Wakana Saeki, M.D.

Introduction

Many physicians believe that stress is universal in patients' lives.¹ However, levels of stress that greatly exceeds one's ability to cope may result in somatic symptoms that lead patients to seek medical care.^{2, 3} These patients are truthfully reporting their physical sensations. Because the symptoms are primarily of psychosocial origins, interventions that address these psychosocial issues must be included, or the patients may not get adequate relief.

Many physicians agree that eliminating undue stress is an important factor in our patients' overall health.^{4, 5} However, some physicians do not feel comfortable performing stress counseling, fearing that such counseling would take up more time than they can afford. This paper will discuss various types of stress our patients encounter, and useful stress reduction techniques that can be shared during primary care office visits.

Defining Stress

Stress can be defined as "a demand for adaptation and coping, usually in response to life changes." Stress can cause mental or physical tension, and when the demand for change surpasses one's capacities and resources to cope, somatic symptoms or physical illnesses may surface.

Different kinds of stress exist in our everyday lives. One of the most common stresses results from financial difficulty. Many people are concerned about not having enough income or savings, or having too much debt. In today's society, inflation, educational costs, and living costs have steadily increased, making budgeting a continual challenge.

Another common form of stress is centered around performance. People often experience overwhelming workloads and expectations at work, especially if they work under tight deadlines. There may be competition among coworkers to get promoted, or just to survive. Women may feel pressured to work extra hard just to prove that they can balance the demands of career and family life. Acute emotional stress can occur suddenly or unexpectedly, resulting from accidents, deaths, or tragedy among friends or family. Illnesses or accidents may also cause physical or medical stresses.

Even environment can cause stress. Noise, pollution, and environmental allergens can contribute to physical and emotional stresses. Relocating or changing jobs can be difficult, and can manifest as an adjustment disorder. Natural disasters such as earthquake, flood, and fire often have devastating emotional impact.

Relationship problems, whether with the significant other, family member, or friend, are common sources of stress. Relationship conflicts can result in various emotional states including anger, depression, and loneliness. Divorce and custody fights can create extreme stress levels. Therefore, relationship issues are frequently sources of social stress factors.

Emotional or mental stress can be both chronic and acute. People experiencing high levels of stress may also have underlying chronic depression or anxiety. Some people may acknowledge their mood instabilities or disorders, but many people do not acknowledge that their lives are disturbed by such conditions. Even those who are aware that they have depression or anxiety may not seek help due to embarrassment or social stigma.

The impact of stress may be manifested on the body in many ways. These may include pain from trauma, fever and fatigue from infections, or weakness or dizziness from neurological problems. Once patients develop physical symptoms of stress, the impact may be compounded, since physical illness increases stress from other sources when patients lose work time or become distressed about their condition.

When all these stresses become overwhelming, the body can manifest them physically, as psychosomatic symptoms. The symptoms may be single or multiple, and may be conscious or subconscious. Table 1 shows some of the psychosomatic symptoms or exacerbation of underlying diseases that are commonly seen as the result of stress.⁶

Solutions: Stress Management Techniques

Once the patient acknowledges that they are under stress, and that their physical symptoms may be manifestations of it, a primary care physician can help them cope with their situation. There are several approaches, and each individual can choose the approach that best fits their need. Physicians should review the following techniques with the patient, and then tailor the counseling to each individual.

Psychosomatic symptoms do not disappear overnight, and thus it is important to understand that patients need to return frequently for follow-up counseling sessions. At each session, different techniques can be discussed, in addition to reviewing progress

Table 1: Psychological and physiological manifestations of stress

with previous stress coping strategies. Emotionally distressed patients may require additional time initially, but once an overall counseling plan has been set and discussed, follow-up sessions can be managed during a regular office visit schedule.

Exercise Exercise can include anything from brisk walking, going to a gym, cycling, aerobics, and competitive individual or team sports. A regular exercise program relaxes muscles, lowers resting pulse, lowers the risk of high blood pressure, and decreases stress hormones.⁷ Exercise can reduce fatigue, insomnia, and irregular bowel movements. It will release brain chemicals to fight depression, pain, and anxiety. Best of all, it can make a person feel better about themselves.

Most people are aware that exercise is good for them, but many manufacture various reasons not to commit to an exercise regimen. It is important for physicians to help each individual overcome his or her obstacles. For example, for a person with pain in the lower extremities, a physician can encourage upper body exercises coupled with a non-jarring walking program. And for those who experience pain with weight bearing, swimming can provide aerobic exercise with low impact. Although many people say they are too tired or busy to exercise, they can often be encouraged to wake up one hour earlier three times a week in order to exercise before work.

Since it is so easy for any of us to say to ourselves "I think I'll skip today. I just don't feel like it," it is very important to teach each individual to commit to a regular exercising schedule. Physicians should suggest that the patient write down their exercise schedule in their calendar. They should be encouraged to follow the plan without allowing for any excuses.

Diet, Good Nutrition A balanced diet is important in staying healthy and fighting illness during stressful times. Vitamin B complex may help increase the threshold level for tolerating stress. Vitamin C is believed to improve the body's immune system and help fight infections. Because stress can cause bowel irregularities such as diarrhea and constipation in irritable bowel syndrome, consuming plenty of fiber and fluid daily is also an important part of a healthy diet.

High levels of caffeine are thought to exacerbate stress in the body. Therefore, it is important to cut out or limit caffeine, including coffee, tea, and chocolate, in the diet.

Relaxation Techniques There are various relaxation techniques which include, but are not limited to, deep breathing, listening to soothing music, pleasant smells, visualization, yoga, meditation, self-hypnosis, and biofeedback.⁸ These relaxation techniques can help the body recover from mental and physical stress by bringing relief from excess muscle tension, anxiety, and fatigue. Repeated practice can improve these relaxation skills, and they can be performed as often as needed.

The most common relaxation technique is deep breathing or abdominal breathing. The physician can create a simple breathing exercise tape using the phrases in handout 1. The tape should be about five to ten minutes long, and can be used during a 15minute office visit. The physician should teach the correct breathing technique explained in handout 2, and practice a few breaths together with the patient before he or she starts the tape. Relaxation can be performed sitting on a comfortable chair or lying down on an examination bed or on a soft floor. If there is a larger conference or patient education room, small group relaxation sessions can be taught.

Patients can create their own relaxation tapes, individualizing the content, length and the background music to their liking. They may combine the breathing techniques with other relaxation techniques such as visualization, aroma therapy, or yoga. Emphasize to patients that it is not hard to find ten minutes per day in their busy schedule to reward themselves with the rest that their body and mind truly deserve.

Massage, Hot Bath Massage therapy can relieve muscle tension and spasms caused by stress.⁹ Friends and family can learn to massage each other, or a simple mechanical massager can be used. A long hot bath, or even a long hot shower, can help relax overworked muscles.

Financial Planning Money problems are frequently one of the biggest sources of stress in people's lives. If the stress stems from lack of money to cover personal or family expenses, the underlying financial problems need to be solved. Two main principles of financial planning are increasing the income, and learning to budget.

One can plan to increase income by completing education, obtaining specialized job training, and seeking a higher-paying job. Talking with a career guidance counselor at a local college or career counseling center may be helpful. If a new job skill is required, vocational rehabilitation and specialized vocational schools are available.

Decreasing everyday expenses is also an important part of financial management. Keeping track of monthly expenses and itemizing bills can help identify ways to cut costs. Unnecessary or luxury spending can be eliminated or postponed until the financial status is improved. It is also essential to have some savings put aside for emergencies. Having three months worth of current salary in an emergency savings account can provide support in case of unforeseen unemployment or illness. Such a financial cushion can also improve the patient's sense of control, and their security.

Cognitive Skills Cognitive stress management techniques involve improving problem solving and time management skills. The following are some examples: z Anticipate and plan ahead. Always prepare a back-up plan in case the original plan or schedule does not work. z If there are too many tasks to do, make a list and prioritize.¹⁰ The most important task should be handled first. Less important tasks can be done at a later time, or can be delegated. z Sticking to a routine can promote a feeling of control and security. z Think positive. Focus on solutions rather than dwelling on problems. z Look at the big picture, and adopt the "don't sweat the small stuff" attitude. z Set realistic goals and deadlines. z Keeping an hour-to-hour activity record can help identify how time is being wasted. Productivity can increase once this wasted time is regained.

Support Group It is difficult to get through stressful times without support. People with inadequate social support manifest psychosomatic symptoms more frequently, and for a longer duration. People with ample support systems exhibit higher levels of well-being through more adaptive coping strategies. Physicians can help identify and encourage patients' development of support systems such as spouses, friends, and family. It is important to understand, though, that spouses and partners may also need support.

Controlling Emotion Because irritability and anger can bring out physical, verbal, or emotional aggression, learning to control anger is vital. Some simple methods of controlling emotion include: breathing deeply in and out, counting to 20 before speaking, retreating to another room, calling a friend, reading a magazine, or taking a hot bath. Emotional catharsis has shown significant benefits throughout history, and stress can be released through activities such as crying, laughing, writing, and exercising. Muscular tension can be reduced by hitting, kicking, or squeezing a inanimate object, such as a pillow or a squeeze toy. Remind patients to take control of themselves before trying to take control of the situation.

Finding a Hobby Sometimes, stressed people forget about hobbies that they used to enjoy. Finding a new hobby or rediscovering an old one can give people pleasure, and take their mind off their worries. Special hobby time could be set aside and incorporated into a schedule. Everyone deserves a break!

Conclusion

Stress is a universal problem in our patients' lives, and has a considerable impact on primary health care. When the stress level exceeds a patients' ability to cope, they may present to a primary care office with emotional instability or somatic symptoms. It is important for primary care physicians to recognize significant psychosocial issues, and provide appropriate help for our patients. Physicians who strongly believe that stress has an adverse impact on health are more likely to explore patients' psychosocial issues and provide counseling.¹¹

Many stress management techniques can be taught in the primary care office. Relaxation techniques, such as deep breathing exercises, are especially helpful, and can be taught in detail. Physicians should individualize stress management counseling, and set long term plans and goals with each patient. In order to be an effective counselor and work productively with a patient, a physician should express empathy, unconditional positive regard, and genuineness, and engage in active listening. A physician can also ask open-ended, exploratory questions to allow the patients to gain more objective perspective on his or her problems. A patient is more likely to make cognitive and behavioral changes when this guided discovery method is used in place of simple advice and reassurance. Studies have shown that when physicians develop their problem-defining and emotion-control skills, they are more likely to undertake management of patients' psychosocial problems, without increasing the length of the visit. They are also able to reduce patients' emotional distress more quickly.¹²

Sometimes counseling by primary care physician is not enough, and treatment may require medications such as antidepressants, analgesics, and hypnotics.¹ It is also important for both physicians and patients to recognize and accept the fact that when stress symptoms appear disproportionately severe or prolonged, more intensive therapies by professional counselors, psychiatrists, or psychologists may be indicated. Stress management counseling in a primary care office can help reduce stress levels quickly in many patients before problems lead to more serious psychiatric illnesses.

REFERENCES

1. Greene JW, Walker LS. Psychosomatic problems and stress in adolescence. Pediatr Clin North Am 1997 Dec; 44(6):1557-72.

2. Turner J, Raphael B. MJA practice essentials. 6. Stress management and counseling in primary care. Med J Aust 1997 Nov 17; 167(10):547-51.

3. Klerman GL, Budman S, Berwick D, Weissman MM, Damico-White J, Demby A, et al. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care 1987 Nov; 25(11):1078-88.

4. Sobal J, Valente CM, Muncie HL Jr, Levine DM, Deforge BR. Physicians' beliefs about the importance of 25 health promoting behaviors. Am J Public Health 1985 Dec; 75(12):1427-8.

5. Liese BS, Larson MW. Practical office-based counseling skills for the primary care physician. Kans Med 1993 Sep; 94(9):241-5.

6. Psychological factors affecting medical condition (psychosomatic disorders). In: Kaplan HI, Sadock BJ, Grebb JA, editors. Kaplan and Sadock's synopsis of psychiatry : behavorial sciences, clinical psychiatry. 7th ed. Baltimore (MD): Williams & Wilkins; 1994. P. 752-8.

7. Knox S, Theorell T, Malmberg BG, Lindqvist R. Stress management in the treatment of essential hypertension in primary health care. Scand J Prim Health Care 1986 Sep; 4(3):175-81.

8. Lippin RA. Stress release: emerging tool in total stress management program. Occup Health Saf 1985 Jun; 54(6):80-2.

9. Nuta VR. Stress and the single parent. Chicago (IL): National Committee to Prevent Child Abuse. 1987.

10. Matheson KH. Stress and stress counselling. Postgrad Med J 1990 Sep; 66(779):738-42.

11. Gottlieb NH, Mullen PD. Stress management in primary care: physicians' beliefs and patterns of practice. Am J Prev Med 1987 Sep-Oct; 3(5):267-70.

12. Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians' interviewing skills and reducing patients' emotional distress. A randomized clinical trial. Arch Intern Med 1995 Sep 25; 155(17):1877-84.

APPENDIX 1

Patient Education Handouts

The following two handouts can be photocopied for use in a clinical setting when counseling patients on stress management.

Handout 1 Sample Content of a Relaxation Tape

Repeat each line 3 times in the following ways:
I relax my legs and feet.
I relax my legs and feet.
My legs and feet are completely relaxed.

1. I relax my legs and feet.

2. I relax my buttocks, pelvis, and abdomen.

3. I relax my lower, middle, and upper spine.

4. I relax my chest and shoulders.

5. I relax my arms, wrists, and fingers.

6. I relax my throat, neck, and scalp.

7. I relax my forehead, eyes, and jaw

8. I relax my inner organs.

9. I am relaxed.
   I am relaxed.
   I am completely relaxed.

When you have completed phrases 1 to 9, return to breath focus for the remainder of your session.

Helpful tips: