Kathleen Ondus, MSN, GCNS, BC Rosanne Radziewicz, RN

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New Concepts in Stress

• Kathleen Ondus, MSN, GCNS, BC
• Rosanne Radziewicz, RN, PMHCNS-BC
• MetroHealth Medical Center and
• Western Reserve Geriatric Education Center, Case
  Western Reserve University

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Objectives

• Discuss evidence based literature supporting the
  use of complementary and alternative therapies as
  integrative modalities in the treatment of stress
• Apply the use of complementary and alternative
  therapy modalities in select case scenarios

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Disclosures

• Neither the speaker nor the planning group has
  any affiliation with any party which would
  influence the content of this program.
• No off-label use of drugs will be discussed.

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The Physiology of Stress Acute
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The Body Self-Regulates
BRAIN Hypothalamus
CRF
Pituitary Gland
ACTH
Turns off ACTH
Adrenal Gland
Cortisol
Circulating Cortisol
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Effects of HPA Stimulation

• Heart rate and force increases
• Blood pressure increases
• Breathing rate increases to deliver oxygen to
  muscles
• Blood diverted from GI tract to skeletal muscles
• Clotting factors increase to prevent bleeding
  from wounding

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Effects of HPA Stimulation

• Pupils widen to heighten visual acuity and
  awareness
• Hormones increase visual and auditory acuity
• Endorphins produced to decrease sensitivity to
  pain

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Acute Indicators of Sympathetic Activation

• Increased ventilation
• Frequent sighing
• Sweating
• Frequent urination
• Agitation
• Anxiety
• Disturbances in sleep
• Changes in appetite
• Acne

• Racing heart
• Dry mouth
• Goose bumps
• GI difficulties
• Diarrhea
• Gas
• Belching
• Muscle tension
• Headaches

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The Physiology of Stress Chronic
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Long Term Effects on CV

• Increased BP
• Plaque formation
• Narrowed arteries
• Surges in BP
• High blood glucose and insulin resistance

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Other Long-Term Effects

• Hypercortisolemia
• Insulin resistant diabetes
• Increased gastric acid to limit calories from
  food
• Release of high-energy fats and clotting agents
  in case of need
• Reallocation of fat to abdomen (obesity)
• Bone mineral/density loss
• Decreased immune function
• Eventual adrenal fatigue/blunted response
• Chronic depression or PTSD can lose cortisol
  responses to stress

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Long-Term Effect on Immunity

• Production of Interleuken 1 (IL-1) and
• sickness behavior
• Fatigue, lack of energy
• Sleep and appetite disruption
• Loss of interest
• Impairs hippocampus memory
• Can induce depression

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Long Term Effects on Cognition

• Activates threat detector
• Impairs specific memory
• Overgeneralized memory/narrative smoothing
• Creates bias to threat related information
• Depletion of serotonin, depression

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Research on Mind/Body Interventions

• Reduced sympathetic and increased parasympathetic
  activity
• Measuring cardiac vagal tone as a marker of
  emotional regulation and psychologic adaptation
• Growing research on association between emotional
  disorders and autonomic functions across the
  lifespan

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Breathwork

• Life force energy in many cultures
• Few rigorous studies that are generalizable
• Relationship between breathing and emotion is
  bidirectional
• By voluntary control, breath can influence
  autonomic nervous system functions

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Breathwork

• Techniques taught can include
• Duration of phases of breath cycle
• Tidal volume
• Use of mouth/nostrils
• Constriction of laryngeal muscles
• Position of the glottis
• Body postures (asanas)
• Taught to focus on breath and sensations in the
  body

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Breathwork

• Slow breathing enhances parasympathetic activity
  and increases indicators of vagal tone, increases
  exercise and stress tolerance in all including
  psychotic patients
• Patients with HTN, CV disease or migraines may
  not tolerate bellows breath or breath holding
• Incorrect technique or overuse can cause
  dizziness, lightheadedness, irritability,
  euphoric states, or psychosis in vulnerable
  patients

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Practicing regular, mindful breathing can be
calming and energizing and can even help with
stress-related health problems ranging from panic
attacks to digestive disorders."Andrew Weil,
M.D.
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Breathwork
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Guided Imagery

• Uses words to direct ones thoughts and attention
  to imagined visual, auditory, tactile, or
  olfactory sensations to elicit the psychological
  and physiologic response of relaxation.

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Guided Imagery

• Mind-body practice used in many religious and
  healing traditions
• Large body research over many decades
  particularly in counseling and allied fields.
• Used alone or in conjunction with other
  modalities

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Guided Imagery

• Useful in
• cancer care
• pain management
• stress management
• grief therapy
• preparing for surgery
• management of headaches

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Guided Imagery

• Effects
• PET scan indicate activation of optic cortex same
  in imagery as actually observing
• Decreased blood pressure heart rate
• Decreased salivary cortisol levels
• Positive effect on immune system
• Increased sense of well-being
• Decreased need for pain medication
• Increased oxygen saturation of blood

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Massage Therapy

• Several versions of therapeutic massage
• Used in a variety of settings
• Provides mental and physical relaxation
• Release of endorphins

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Massage Therapy

• Evidence-based effects
• Increased serotonin and dopamine levels
• Decreased anxiety and stress scores
• Decreased BP and heart rate
• Decreased cortisol levels
• Increased peak flow, O2 saturation, and forced
  vital capacity
• Improved sleep patterns

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Meditation

• Well studied for its effect on
• Attention/concentration
• Cortical growth
• Reduction in pain, anxiety, panic
• Enhanced psychological hardiness (Kobasa)
• Greater sense of coherence (Antonovsky)
• Helps the body turn on and off genes associated
  with inflammation, cell aging, and free radicals
• Dusek JA, Otu HH, Wohlhueter AL, Bhasin M,
  Zerbini LF, et al. (2008) Genomic Counter-Stress
  Changes Induced by the Relaxation Response. PloS
  ONE 3(7) e2576. doi10.1371/journal.pone.0002576

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Meditation

• Some reports of contraindications in populations
  and others substantiate its use
• Case reports of psychotic symptoms, anxiety,
  depersonalization and derealization, and mania in
  vulnerable patients

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Music

• Slows rapid heart rate/BP
• Rhythm helps to develop/heal brain
• As transformed sound waves move through the
  brain, they can generate motor responses,
  emotions, hormone release and higher order
  processes (e.g., recognition and memory recall).
• Manipulate consumers behavior (drinking pop
  faster with rapid music in background)
• http//www.musictherapy.org/

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Music

• Patients pulse rates fell by more beats/minute
  when they made their own music selections,
  compared with those who listened to music
  selected by researchers
• Improved mood and increased feelings of
  relaxation
• Decreased anxiety

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Reflexology

• Randomized Controlled Trial on PMS
  symptomssuggests that massage may relieve PMS
  symptoms but does not validate the alleged
  connection between reflex points and body organs
• Decrease in anxiety with patients with lung
  cancer
• Improvement in cancer QOL
• Oleson T, Flocco W. Randomized controlled study
  of premenstrual symptoms treated with ear, hand
  and foot reflexology. Obstetrics and Gynecology
  82906-911, 1993.

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Reiki

• Studies funded through NCCAM
• Whether Reiki is effective and safe for treating
  the symptoms of fibromyalgia
• Reiki's possible impact on the well-being and
  quality of life in people with advanced AIDS
• Whether Reiki can help reduce nerve pain and
  cardiovascular risk in people with type 2
  diabetes.

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Reiki continued

• Case report evidence of effect
• Anxiety, pain, stress
• Individual belief system may not embrace
  metaphysical concepts
• Case reports of psychotic symptoms,
  depersonalization

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Case Scenarios

• Highly successful physician in his 50s
• Avoidant
• Socially isolated

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Considerations

• Is the patient likely to practice on own or would
  prefer/require a practitioner
• Cost of practice
• Ability to focus or concentrate
• Availability of resources

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Resources

• American Holistic Medical Association
• http//www.holisticmedicine.org/
• Breathwork
• http//www.drweil.com/drw/u/ART00521/three-breathi
  ng-exercises.html
• http//www.resperate.com
• Guided Imagery
• http//www.healthjourneys.com/
• Massage/Reflexology
• www.miami.edu/touch-research/Massage.htm
• http//www.ncbtmb.org/
• http//www.americanmedicalmassage.com/

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Resources

• Meditation
• Center for Mindfulness
• http//www.umassmed.edu/cfm/index.aspx
• University of Toronto, Dept of Psychiatry
• www.mbct.com
• Center for Mindful Eating, Indiana State U
• www.tcme.org
• Music
• Certified Music Practitioners
• Music for Healing Transition
• www.mhtp.org
• Music Therapists
• American Music Therapy Assoc.
• www.musictherapy.org
• National Council Against Health Fraud
• http//www.ncahf.org/

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Resources

• Reflexology
• International Academy of Advanced Reflexology
• http//www.reflexology.net/about_academy.htm
• Association of Reflexologists
• http//www.reflexology.org/index.php
• Reiki
• International Assoc. of Reiki Professionals
• www.iarp.org
• Reiki in Hospitals
• http//www.reikiinhospitals.org/
• International Center for Reiki Training
• www.reiki.org