16
Florida Heart CPR*
Stress and Stress Management
3 hours
Learning Objectives: After completion of this activity, the participant will be able to define acute stress, chronic stress, and be able to utilize and demonstrate a knowledge of stress management techniques.
Life is filled with stress, which can be short-term (acute) or long-term (chronic). Acute stress is the reaction to an immediate threat, commonly known as the "fight or flight" response. The threat can be any situation that is experienced, even subconsciously or falsely, as a danger. Common stressors include noise, crowding, isolation, hunger, danger, and infection. Imagining a threat or remembering a dangerous event can also evoke a stress response. Frequently, however, modern life poses on-going stressful situations that are not short-lived such as difficult work or personal situations and against which the urge to act -- to fight or to flee -- must be suppressed. Psychological pressures such as relationship problems, loneliness, continual deadlines, or financial worries may be unrelenting and lead to chronic stress.
The body's stress response is somewhat like an airplane readying for take-off; virtually all systems -- the heart and blood vessels, the immune system, the lungs, the digestive system, the sensory organs and brain -- are modified to meet the perceived danger. Under most circumstances, once the threat has passed the response becomes inactivated and levels of stress hormones return to normal -- a condition called the relaxation response.
The Physical Responses to Acute Stress
The Brain
Following a threat, the part of the brain called the hypothalamic-pituitary-adrenal (HPA) system releases certain neurotransmitters (chemical messengers) called catecholamines, particularly those known as dopamine, norepinephrine, and epinephrine (also called adrenaline). The HPA systems also trigger the production and release of steroid hormones (glucocorticoids), including cortisol -- the primary stress hormone. Cortisol affects systems throughout the body. Catecholamines also activate an area inside the brain called the amygdala, which apparently triggers an emotional response to a stressful event and also signals the hippocampus -- a nearby area in the brain -- to store the emotionally loaded experience in long-term memory. In primitive times, this combination of responses would have been essential for survival, when long-lasting memories of dangerous stimuli (such as a large animal) would be critical for avoiding such threats in the future. During a stressful event, catecholamines also suppress activity in areas at the front of the brain concerned with short-term memory, concentration, inhibition, and rational thought. This sequence of mental events allows a person to react quickly -- either to fight or to flee -- in emergency situations; however, this also hinders a person's ability to handle complex social or intellectual tasks and behaviors.
Heart, Lungs, and Circulation
The heart rate and blood pressure increase instantaneously in response to stressful situations. Breathing becomes rapid and the lungs take in more oxygen. Blood flow may actually increase 300% to 400%, priming the muscles, lungs, and brain for added demands. In addition, the spleen discharges red and white blood cells, allowing the blood to transport more oxygen.
Metabolic Response
Stress shuts down digestive activity, a nonessential body function during short-term periods of physical exertion or crisis.
The Immune System
The immediate effect of stress is to dampen parts of the immune system. In addition, certain factors in the immune system -- including important white blood cells -- are redistributed, much like marshaling soldiers to potentially critical areas. In the case of stress, these immune-boosting troops are sent to the body's front lines where injury or infection is most likely, such as the skin, the bone marrow, and the lymph nodes.
Mouth and Throat
During stress, fluids are diverted from nonessential locations, including the mouth, causing dryness and difficulty in talking. In addition, stress can cause spasms of the throat muscles, making it difficult to swallow and fight infection.
The Skin
Stress commonly results in cool, clammy sweaty skin and in a tightening of the scalp that makes the hair seem to stand on end. The skin is cool because blood flow is diverted away so it can support the heart and muscle tissues. As a result, physical capacity is increased and blood loss is reduced in the event of injury.
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 under activated, causing physical or psychological damage.
Psychological 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 psychological 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 might, 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 diminish 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.