriction (selective)

Blood shunted to periphery

Decreased GI activity

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The Modern Dilemma

Our body does a poor job of distinguishing

between life-threatening events and day-to-day

stressful situations

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Source: Stress Management (Harvard Medical School Special Health Report)


“We end up pumping high-energy chemicals for low-

energy needs”

Robert Eliot, MD

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Chronic Stress

State of continued sympathetic nervous system activation

“Constant emergency mode”Decreases stress thresholdStress response kicks in sooner or more

frequently

Wears down our ability to adapt and copeStress becomes a “habit”

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Effects of Chronic Stress

Medium-termMuscle tension and

pain

Headaches

Fatigue

Upset stomach

Difficulty sleeping

Grinding or clenching teeth

Infection

Long-termCardiovascular disease

Hypertension

GI disorders

Impaired immunity

Premature aging

Chronic inflammation

Central adiposity

…and many, many others!

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Symptoms of Stress

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Source: Stress in America 2015, American Psychological Association


Stress Management Action Plan

How does stress affect you?


THE RELAXATION RESPONSE

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After the Stress Response…

Parasympathetic nervous system (“rest and digest”)Reverses effects of stress responseRestores homeostasis

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Rest and Digest Effects

heart rate cardiac output blood pressure respiratory rate pulse rate O2 demand muscle tension coagulation metabolic activity

Blood shunted to internal organs

Normal GI function resumes

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The Relaxation Response

Herbert Benson, MDMind-Body Medical

Institute, Massachusetts General Hospital (now the Benson-Henry Institute for Mind Body Medicine)

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1975

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When we invokethe Relaxation Response,

we switch from the fight-or-flight responseto parasympathetic activity

BREATHINGChange the Consequences


Fight or Flight Breathing

Chest (thoracic) breathingChest expands, shoulders riseShallow breaths (upper portion of lungs)Rapid breathing

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Relaxation Response Breathing

Source: Stress Management (Harvard Medical School Special Health Report)29

Relaxation Response Breathing

Diaphragmatic (abdominal) breathingBelly expands out; chest remains stationaryDeep breathsSlow breaths Stimulates vagus nerve “There is no threat—return to homeostasis”

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Breathing is the only process regulated by the

autonomic nervous systemthat can be controlled consciously

Stress Toolkit for Pharmacy Practice

Option 1Breathe in deeply

Pause for a count of three

Breathe out slowly

Pause for a count of three

Option 2Breathe in —

“Calm…”

Breathe out —“down…”



PROGRESSIVE MUSCLE RELAXATION

Change the Consequences


Progressive Muscle Relaxation

Tightening and releasing all major muscle groups in an exaggerated fashionTeaches what muscle tension feels likeReduces muscle tension through focused

attentionActivates parasympathetic nervous system

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The 5-second “scrunch”Sit comfortably

Clench both fists, bend both arms, tense both biceps

Scrunch up face (close eyes, furrow brow, clench jaw, purse lips

Bring shoulders to ears

Tense stomach muscles

Hold 5 seconds

Release fully


MINDFULNESS MEDITATION

Change the Consequences



MINDFULNESS

“The awareness that arises from paying attention on purpose, in

the present moment, and nonjudgmentally”

Jon Kabat-Zinn

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—James BarazAwakening Joy: 10 Steps to Happiness

Mindfulness Is…

• Simply being aware of what is happening right now without wishing anything were different

• Enjoying pleasant experiences without holding on to them when they pass (which they will)

• Remaining present with unpleasant experiences without fearing they will always be this way (which they won’t)

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“…consciously placing the mind”

Sakyong Mipham

Mindfulness Meditation Is…

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Where Are You Right Now?

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Image: Shutterstock.com

What might happen

What has already happened

What is happening right now


Most stressful thoughts concern the past or the future

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“Monkey Mind”


“…allows you to see what’s going on in your head without getting carried away by it”

Dan Harris

Mindfulness Meditation…

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Image: http://cbicounseling.com/mindfulness-101/44

Active, open, intentional attention on the present—

not an “empty” mind


Meditation Practice

Focus attention

Get distracted

Notice the distraction

Release and return

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Practice “returning”Select a cue (e.g., telephone, chime)Stop and noticeConsciously practice mindful breaths


Practice While You Drive

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There’s an App for That

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10% Happier: Meditation for Fidgety Skeptics

7-day free introduction

$9.99/month

Calm

7-day free introduction

$9.99/month, $39.99/year

Buddhify

$4.99


COGNITIVE STRATEGIES

Change Your Perception

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Is It…

The stress?

How we relate to the stress?

or

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Maybe It’s How We Relate

…exposure to daily stressors may be less important for cardiac autonomic control than how people perceive and respond to those stressors, as well as their overall daily experiences of negative affect.

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Sin N et al. Psychosom Med. 2016 Jun;78(5):573-82.

“Between stimulus and response there is a space. In that space is our power to choose our response.”

Victor E. Frankl, MD, PhD

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Source: Tim’s Printables http://timvandevall.com/human-brain-diagram/

Prefrontal cortex

Amygdala

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How Mindfulness Helps

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Mindlessness (you don’t notice)

Stressor Fight or flight

Mindfulness (you notice)

Mindful response Automatic response

Stress reduces Stress increases

Better able to deal with next stressor

Stress cycle continues

Alidina S, The Mindful Way Through Stress

Don’t bite the hook

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The STOP Technique

Stop what you’re doing Initial step that helps break the

autopilot stress cycle

Take a few deep breaths Observe your

experience just as it is Proceed

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The PRO Technique

PauseInitial step that helps break

the autopilot stress cycle

Relax your body Open to what matters in

the momentFocus on the task at hand

P

R

O

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Practice While You Drive

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Someone cuts you off

You think, “I’m

angry!”

You actually become angry

OR…you stop or pause


Choose a different thought“I don’t need to be stressed about this—I’m

not in any danger”“I can’t control how others behave, but I can

control the way I think about it”“I choose ease”


Your Stress Toolkit

Stress Management Practices “In the Moment” Practices

Relaxation response breathing

Progressive muscle relaxation

Mindfulness meditation

STOP technique

PRO technique

Breathe in, pause, breathe out, pause

Breathe in “calm,” breathe out “down”

5-second scrunch

Practice returning

Choose a different thought

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My Stress Management Action Plan

My biggest sources of stress in pharmacy practice are:

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How stress affects me

Anxiety, worry, panic

Dizziness

Fatigue, lethargy

Headaches

Muscle tension (e.g., tight neck or shoulders, back pain)

Decreased libido

Difficulty falling asleep

Insomnia

Irritability, impatience

Bouts of anger or hostility

Moodiness

Sadness or depression

Eating too much

Eating too little

Heartburn, indigestion

GI symptoms (e.g., diarrhea, gas, cramps, constipation)

Rashes, hives, itching

Cold sores

Restlessness

Fidgeting

“Nervous habits” (e.g., nail biting, hair-twirling)

Frequent urination

Grinding teeth, clenching jaw while sleeping

Difficulty concentrating

“Fuzzy” thinking

Trouble remembering things

Heart palpitations

Shakiness, tremors, tics, twitches

Loss of sense of humor

Overly critical attitude

Feeling overwhelmed

Increased use of alcohol or drugs

Increased smoking

Other:

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Stress management practices I liked

Relaxation response breathing

Progressive muscle relaxation

Mindfulness meditation

STOP technique

PRO technique

How I will manage stressful situations “in the moment”

Breathe in, pause, breathe out, pause

Breathe in “calm,” breathe out “down”

5-second scrunch

Practice returning

Choose a different thought

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