How To Deal With Stress

Stressed out?  How can one deal with stress without getting stressed!?

What is stress and what’s the best way to deal with it?  Stress comes from multiple sources-work, family, expectations, health, finances, but the most important source of stress is YOU.

Stress has been studied a lot in the medical literature.  How do medical researchers measure stress? How do they quantify it? Do they run a battery of test? No, they just ask.  Patients are asked how much stress they are under.  No blood pressure or heart rate measurements. No galvanic skin response measurements. No EEG brain recordings or MRI scans.  Just a simple question.

The fact is, everyone is under stress.  The most common conditions leading to stress in a large survey done by the Robert Wood Johnson Foundation were poor health, disability, chronic illness, low income, experiencing dangerous situations at home or at work, single parenting, or being the parent of a teen.  Many of us can relate to at least one, or more, of these factors.

This leads us to the first and most important finding in the stress research literature:

Perception is everything.

In an interesting study, patients were placed into groups that had ‘almost no stress’, ‘mild stress’, ‘moderate stress’, and ‘a lot of stress’. They also asked them if they felt that their stress impacted their health.  Out of all 8 groups the only group that had more clinical events was the group that had a lot of stress AND felt that it was impacting their health.  If you had a lot of stress, but felt it was not effecting your health, it didn’t!

In another study researchers simply asked patients AFTER a heart attack if they had low stress, moderate, or high stress.  The group that said they had low stress had less clinical events after their heart attack compared to the group that had moderate to high stress after their heart attack!

Stress is real, but the more important aspect of stress is how we choose to respond to it.  Attitude itself is highly associated with death rate.  In a large review article multiple studies were listed that showed between a 10% to a high of 73% reduction in cardiovascular complications with an optimistic outlook.  Conversely, pessimism was associated with a 32-42% increase in events.

Two large philosophical groups also espouse this view.  One is the Stoics and the other are the Christians.

Seneca, one of the most famous Stoics said, “He who suffers before it is necessary suffers MORE than is necessary.”  The idea is that worry about a future problem only increases stress.

The most famous Christian verse in this regard is Matthew 6:25-27, 34 which states that worry and being stressed are a waste of time.

“Therefore I tell you, do not be anxious about your life, what you will eat or what you will drink, nor about your body, what you will put on. Is not life more than food, and the body more than clothing?  Look at the birds of the air: they neither sow nor reap nor gather into barns, and yet your heavenly Father feeds them. Are you not of more value than they? And which of you by being anxious can add a single hour to his span of life? Therefore do not worry about tomorrow, for tomorrow will worry about itself. Each day has enough trouble of its own.

Mark Twain has an excellent quote that puts this all into perspective.  He said, “I am an old man and I have known a great many troubles, but most of them never happened.”

Perspective is also incredibly important to how your form your outlook which leads to your attitude. Here are some examples.

During a discussion about making movies Denzil Washington got irritated when other actors were talking about how difficult it was to make a movie.  He then went on this mini rant:

“People say, ‘Oh the difficulty of making a movie.’ I say, ‘Send your son to Iraq. That’s difficult.’ It’s just a movie. It’s like, relax. I don’t play that precious nonsense. Get outta here. Your son got shot in the face? That’s difficult. Making a movie is a luxury. It’s a gift. It’s an opportunity and most importantly it’s a gift. Obviously everybody here is talented enough to do that. But don’t get it twisted.”

This also occurs in sports, but a great example of the opposite mindset was demonstrated by Steph Curry several years ago.  He was asked how he felt to be the 4^th highest paid player, not in the league, but on his own team after winning league MVP.  Here is what he said,

“One thing my pops always told me is you never count another man’s money. It’s what you’ve got and how you take care of it. And if I’m complaining about $44 million over four years, then I’ve got other issues in my life.”

So attitude, mindset, outlook, perspective, and mood can impact overall health, but how does this happen?

Can stress be transformed into biochemical and physiologic mechanisms that result in cardiovascular disease?  In an excellent study researchers put this idea to the test. They thought that increased stress would activate the amygdala (one of the emotional centers of the brain), thus releasing stress hormones, which in turn would activate the bone marrow to release pro-inflammatory monocytes and cytokines which would then lead to atherosclerotic inflammation of the arteries which then could cause stroke, heart attack, and death.  They checked their hypothesis by looking at radioactive imaging of the brain, bone marrow, and aorta with positron emission tomography (PET) scanning.  What they found was that as a patients perceived stress score increased the degree of amygdala activation, bone marrow activation, and aortic inflammation all increased proportionally.  Also CRP (c reactive protein) levels (a blood test that is associated with global inflammation) was also increased with increased stress scores.  Finally, and most importantly, patients with high amygdalar activity had more clinical events!

Another physical manifestation of stress is that it actually ages your cells. Telomeres are the end caps of your chromosomes and the longer they are the ‘younger’ your cell is.  People with increased stress have measurably shorter telomeres consistent with their cells being older than they should be!  If your cells are old, then you are too.

What can cause stress?  It’s hard to measure, but there are 2 things that are associated with stress and stress relief that are easily measurable and correlate with clinical outcome. These 2 factors are work hours and sleep duration.  Interestingly these both also have a u shaped relationship.

Regarding work if you work less than 25 hours a week the event rate starts to climb.  If you work more than 55 hours a week the event rate also climbs. The sweet spot is in between. This probably relates to being underemployed and financially stressed at the low end, and being overworked and stressed out at the high end.

But wouldn’t people be less stressed and happier if they didn’t work at all?  What if they were rich and didn’t need to work?  Well psychologist Mihaly Csikszentmihalyi looked at that in his well-known book Flow.  Flow is that state when you are in the ‘zone’ and time doesn’t matter, you are totally focused on what you are doing, and where and when most people feel the most enjoyment.  Interesting flow occurred most often at work, 54% of the time.  Flow only occurred 18% of the time at leisure. In fact one of the least flow inducing activities was power boating which is typically in the domain of rich people.  Apathy occurred only 16% at work, while 52% at leisure.  This makes sense.  How often have you been bored during vacation and looking to ‘fill in’ the time?  In contrast work often requires focus, but also provided purpose which leads to enjoyment.  Also most people are actually good at their jobs which also helps fulfillment and enjoyment.

Sleep is similar. The sweet spot is from 6-9 hours with less or more associated with increased death.  Too little sleep is probably related to increased stress and worry and also poor sleep quality.  Also, too little and too much sleep are both factors in major depression.  The great thing is that adjusting your sleep time actually reduces your risk so this is something that should be worked on.

Environment can also impact stress levels and even mental illness.  Studies have shown that just living in an area that has greenspaces is associated with less stress and decreased incidence of multiple different mental health disorders.  The interesting factor is that it is unclear if those people even utilized those greenspaces, but that just by living near them it positively impacted their mental health.

But what if you took the next step and went outside and used those greenspaces?  ‘Forest bathing’, what used to be called taking a hike, has now been studied scientifically and been associated with quantitative results such as lower blood pressure and reducing cortisol levels (a stress hormone), and also improving mood, decreasing depression, decreasing stress, improving immune function, and enhancing brain function.

Emotion is also not just a powerful outlet for stress, but can impact your internal physiology as well.

Angry outbursts are closely linked to increased rates of heart attack, stroke, abnormal heart rhythm, and aneurysm rupture. What is the time frame between the angry outburst and the event?  How long does that risk last?  For 2 hours. This has also been seen after earthquakes where there is an increased heart attack risk shortly after he event.  Short term stress or anger can lead to physiological changes, but how?

In a very interesting study a group of cardiology trainees had their arterial reactivity tested at baseline.  Normal arteries should dilate after being constricted. This was done with a blood pressure cuff and measured by ultrasound imaging.  They studied the trainees after watching a comedy movie and after watching Saving Private Ryan, which is an intense war movie.  Their arteries dilated more after laughing at the funny movie, but actually constricted after watching Saving Private Ryan. They were not exposed to war, they were just watching a movie.  How long did the positive effects of laughter last?  24-48 hours.  Our bodies are incredibly made.  Laughter is protective for up to 2 days, while anger only puts you at risk for 2 hours.

So what can we do to reduce stress?

In the same Robert Wood Johnson Foundation survey we talked about at the start of this article they also asked what people did to reduce stress that was effective.  The most common responses were in decreasing order: spending time outside (94%), spend time on a hobby (93%), exercise (89%), spend time with a pet (87%), meditate or pray, (85%) spend time with family or friends (83%), time off of work (79%), full night’s sleep (76%), use medication (70%), get professional help (65%), and eat healthy (63%).

First off, and most importantly you have to decide to be less stressed. De-stress.  Remember perception is everything.  How you let stress affect you is much more important than the actual stressor itself.  This is not something that can occur overnight, but something you will have to practice until it becomes a habit.  Towards that goal Stephen Covey has this great quote:

“I am not a product of my circumstances. I am a product of my decisions.”

But is there a way to do this?  This seems easier said than done.  There are 2 well known ways that can help you mitigate the stress of stress.

Be Thankful

The first one is to practice gratitude.  Studies have shown that people who do a daily gratitude journal or gratitude list out loud have improved sleep, mood, self-sufficiency, lower cortisol (stress hormone levels), and lower inflammatory biomarkers.  All you need to do is to list 2-3 things that you are grateful for.  They actually recommend only going for a short list as going for 5-7 things often lead to more stress.  Not being able to list 5 good things in a persons life made them feel that they had a bad life.  Once again perspective is so important.

Pray

The other is the Serenity Prayer.  This short prayer is typically attributed to theologian Reinhold Niebuhr, but made famous by Alcoholics Anonymous.

God grant me the serenity
To accept the things I cannot change;
Courage to change the things I can;
And wisdom to know the difference.

Living one day at a time;
Enjoying one moment at a time;
Accepting hardships as the pathway to peace;
Taking, as He did, this sinful world
As it is, not as I would have it;
Trusting that He will make all things right
If I surrender to His Will;
So that I may be reasonably happy in this life
And supremely happy with Him
Forever and ever in the next.
Amen.

The power is in the simplicity, the call to a higher power (God), and realizing that not everything can be changed, or even should be.  Worry doesn’t change anything, but just leads to more stress.

What else can one do to reduce stress?

6 Ways To Reduce Stress NOW!

1. Get outside more.  Sunlight, fresh air, and nature can help with stress as detailed above.
2. Sleep more.  Adding 1 hour more to your sleep actually will make you more rested, more able to tolerate stress, but also reduce your risk of dying by 20%.
3. Spend time with friends.  Being socially connected is so important in life. No man is an island.  One of the major factors in prolonged life in the so called ‘Blue Zones’ is being social. Blue Zones are communities where the average life span is 10 years more than surrounding areas.  There were 9 factors associated with the extra 10 years and 3 of them involved being social-loved ones first, right tribe, and belonging.  In another study just going to church reduced the risk of suicide by over 50%.  Low social support was associated with worse physical, mental, mood, and quality of life scores.  Finally, the opposite of being social is loneliness which is a growing problem which can lead to depression. In the 2018 Cigna loneliness study 46% admitted to be lonely or felt left out.  Generation Z had the highest loneliness scores as well.
4. Exercise.  Exercise is probably the cheapest and best treatment for stress, mood, sleep, and energy.  Social exercise (such as tennis) is the best for longevity.  Also hard efforts such as fast running, HIIT, lifting heavy weights, or punching or kicking (or martial arts) typically dissipate stress the best.  All you need for increased lifespan is at least 15 minutes of consecutive exercise a day.  To reduce stress and ward off mental illness the sweet spot is 45 minutes a day, 3-5 times a week.  There may be increased stress for those that exercise 6-7 days a week, probably reflecting the need of everyone to relax and recover, even from ‘good’ activities such as exercise.  Striving to exercise everyday may actually be a cause of stress.
5. Get a dog (or any kind of pet).  A large meta-analysis showed that owning a dog reduced the risk of heart attack and death. It is unclear why, but we can guess that it probably involves the social connection with the dog and the happy feeling that the dog generates in the owner.
6. Another thing to try is prayer.  Prayer and devotion (quiet time) can help center your day and give you more of a sense of purpose.  Many feel that prayer is even more subjective than asking patients how much stress they have, but teaching prayer as an intervention has been studied in multiple studies, in multiple fields, and across multiple cultures.  Several studies have shown that prayer lead to a lower self-reported stress score, but also reduced blood pressure response to stressful situations.  A large study of over 900 teachers used prayer as a way to deal with work stress.  Frequency of prayer correlated with better job satisfaction.  Another study found that prayer also reduced stress level and improved life satisfaction scores in Muslim nursing students.  There have been studies on interventional prayer as well with mixed results.  While many believe that prayer can help change external outcomes, many don’t.  But what most studies show is that prayer will change yourself.

You may never be able to completely eliminate stress from your life. But by employing some or all of the 6 steps above, and by maintaining an attitude of thankfulness, you can literally change the negative physical impact stress can have on your body. So next time you feel overwhelmed, remember you can choose to control, to a large extent, the effect of stress on your body and mind by what you choose to believe and think.

Harvey Hahn, MD, FACC

Dr. Hahn graduated from Loma Linda University in 1994. He is currently the director of the Cardiovascular Fellowship Training Program at the Kettering Medical Center in Kettering Ohio.