Coping Well:
Implementing the Principles
of Stress Resilience
N. Lee Smith, MD
Adjunct Associate Professor of Medicine
University of Utah
Director, Stress Medicine
Lifetree Clinical Research and Pain Clinic
Salt Lake City, Utah
Our purposes todayTo identify:
• Four core principles of stress resilience
– And what these have do do with mental and
physical well-being (health)
• Some specific techniques
for applying these principles
What does mental stress have
to do with medical illness?
INTERHEART Study:
Significance of Coronary Risk Factors
(15123 MI Cases; 14820 controls; 52 countries)
40
35
30
Attributable
Risk %
25
20
15
10
5
0
Smoking Depression Obesity Hypertension
Yusef S; also Rosengren A. Lancet 2004;364:937-52 and 364:953-62
Outcome Effects of Treating
MI Depression with Sertraline
(SADHART Trial: n = 369)
0
Mortality
Stroke
2nd MI
Angina
CHF
-2
-10
-15
Percent
-20
reduction
from
-30
placebo
-30
-30
-40
-50
-60
-61
-70
Glassman AH, (SADHART) JAMA 2002;288:701-709
Many Very Common Medical
Problems Involve Central Nervous
System Hypersensitivity:
• Irritable bowel syndrome
• Atypical chest pain
• Migraine and Tension Headaches
• Fibromyalgia & Myofascial Pain Syndromes
• Anxiety and depression disorders
Inhibitory track
serotonin,
norepinephrine,
dopamine
Interventions improving
chronic pain and hypersensitivity
usually require improvements
in the central function of:
•
•
•
•
•
•
•
Serotonin
Norepinephrine
Dopamine
Endorphins
GABA
Deep sleep
Reduced sympathetic tone
What are the effects of cognitivebehavioral interventions on
these protective mechanisms?
• Sense of internal control
 Serotonin
• Love, cooperation  Dopamine,Endorphins
• Exercise, pos. excitement   NE and DA
“Turned on”-purpose
  Endorphins
• Deep Relaxation,
  Sleep, Serotonin
& mindfulness
  sympathetic tone
meditation
  GABA (?)
Coping Styles and Health
45 year Harvard Study (Vaillant, et al)
Coping Styles
• Denial
• Blaming and victimizing
– denying personal responsibility
• Repression, intellectualizing
• Mature, adaptive
– Internal control, connectedness, humor
Coping Styles and Health:
Outcomes
• Styles 20 years later tended to be the same
(with no intervention)
• Middle age (53): % chronic illness or death:
– Mature adaptive style: 3%
– The others combined: 37%
• Additional analysis:
– optimism (hope) and altruism (meaning) were
important for outcome
Vaillant G, et al; also Seligman M and Peterson C Learned Optimism 1990s
Connectedness and Health
• Roseto, PA study
– 1/6 the national average of MIs and CV death
– Average exercise, smoking, obesity, hypertension
• Multifactorial analysis —The keys:
– Strong sense of community: unconditional support
—Social and family ties
—
Elderly honored
• When these deteriorated: MI rates = average
—Stewart Wolf, Temple Univ.
• (Compare 10000 Israeli men with CAD risk)
Stress Hardiness
• Control
The Three C’s”
– Internal source of power to choose responses
– Refusal to be a victim
• Challenge
– Sees change as opportunity
– Enjoys growth
– Tightly linked to hope
• Commitment
– Curiosity and deep involvement
– Finding meaning and purpose
Suzanne Kobasa and Salvatore Maddi
Four Principles of Stress
Resilience Clearly Related to
Improved Health Outcomes
• An internal locus of control
• A sense of connectedness
• A sense of purpose and meaning
• Hope
Karren K, Smith NL, Hafen B, Frandsen K: Mind-Body Health…
(3rd edition) 2005 (San Francisco, Benjamin Cummmings Publ)
Dealing with Times of Chaos
What gives a sense of control?
–Hope
–Loving support
A Sense of Connectedness:
• To one’s deepest self
• To other people
• To the larger sources
of one’s power
Is the way I’m handling this
situation:
Connecting us more deeply?
or
Disconnecting us?
Does stress reduction work?
If so, what are the keys to success?
Stress and Heart Disease
What are the
cardiotoxic components of
Type A behavior?
• Cynicism
• Hostility and anger
•  Relationship problems
Anger/Hostility and Carotid Disease
Middle aged women- over 3 years
7
6
Percent
progression
on IMT
5
4
3
2
1
0
Lowest
Raikkonen K Psychosom
Med 2004;66:903-908
Highest
Trait Anger Quartiles
Stress Reduction Reduces
Carotid Atherosclerosis
• A meditation-based stress reduction program
reduced carotid intimal thickening
– compared with health education
in hypertensive African Americans
– carotid intimal thickening = predictive of coronary disease
• The meditation group: decrease in carotid
intima-media thickness of -0.098 mm
• Control group: increased of 0.054 mm
Castillo-Richmond A. Stroke 2000;31(3):568-73
Coronary Events (%)
Comparing Stress Reduction
and Exercise in CAD Patients
30
25
20
15
10
5
0
Usual Care
Exercise
Stress
Reduction
Intervention
Blumenthal JA, et al Arch Int Med 1997;157:2213-2223
Stress Resilience
can be learned
It takes practicing experientially
to do so
Creating Stress Resilience
• Is stress good or bad?
• What makes the difference?
• An important key:
– How much sense of control do you feel in
dealing with it?
Animal Studies:
Cancer Cell Rejection
70
60
Percent
immune
rejection of
the cancer
cells
50
40
30
20
10
0
In Control
Victims
No Stress
-Martin Seligman,
U. of Penn
The Paradox of Control
• The more you try to take control of the
world out there,
the more out of control it seems
• The more you let go trying to control the
external world (and stop blaming),
and instead, respond in a way that you
would deeply admire as wise,
the more personal control you feel
Hindus:
“You have given your power
(spirit) away.
Call your power back”
How to Create a Sense of
Personal Control and Hope
• Conscious awareness
“I can respond as I choose.”
• Relaxation skills:
To let go and get focused
• Clarify deep values
“How do I want to be?”
• Visualizing (experiencing) responding the new way
Creating Hope
• Visualizing (experiencing) one’s self handling
the situation well,
in accord with wisdom and deepest values
A Sense of Personal Control
has much to do with identifying
one’s deepest, wise values,
then creating ways to respond
through them
Creating Connectedness:
We have been highly conditioned to
see (and respond to) the world
through eyes of fear and judging
Suppose instead, we saw through
eyes of love
lift each other
safe, acceptance
caring
honest, authentic
A truly great relationship
honors needs
humor
create hope
win-win
kind
Example:
Overwhelmed:
“Have too much to do”
A Philosophical Checkup:
Discovering the core, wise mind:
What is life really about, anyway?
– Productivity in numbers generated?
– Proving oneself worthy, or right?
or
– Learning to love?
– Becoming wise and resilient?
Spiritual
well-being
– Making a difference?
– Joy?
}
A Philosophical Checkup:
Discovering the core, wise mind:
• Why did I get into my work in the first place?
– external rewards? (income, status)
– or intrinsic meaning?
• What is the real purpose of my work?
Journaling for Meaning
Review your day backwards, asking:
• “What surprised me today?”
• “What moved or touched me today?”
• “What inspired me today?”
Look for the stories.
After some time, the gap to seeing the
answers will narrow, until they are seen
as they happen
Remen RN. Int Med News 1/15/02, p.5
What is Health?
(from: World Health Organization)
Total well-being:
Physical
Mental
Social
control (personal)
connectedness
meaning
hope
Spiritual
Summary
(1)
• Depression, anxiety
and associated traits of cynicism, hostility and anger
are highly associated with cardiovascular disease
and with many very common pain problems
• Several mechanisms of this are known
• Effectively teaching stress resilience
(and treating dpression/anxiety)
improves health outcomes
Summary
(2)
To be medically effective, stress resilience training:
• needs to be experiential
• needs to be directed at four core (spiritual) principles:
–
–
–
–
An internal locus of control (remember the paradox)
Enhancing connectedness (oneness)
Finding purpose and meaning (in all experience)
Creating hope