limiting the amount of salt and water the kidney is allowed to excrete. Cortisol increases the production of glucose and assists in the breakdown of fat and proteins to provide the additional energy needed to protect the body from the perceived threat. When cortisol levels are increased, DHEA (dehydroepiandrosterone) levels are reduced. The hormones released during the stress response have many effects on the body ( Exhibit 6-1 ). EXHIBIT 61 EFFECTS OF STRESS P HYSIOLOGIC Increased heart rate, grinding of teeth, rise in blood pressure, insomnia, dryness of mouth and throat, anorexia, sweating, fatigue, tightness of chest, slumped posture, headache, pain, tightness in neck and back, nausea, vomiting, urinary frequency, indigestion, missed menstrual cycle, diarrhea, trembling, twitching, and accident proneness E MOTIONAL Irritability, tendency to cry easily, depression, nightmares, angry outbursts, suspiciousness, emotional instability, jealousy, poor concentration, decreased social involvement, disinterest in activities, bickering, withdrawal, complaining, criticizing, restlessness, tendency to be easily startled, anxiety, increased smoking, increased use of sarcasm, reduced interest in sex, and use of drugs or alcohol I NTELLECTUAL Forgetfulness, errors in arithmetic and grammar, poor judgment, preoccupation, poor concentration, inattention to detail, reduced creativity, blocking, less fantasizing, reduced productivity W ORK H ABITS Increased lateness, absenteeism, low morale, depersonalization, 209 avoidance of contact with coworkers, excess breaks, resistance to change, impatience, negative attitude, reluctance to assist others, carelessness, verbal or physical abuse, poor quality and quantity of work, threats to resign, resignation Sources of Stress The sources of stress in daily life are different for each individual. One person may find a 20-mile drive home through a mountain pass after work tedious and frustrating, whereas another may view it as a source of pleasure and relaxation. Sources of stress can be associated with the physical environment, job, interpersonal relationships, past experiences, work, finances, and psychological makeup. Identifying what stresses them and how they react to that stress is the first step for people to take in developing effective personal stressmanagement strategies. A variety of tools can help people to identify the stresses in their lives, one of which is offered in Exhibit 6-2 . EXHIBIT 62 HOLISTIC SELF-ASSESSMENT OF STRESS L IST MAJOR FORMS OF STRESSES IN YOUR LIFE I DENTIFY THE SOURCE OF EACH FORM OF STRESS L IST ACTIONS THAT CAN BE TAKEN TO ADDRESS EACH SOURCE OF STRESS Sources of stress can be: Mental (e.g., feeling bored, overloaded) a b a 210 Physical (e.g., disease, injury) Emotional (e.g., anger, grief, fear) Relational (e.g., altered feelings between self and significant others, violation of trust) Spiritual (e.g., values conflict, feeling God is not listening) Vocational (e.g., job dissatisfaction, undesirable schedule, insecurity, poor work conditions) Examples of actions that can be taken to reduce stress Obtaining medical attention Asking for help with a project Being realistic in what can be achieved Following a reasonable schedule Seeking counseling Developing a hobby Exercising Meditating Praying Overscheduling has been shown to be a source of considerable stress for a growing number of people. More than one-third of Americans claim they have hectic schedules and don’t have sufficient time in the day to fulfill all their demands ( Dickinson, 2016 ). Busyness and the “time poverty” that results can lead to irritability, trouble focusing, sleep problems, and mental and physical fatigue. To combat this problem it is recommended that people should reduce their commitments, structure their lives around what matters (which may mean b 211 sacrificing some income to have time to do what is viewed as important), and be intentional about carving out time to do what they desire. REFLECTION Take a few minutes to complete the self-assessment in Exhibit 6-2 . What are the three major stresses in your life that you have identified? Stress and Disease As mentioned, the recognition of the link between the mind and the body is not new; however, the specific mechanism to explain the link between stress and disease is still unclear despite years of scientific research. It is widely believed that the impact of stress—especially chronic stress—on the human body greatly increases the risk of developing a variety of diseases such as asthma, arthritis, cancer, hypertension, heart disease, migraine headaches, strokes, and ulcers. Statistics from a variety of sources state that 50% to 90% of healthrelated problems are linked to or aggravated by stress ( Seward, 2013 ). Nearly every consumeroriented publication from hospitals, public health departments, health maintenance organizations, and physicians’ offices recommends or offers some type of stress-management program. 212 Most people probably are able to recognize the major physical symptoms of stress in their lives. They also need to be aware of other important behavioral, emotional, or mental symptoms that may be stress related, such as compulsive eating, drinking or smoking, restlessness, irritability or aggressiveness, boredom, inability to focus on the task at hand, trouble thinking clearly, memory loss, or inability to make decisions. Exhibit 6-3 lists common physical symptoms often related to stress. It is helpful for people to engage in a selfassessment as a means to gain insight into the impact of stress in their lives. This is not only important to maintaining a state of wellness, but also as part of living with chronic conditions. EXHIBIT 63 PHYSICAL SIGNS OF STRESS This list can be used for a self-assessment for the impact of stress on one’s life. Consider how frequently a sign/symptom occurred and if it is related to any specific event. • Tense muscles • Upset stomach • Headache • Change in bowel habits • Dizziness • Palpitations • Chest pain • Fatigue 213 • Insomnia • Frequent colds, infections Stress-Reduction Measures After people recognize the symptoms of stress in their lives, they can minimize the impact of stress on their physical, mental, emotional, and spiritual wellbeing by using one or a combination of measures designed for stress reduction. The ultimate goal of stress reduction or stress management is the relaxation response, or a state of profound rest and peace. The term relaxation response was first used by Dr. Herbert Benson in his book of the same name. He and others have described elements common in most stress-reduction measures ( Benson, 2000 , pp. 110–111; Benson & Proctor, 2011 , pp. 111–112): • A quiet environment • Focus on a word, short prayer, or a phrase that is repeated over and over again • The adoption of a passive attitude (which is perhaps the most important of the elements). A passive attitude is one in which a person is open to a free flow of thoughts without analysis or judgment • A comfortable position, sitting calmly with eyes closed • Slow, deep breathing • Progressive relaxation of all muscles. 214 K EY P OINT Numerous studies of the results of stress reduction have demonstrated positive findings to include the reduction of blood pressure in individuals with hypertension, improved sleeping patterns in individuals suffering from insomnia, decreased nausea and vomiting in chemotherapy patients, and reduction in the multiple symptoms of women diagnosed with premenstrual syndrome or who are experiencing menopausal symptoms ( Cash et al., 2015 ; Kwekkeboom & Gretarsdottir, 2006 ; la Cour & Petersen, 2015 ). T IP FOR P RACTICTIONERS Individual preferences and circumstances influence the selection of stress-reduction measures. Some stress-management techniques are simple, whereas others require some initial instruction. Regardless of the choice of method or combination of methods, all require practice and need to be used on a regular basis to be effective. Instructing, assisting, and coaching people in the use of stress-reduction techniques can increase their success in addressing this problem. Exercise In the early days of human existence, most threats were physical and demanded an immediate, intense physical response to ensure survival. The response was literally fight or flight. All of the stress hormones 215 released were quickly consumed, and their physical effects were diminished in that burst of activity. In today’s environment, the majority of the sources of stress are much less physical and more complex. They usually result from cumulative factors, such as multiple, often simultaneous demands at home and at work. Physical, emotional, and mental well-being depends on finding a way to dissipate the negative effects of those stressors. Aerobic exercise burns off existing catecholamines and stress hormones by directing them toward their intended metabolic functions, rather than allowing them to linger in the body to undermine the integrity of vital organs. A consistent exercise program has also been demonstrated to help decrease the level of reaction to future stressors. The key to using exercise for stress reduction is to develop an individualized program that is tailored to one’s physical abilities, time constraints, and finances. Additionally, to reduce stress, it is beneficial to select an activity that is relaxing and enjoyable rather than competitive. Progressive Muscular Relaxation When you are stressed, anxious, angry, or frightened, your body automatically responds by increasing muscle tension. You may have experienced the effects of that response resulting in 216 muscular aches and pains in various parts of your body after an unpleasant encounter or a hectic day. Progressive muscular relaxation (PMR) was developed in the 1930s by Dr. Edmund Jacobson, a physician–researcher at the University of Chicago, as a method to reverse this tension and elicit the relaxation response. Moving sequentially from one major muscle group or area of the body to another, for example, from head to toes or vice versa, muscles will be consciously tensed and then relaxed. This conscious muscular activity interrupts the stress response by interfering with the transmission of stress-related tension via the sympathetic nervous system to the muscle fibers. Among the benefits of PMR are decreases in the body’s oxygen use, metabolic rate, respiratory rate, and blood pressure. These effects can have benefits for people diagnosed with hypertension and chronic obstructive lung disease. Additionally, PMR has been shown to be a useful pain management tool in some patients with cancer and chronic pain ( Chang, Fillingim, Hurley, & Schmidt, 2015 ; Kwekkeboom & Gretarsdottir, 2006 ; Zhou et al., 2015 ). PMR is relatively easy to learn. The method cited Exhibit 6-4 is only one of the variations on the original technique designed by Dr. Jacobson.