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The Well Being Way Stress Management Program Summary


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Other possible causes

Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faintness but does not usually result in syncope. In most cases reassurance is all that is necessary rebreathing from cupped hands or a bag may be helpful but calls for careful supervision. Adrenal insufficiency or arrhythmias are other possible causes of syncope, see p. 26 and p. 29.

Future research into pain associated with rheumatoid arthritis

Many patients describe flares of RA, with exacerbation of all symptoms including pain, after stressful events such as bereavement or divorce. The relationship between mood, stress and the immune response is another potential area of research. Early work suggests that abnormalities in the hypotha-lamic-pituitary-adrenal axis may provide a link between psychosocial stress and disease activity in RA.

Psychoneuroendocrinology Introduction

Major depression is considered to be a maladaptive, exaggerated response to stress, and although it is accompanied by abnormalities in multiple endocrine systems, it is the hypothalamic-pituitary-adrenal (HPA) axis that is the main component of the physiological stress response that plays the key role. Stressful life events, particularly those related to loss, have a strong causal relationship with depressive episodes. However, not all people who experience such events develop depression, and an individual's vulnerability to depression depends on the interaction of genetic, developmental, and environmental factors. In addition to the role of the HPA axis in depression, there is growing evidence of HPA axis abnormalities in anxiety disorders and posttraumatic stress disorder (PTSD).

Mindful Cam Therapies

Pain clinics in the United States frequently utilize mindful therapies (MT) for patients with pain because they have been found experientially to be beneficial. Frequently, nurses or psychologists receive training in one or more of these therapies and teach the patients to utilize them on a regular basis, for both prevention of pain and to manage pain flares. These therapies include relaxation breathing, meditation, mindfulness-based stress reduction (MBSR), self-hypnosis, guided imagery, autogenic training, and progressive muscle relaxation (PMR).79

Commonly used interventions currently unproven

Mechanical exercises are often prescribed as it is thought that patients with pain are often reluctant to use the body part that is causing pain. Use of occlu-sal appliances is common as these are easy for dental surgeons to construct and they are more familiar with this method of treatment rather than systemic drugs. Patients with TMD pain can be divided into three treatment groups based on their response to the Graded Chronic Pain Scale minimal contact approach (one or two sessions with or without the help of a psychologist), integrated approach (with appliances, biofeedback and stress management led by hygienist) and a structured behavioral programme (psychologist led for six sessions) 45 .

Sensitization to Stressors

Because this pattern of behavioral sensitization is paralleled by sensitization of neuroendocrine and autonomic stress responses (Antelman, De Giovanni, & Kocan, 1989, Fig IB, 1C), this form of long- lasting stress sensitization may reflect a state of increased stress vulnerability as seen in various psychiatric disorders (Akil & Ines Morano, 1995). In support of this, footshock-induced long-lasting behavioral sensitization was associated with increased anxiety related behavior, and anxiolytics were found to reverse these aberrant responses (Van Dijken, Mos, Van Der Heijden, & Tilders, 1992a Van Dijken, Tilders, Olivier, & Mos, 1992b). Several other stressors including social defeat have been reported to induce alterations in behavioral and metabolic parameters that last for a week or more (Meerlo, Overkamp, & Koolhaas, 1997 Sherman & Petty 1982). Thus, although the effects of most stressors on subsequent responses dissipate within a few days, certain stressful events appear to...

Generic treatment options

Tricyclic and tetracyclic antidepressant drugs may have a role if the clinical presentation suggests pain of neuropathic origin. The best evidence is for amitriptyline. SSRIs and SNRIs may have a role. The best evidence in neuropathic pain is for venlafax-ine (but this has cardiac side effects) and duloxetine (which may also reduce stress incontinence).

Molecular and Cellular Aspects of Oxidative Damage in Alzheimers Disease

Evidence for free radical damage in Alzheimer's disease includes damage to lipids, proteins, and nucleic acids and is likely a consequence of redox-active metal accumulations, mitochondrial damage, and the formation of advanced gly-cation end-products. Furthermore, free radical-mediated events are linked to all of the genetic modulators of the disease since P-protein precursor, amyloid-P, presenilins, and apolipoprotein E are associated with reactive oxygen species production or processes intimately associated with oxidative stress such as apoptosis. An involvement of free radicals accounts for the two most striking features of Alzheimer's disease, namely, the multitude of abnormalities affecting essentially every system and the strict age dependence. Furthermore, in therapeutics, the commonality between a number of efficacious agents appears to be oxi-dative stress reduction. In this chapter, we present evidence that oxidative stress is the element that links the multitude of changes...

Table 81 Evaluation of the headache patient

In a recent study, nefazodone was effective in treating patients with chronic daily headache. However, patients with comorbid depression had better results from nefazodone than did those who were not depressed (Saper et al. 2001). Other researchers have reported that patients with chronic daily headache had reduced symptoms with amitriptyline, nortriptyline, or stress management. No information was provided about which patients with headache were more apt to benefit from these measures (Holroyd et al. 2001). Serotonin-selective antidepressants, mirtazapine, and venlafaxine might also be efficacious in chronic headache (Ansari 2000 Bendtsen and Jensen 2004 Diamond 1995). Effective psychotherapeutic modalities include biofeedback training and relaxation training (see Chapter 6, Psychotherapy, of this book). Stress management therapy and cognitive-behavioral therapy (CBT) may also be helpful in reducing stress levels, but they are probably most effective when combined with relaxation or...

Stress And The Immune System

There is a large and relatively consistent literature on the effects of stressful life events on predisposition to both physical illness and infections. While the correlations between such life events and illness are not large, generally accounting for only about 10 of the variance (Weisse 1992), the effects are consistent across populations and different types of life events.

Are Changes In Immune Function Causally Or Coincidentally Consequences Of Stress Or Depression

It is evident that both stressful and non stressful environmental events can profoundly affect the immune systems. The degree to which stressor can cause suppression of the immune system can be influenced by the perception of the stressful event. Thus there is evidence that the immune system can be classically conditioned (Ader and Cohen, 1991). Animals can learn to immunosuppress, or more dramatically immunoenhance, their T-cell, B-cell, NKC, and most immune cell functions (Dark, Peeke, Ellman, and Salfi, 1987 Solvason, Ghanta, and Hiramoto, 1988). Such factors are frequently ignored in both clinical and experimental studies that seek to explore the relationships between the effects of different types of stress on the immune system.

Antipsychotic Drugs Smoking And Schizophrenia

There are substantial advantages to studying smoking among hospitalized inpa-tients with schizophrenia 1) patients with schizophrenia have high rates of noncom-pliance with clinical or investigational procedures without the close supervision that the inpatient setting can provide 2) the inpatient environment is stable, and patients are largely protected from stressful events or concurrent substance abuse that may alter their response to nicotine and, 3) the protective containment of the inpatient environment permits rapid detection of and attention to any adverse reactions developing in relation to novel interventions under study.

Psychological therapies

Psychological evaluation should be performed early in the evaluation of CPP. Stress reduction, relaxation, and behavioral therapies should also be addressed.143 II Assessment should evaluate the pain complaint, impact on life circumstances, controlling factors, and coping mechanisms. Issues often involve relationship dysfunction requiring family and marital therapy, presence of past or current physical or sexual abuse, and the negative effects on self-esteem and independence. Prolonged psychotherapy for these issues is generally not part of pain management but can be used in conjunction. No RCTs have assessed the effect of psychological approaches on chronic pelvic pain, however, a randomized trial of multidisciplinary management of CPP (which involves a component of psychological assessment and therapy) has demonstrated significant improvement in pain and well-being with the multi-disciplinary approach compared with standard gynecologic treatment. Standardized psychological testing...

Adrenocortical Steroids

PHYSIOLOGICALACTIONS The effects of corticosteroids are numerous and widespread, and include alterations in carbohydrate, protein, and lipid metabolism maintenance of fluid and electrolyte balance and preservation of normal function of the cardiovascular system, the immune system, the kidney, skeletal muscle, the endocrine system, and the nervous system. In addition, corticosteroids endow the organism with the capacity to resist such stressful circumstances as noxious stimuli and environmental changes. In the absence of the adrenal cortex, survival is made possible only by maintaining an optimal environment, including adequate and regular feedings, ingestion of relatively large amounts of sodium chloride, and maintenance of an appropriate environmental temperature stresses such as infection and trauma can be life-threatening when adrenal function is impaired.

Summary And Conclusion

The heart possesses the remarkable ability to adapt itself against any stressful situation by increasing resistance to the adverse consequences. Creating a stress reaction by repeated ischemia and reperfusion or subjecting the hearts to heat or oxidative stress enables the heart to meet the future stress challenge by upregulating its cellular defense through the direct accumulation of intracellular mediators that constitute the material basis of increased adaptation to stress. Thus, the powerful cardioprotective effect of adaptation is likely to originate at cellular and molecular levels (Das, 1996).

Psychological symptoms

FAP has been associated with elevated anxiety and depression 134 IV , 135 IV however, the presence of abdominal pain, regardless of identification of a functional or organic problem, is associated with increased levels of distress. 136 IV Stressful life events and or a lack of coping skills are triggers of symptom flares in both irritable bowel syndrome and inflammatory bowel disease.137 IV

Neuromatrix Theory and the Biopsychosocial Model

The Biomedical Model Structure

Normally, physical and or psychological stress triggers mechanisms to attempt to restore homeostasis. When stress persists (e.g., in the form of ongoing pain, psychological distress, inadequate coping with environmental stressors, and persisting depression), multiple processes are set in motion that exceed the delicately balanced regulatory homeostatic mechanisms initially intended to effectively manage stress, and instead generate destructive processes perpetuating pain. Several lines of research have pointed to plausible mechanisms underlying the reciprocal relationships between pain, affective distress, and stress

Of epidural analgesia and postoperative outcome

As a working hypothesis, the second explanation may be more constructive and is probably correct. Thus, several recent studies have clearly shown that postoperative outcome is determined by multiple factors involved in perioperative care13,18-20 including patient information, stress reduction, pain relief, mobilisation, and early nutrition.21 Several of these factors are positively achieved or supported by a continuous postoperative epidural regimen, but it is noticeable that the hitherto available randomised studies have not included such a revision of the perioperative care programme towards enforced early multimodal rehabilitation.13 Thus, it may be thought-provoking that studies with a revision of the perioperative programme have decreased hospital stay to about three days after elective aortic surgery without using epidural analgesia,22 which is significantly less than the 7-10 days reported in the randomised studies on epidural analgesia.5 These results clearly indicate that...

Hypothalamic Pituitary Adrenal HPA Axis in Depression CRF

Neurotransmitters Concentration

The mechanisms underlying disturbance in the HPA axis include increased secretion of any or all of the hormones in the cascade or decreased sensitivity to negative feedback at any or all levels of the axis (38). CRF antagonists reduce stress-induced increases in plasma catecholamines, tyrosine hydroxylase mRNA in the locus coeruleus (LC), and CRF mRNA and Type 1 CRF receptor mRNA in the paraventricular nucleus (PVN) (39), giving evidence of a tonic regulatory role of CRF in specific brain regions in animal models.

A stepwise treatment approach to FMS

Multidisciplinary pain management, psychopharma-cology, opioids, experimental therapies and combinations is the third-line therapy recommended by the APS in cases of persisting symptoms. In cases lacking adaptation to symptoms or persistent restrictions of daily functioning, the German guideline recommended either no therapy or self-management (aerobic exercise, stress management, pool-based exercise), or booster multi-component therapy, or psychotherapy (hypnotherapy, written emotional disclosure), or pharmacologic therapy (duloxetine or fluoxetine or paroxetin or prega-balin, or tramadol with or without acetaminophen), or complementary alternative therapies (homeopathy, vegetarian diet) as third-line therapy. The choice of treatment options should be based on informed patient consent, the patient's preferences and co-morbidities, and the treatment options locally available 24 .

Premenstrual Dysphoric Disorder

Another period of increased vulnerability to depression in women is the postpartum period. Although it is known that this period is accompanied by a sudden drop in progesterone and estradiol levels, there is limited information available on how this relates to the onset of depression. Postpartum depression is associated with a history of depression (O'Hara 1986 O'Hara et al. 1991), marital disharmony, and a higher number of stressful life events in the previous year (Cox et al. 1982). Gregoire et al. (1996) reported that transdermal estrogen is an effective treatment for depression. However, the group of women studied was small, heterogeneous, and ill-defined, and no information was available on whether these women had a new onset of depression or a prior psychiatric history. Furthermore, some of the patients were being concurrently treated with antidepressants.

Hypothalamicpituitaryadrenal Axis

The HPA axis transforms stressful stimuli into hormonal messages that enable the organism to adapt to environmental change and to maintain the body's homeostasis. Corticotropin-releasing hormone (CRH) is synthesized in the hypothalamus and is stimulated by stressors, which can be either physical (e.g., exercise, starvation) or psychological (e.g., perceived danger, stressful life events). The HPA axis is closely linked to the autonomic nervous system, and brain stem catecholamine systems can also activate CRH release (Herman et al. 1990 Plotsky 1987 Plotsky et al. 1989). CRH stimulates secretion of pituitary adrenocorticotropic hormone (ACTH), resulting in the secretion of glucocorticoids by the adrenal cortex in a feedforward cascade. Cortisol is the main glucocorticoid, and its secretion is tightly controlled by negative feedback effects of glucocorticoids at both pituitary and brain sites. These comprise very rapid real-time inhibition of the stress response that prevents...

Occupational therapy incorporates a variety of pain management strategies to promote participation and quality of life

The answer is B. Stress management, relaxation training, and cognitive-behavioral approaches have all been demonstrated to promote positive psychological coping strategies for acute or chronic pain management. Thus, home safety modification, although helpful for environmental contextual intervention, will be less likely to have an impact on a client's immediate need for positive coping strategies to address managing or lessening the impact of pain on their daily living.

Key Learning Points

Mindful CAM therapies include relaxation breathing, meditation, mindfulness-based stress reduction, self-hypnosis, guided imagery, autogenic training, and progressive muscle relaxation. Therapeutic touch, healing touch, Reiki, Qi Gong, and shamanic healing are all examples of energy healing therapies. These therapies are based on the construct that energy flow can be manipulated by practitioners and brought into balance to induce healing and pain relief.

The Developmental Deregulation Model

Family Ecomap Examples

This time course suggests a disorder in which a neuronal deficit progresses during childhood development. The florid episodes in young adulthood, which are often precipitated by stressful events or by stimulant drug abuse, suggest that the putative developmental deficit has weakened the regulation of the modulatory monoamine neurotransmitters, especially dopamine. Dopamine modulates the function of the various cortical and subcortical areas implicated in the expression of the three syndromes.60 Consequently, poorly regulated changes in the levels of modulatory neurotransmitters in response to stresses of various kinds might be expected to exacerbate any preexisting impairment of coordination between these cerebral sites. This would increase the likelihood of overt symptoms in previously asymptomatic cases or exacerbate symptoms in those with preexisting symptoms. In later adult life, age-related diminution in activity of the modulatory neurotransmitters would result in a tendency...

Serotonergic Regulation of Adult Neurogenesis

Among monoamines, the 5-HT control of adult neurogenesis has been the most largely investigated, notably when studying the consequences of serotonergic antidepressants. Indeed, chronic increases in extracellular level of 5-HT by selective serotonin reuptake inhibitors (SSRIs) fluoxetine, citalopram, or paroxetine have repeatedly been shown to increase hippocampal neurogenesis in basal conditions and reverse the suppressive effects of stress or treatments associated with stressful events (Malberg et al. 2000 Lee et al. 2001 Malberg and Duman 2003 Encinas et al. 2006 Chen et al. 2006 Jayatissa et al. 2006 Qiu et al. 2007 Marcussen et al. 2008 Wang et al. 2008). Recent studies also indicated that fluoxetine-induced increases in neurogenesis can depend on age (Cowen et al. 2008 Couillard-Despres et al. 2009), on genetic background (Miller et al. 2008), and on interactions with the hypothalamic-pituitary-adrenal axis activity (Huang and Herbert 2006). Both hippocampal neurogenesis and...

Treatment Of Alcoholdependence

An alternative mechanism could implicate the modification of stress coping capacity, as some alcohol-dependent patients sustain a relative deficiency in endogenous opioids after experiencing a stressful life event (Volpicelli, 1987 Volpicelli et al., 1990 Kreek, 1996). Fuerthermore, cortisol stimulation in early abstinent alcoholics showed a blunted response after psychosocial stress (Lovallo et al., 2000). A successful response to stress plays an important role in maintaining health and well-being. In recently detoxified alcoholics, the HPA system is indeed dysregulated with non-suppression of cortisol after dexamethasone administration. Corticotropin releasing factor (CRF) neurons, within the paraventricular nucleus of the hypothalamus, initiate activation of the hypothalamic-pituitary-adrenal (HPA) axis (Bell et al., 1998) and express mu-opioid receptors. CRF neurons are thus modulated by inhibitory tone imposed by P-endorphin neurons originating in the arcuate nucleus (Wand et...

Neurochemical Consequences of Cytokines Stressorlike Effects

Stressors, like antigenic challenge, increase IL-ip mRNA expression, as well as that of IL-IRa (Suzuki, Shintani, Kanba, Asai, & Nakaki, 1997). Interestingly, in the absence of the inhibitory effects of glucocorticoids (i.e., in adrenalectomized animals), stressor exposure markedly increased IL-ip protein in hypothalamus, hippocampus, cerebellum, and nucleus tractis solitaris (Nguyen, Deak, Owens Kohn, Fleshner, Watkins, & Maier, 1998). Inasmuch as IL-ip strongly influences CRH release from the PVN, thus provoking HPA activity (Ericsson, Arias, & Sawchenko, 1997 Ericsson, Ek, Wahlstrom, Kovacs, Liu, Hart, & Sawchenko, 1996 Rivest, 1995 Rivest & Rivier, 1994), the possibility has been explored that this cytokine may play a pivotal role in the HPA activation associated with stressful events. Indeed, it was demonstrated (Shintani et al., 1993 Shintani, Nakaki, Kanba, Sato, Kato, & Asai, 1995 Shintani, Nakaki, Kanba, Sato, Yagi, Shiozawa, Aiso, Kato, & Asai, 1995) that the increased...


Many commonly used first-line strategies such as analgesic, anti-inflammatory agents, tricyclic antide-pressants, reduction in the number of pillows, stress management, and postural advice have not been studied but remain mainstays of treatment. Other modalities such as acupuncture, traction, electrotherapy, and psychotherapy are of uncertain value and also need further study 2 . tested. While exercise, mobilization, and manipulation are mainstays of therapy, any regime must address postural factors identified in individual patients. Reduction in the number of pillows at night is often important, but there is no evidence to suggest that special pillows justify the additional cost. Stress management, yoga, Pilates and the Alexander Technique all improve neck posture and are useful, but require further study.


Environmental triggers for RA have not been clarified, despite extensive searches for infectious organisms. Many patients blame their RA on a stressful event though this is unlikely to be causal, there is increasing evidence that stress may modify the immune system and be associated with exacerbations of RA. Hormones clearly play a role in RA. Before the menopause, there is an excess of females affected but this gender difference disappears after the menopause. Pregnancy usually results in amelioration of symptoms though a postpartum flare is often seen. Finally, the contraceptive pill may be weakly protective against RA.


We should now discuss the issue of altered movement patterns in pain patients. If a patient has pain, he she will try to compensate by using other muscles and modifying movement patterns. Often these compensations lead to the development of myofascial pain (Table 14.3) on top of the original pain source and may even cause injury to other body segments or systems. If the patient is unable to compensate (or as pain of compensation increases), his her function will decline. As function decreases, the muscles become weaker, joints become stiffer, motor control decreases, and cardiovascular performance suffers. In fact, over time, the patient does less and less. This decline in function might result in emotional distress which could present itself as anxiety, decreased self-esteem, loss of stress management strategies, decreased social interaction, isolation, inactivity, and depression. The dysfunction also causes strain on relationships due to increased workload on the partner and family...


Currently, FMS cannot be cured by any therapy and overall treatment effects are modest at best. According to expert opinion, the aims of therapy are the preservation or improvement of daily functioning and coping with symptoms and disabilities. Coping with symptoms includes both the acceptance of symptoms and of some limitations (e.g. hard physical work) as well as continous self-management (physical activity, stress management) to reduce the impact of the symptoms. Therefore the patient has the major task in FMS therapy 1, 24 .

Stress disorders

Adjustment disorders consist of states of emotional distress that arise following a major life change or stressful life event. The symptoms accompanying this disorder include excessive worrying, mild depressed mood, poor sleep, inability to cope, and some difficulties in carrying out daily routines. However, the symptoms are not usually persistent and do not reach the threshold to enable an alternative psychiatric illness to be diagnosed. These disorders are considered to develop in response to a variety of stressful events, the symptoms representing an adaptation to these stressors or to their continuing effects. The difficulty is in deciding what is abnormal or delayed adaptation. By definition, these disorders would not have developed but for the stressful event. Symptoms last for less than six months, except in the case of prolonged depressive reaction, otherwise an alternative diagnosis should be sought. In an early study of patients with chronic pain, male patients had...

Management of Ulcers

Aphthous ulcers can be treated with triamcinolone acetonide in an 0.1 orabase-topical application. Alternative stress reduction strategies such as meditation and yoga can be employed. Vitamin B complex is often prescribed to forestall micronutrient deficiencies. Bruxism can be managed with night bite guards and dental crowns.

Open Field Test

Round Rat Open Field Test Analysis

In this free confrontation situation, rodents will generally show avoidance for the brightly lit environment before entering the arena, the animal will show risk assessment postures directed toward the open field. This is a first argument indicating that the open field may be a stressful situation. In case of forced confrontation, the animal is placed in the apparatus and the following behavioral items are recorded, usually during five min locomotion, frequency of rearing or leaning (sometimes termed vertical activity), and grooming. Increase of time spent in the central part, higher ratio of central total locomotion, or decrease of the latency to enter the central part are indications of reduced anxiety-like behavior. Therefore, experimenters are not measuring the effects of the factors they are interested in on exploration, as is sometimes claimed, but the effects on the reaction of the subjects to a stressful event. Additionally, other parameters may be measured, including...

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