I’ve been making a sincere effort to reduce referring to “stress” when talking with patients.
Why?
You might think it’s obvious two minutes into a new doom scrolling session on Twitter, but as soon I enter into the discussion with patients, I’ve just started to feel as if it’s a moot point. Here’s often how the conversation goes.
“So, talk to me about your stress levels?”
“Well, I’ve been homeschooling my children for what seems like an eternity; I’m unsure as to whether I’m going to pick up a life-changing viral infection just by doing the shopping, and the news is telling me that no one knows when it’s going to end.”
The crazy thing about the reply above is that it was pretty close to an answer I received not long ago in the clinic.
Certainly puts the title into context, doesn’t it?
Being told to stress less seems like the most impractical advice we could all receive at the beginning of 2022. Especially if you are living in Hong Kong. Sure we can all experience stress from circumstances beyond our control. However, over the last few years, what’s happened now places us in a unique situation.
During the COVID outbreak in Hong Kong, even without lockdowns, stress levels in 1500 respondents randomly interviewed increased by almost thirty per cent compared to 2016/17 levels. Prevalence of anxiety increased by over forty per cent, depression and unhappiness symptoms compared to the same parameters.[1]
It’s not just Hong Kong.
Globally, small scale studies are slowly coming out to give us more insight into increases in loneliness scores and depressive symptoms worldwide, especially in young people and students.[2] [3]
The needed healing from a global pandemic aside, how can we better understand stress management?
In this article, I will deconstruct stress, offer new ways to build awareness of how it affects you, and what the science says about articulating your stress differently and why that can be beneficial.
Some of your stress may help you, such as improving your immune system, for example.[4]
To begin simply, stress, by definition, occurs when the balance or stasis of the body is affected by something internal or external.
The more comprehensive definition is that stress constitutes a state of threatened homeostasis or disharmony, triggered by intrinsic or extrinsic adverse forces (stressors) and is counteracted by an intricate variety of physical and behavioural responses to reestablish the optimal balance referred to as eustasis.[5]
An important point you can draw immediately from the basic definitions of stress is that the complete absence of stress, in general, is not suitable for you; it’s all about harmony.
Your body systems are programmed over the course of evolution to maintain a very particular state. This state puts your body into the optimal conditions for life and a sense of well-being.[6]
When you encounter a stressor that challenges this homeostasis or optimised state, multiple body systems react and respond to the stressor to adapt to the threat and regain harmony.
This adaption occurs in multiple ways you might be able to feel as they happen. The behavioural portions include enhanced arousal, alertness, vigilance, cognition, focused attention, and tolerance to pain.[7]
It partly sounds like anxiety, doesn’t it?
But I digress. The more physical adaptions to the stressor are best described as a redirection of energy and body resources.
Increases in cardiovascular and respiratory activity, think breathing and your heart pumping blood faster around the body are paid for by increasing metabolic processes that release fat and sugar into the bloodstream to be utilised where needed. This redirection also occurs with nutrients, such as vitamins and minerals and all-important oxygen mainly being sent to the central nervous system.
Further to these metabolic changes, the body also moves to suppress any energy-sapping processes that draw energy into places that aren’t needed to maintain the adaptive response acutely. These functions include digestion, immunity, reproduction and growth.[8]
Let me say that again. The body suppresses functions including digestion, immunity, reproduction, and growth when under stress as they are considered energy-intensive.
Wonder how much of a chance the sandwich you’re eating during that meeting has of being digested effectively?
You can imagine that this adaptive response should be temporary and may cause problems if maintained for too long.
And as per usual, we’ll be exploring the more profound physical, hormonal and mental changes with stress in more detail in other articles.
I wanted to introduce some of the physical and behavioural changes to build into one of the first questions I ask my patients around stress.
How do you feel stress in your body?
This question is easy to ask if you are one of those people I’m referring to in the title of this article.
I’ve often commented that people living in fast-moving cities such as Hong Kong, London or New York have a peculiar talent at disassociating physically from constant chronic stress.
I suppose it can be better defined as a tolerance. As that tolerance becomes stronger and stronger, when the time comes to reconnect with the body post what is often a temporary cessation of the stress, it can be hard to know how not being stressed actually feels.
Connecting with your body is the first step in understanding how stress is affecting you in the first place, helping you build from a more solid baseline.
Let’s revisit some of the features of the body’s reaction to stress listed above.
Increased vigilance, cognition, focused attention and alertness along with the physical adaptations, high respiratory and heart rates, sugar cravings, digestive and immune suppression.
Some of these things may not necessarily appear obvious until you can’t seem to shake an infection or food starts to have an unexpected effect on your digestion. In fact, if these adaptations continue for too long, your blood pressure can increase and affect the structural integrity of your heart.[9]
Now that you know that, do you perhaps feel stress in your body via headaches, dizziness, hot flushes, irritability, chest tightness, blurred vision, palpitations and an aching back?
Then these symptoms, whilst seemingly unrelated, are all commonly reported symptoms associated with hypertension or high blood pressure.[10]
Sometimes the way stress presents in the body might not be as obvious.
An example of this is “Leisure illness.” This condition is strange to some, but I have encountered it and treated it so often.
Leisure illness refers to symptoms that develop when going from work to nonwork. This development usually happens when taking a holiday or at the end of a big project.
Symptoms are often very similar to viral infections like colds and flu, including headaches/migraines, fatigue, muscle pain and nausea.[11]
It seemed out of the cases studied that most had been experiencing this kind of condition for almost ten years. A Dutch pilot study found this to be especially common. However, the personality traits they found connected with leisure illness made this study most interesting.
Risk factors for leisure illness connected the inability to adapt to nonworking situations, a high need for achievement and a heightened sense of responsibility when working.[12]
The good news is that I’ve treated leisure illness successfully with herbal medicine leading up to the trip and during the journey. Just ask one of my longest-standing patients referred to me ten years ago because her husband couldn’t work out why she would get sick every time they went on vacation!
This insight into how our personality can affect things perfectly leads to one of the following questions when looking at how to act on the “stress management” side of things.
Are there characteristics of your personality that make you more prone to experiencing stress?
This question in the clinic can be a little broad. It is better to have a conversation with a qualified psychotherapist or counsellor. If it’s a bit early for that, let’s explore the connection between your personality and how you experience stress.
Circumstantial events such as loss, humiliation, entrapment, and danger are significant sources of stress and predispose you to develop mental health issues.[13]
For the sake of this article, it’s less about what’s happened to you and more about how certain personality traits.
For example, higher levels of neuroticism (a disposition towards feeling adverse effects),[14] emotionality and reactivity correlate with poor interpersonal relationships[15] and “event proneness.”
Remember that correlation doesn’t equal causation, but this may make interactions with those around you a little more stressful. The good news is that a qualified mental health practitioner can deconstruct these personality traits over time.
Sometimes, it just requires a little courage to give it a try.
Building on this further, studies have shown specific personality characteristics to protect us from stress!
The characteristics include, amongst others, self-esteem, optimism and an ability to find meaning.[16] You may often hear of a famous book called “Man’s search for meaning”, which very much personifies this, but another study also shows how protective meaning can be to the long-term effects of stress.
In the case of this study, it was where horrific torture had occurred and the development of PTSD. The 1994 study found that left-wing activists tortured by Turkey’s military regime had lower rates of PTSD than nonactivists who were detained and tortured by police.[17]
Ok, so that’s an extreme example, and if you’ve experienced this type of traumatic experience at all, I hope you have the measures and resources at hand to heal if necessary.
I think though I’ve illustrated my point.
There are broader ways to manage stress than signing up for your local meditation class. Sometimes the understanding that encountering elements of your personality with a sense of curiosity, often for the first time, is what “managing stress” is for you.
It may not be that deep. Maybe you just notice that your digestion gets a little vulnerable, or you find it hard to focus for a long time.
Once you can accurately identify how stress affects your body, you can then measure whether or not any of the things you are trying are working or not.
As always, this is just the beginning. There are many ways we can enlist our sovereignty to control our reactions and responses to our day and manage what, for some, is just a high level of engagement in a favourable situation.
Hope this has helped start the process.
References
[1] Zhao SZ, Wong JYH, Luk TT, Wai AKC, Lam TH, Wang MP. Mental health crisis under COVID-19 pandemic in Hong Kong, China. Int J Infect Dis. 2020;100:431-433. doi:10.1016/j.ijid.2020.09.030
[2] Werner AM, Tibubos AN, Mülder LM, et al. The impact of lockdown stress and loneliness during the COVID-19 pandemic on mental health among university students in Germany. Sci Rep. 2021;11(1):22637. Published 2021 Nov 22. doi:10.1038/s41598-021-02024-5
[3] Rehman, U., Shahnawaz, M.G., Khan, N.H. et al. Depression, Anxiety and Stress Among Indians in Times of Covid-19 Lockdown. Community Ment Health J 57, 42–48 (2021). https://doi.org/10.1007/s10597-020-00664-x
[4] Dhabhar FS. Effects of stress on immune function: the good, the bad, and the beautiful. Immunol Res. 2014;58(2-3):193-210. doi:10.1007/s12026-014-8517-0
[5] Tsigos C, Kyrou I, Kassi E, et al. Stress: Endocrine Physiology and Pathophysiology. [Updated 2020 Oct 17]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278995/
[6] Kyrou I, Chrousos GP, Tsigos C. Stress, visceral obesity, and metabolic complications. Ann N Y Acad Sci. 2006;1083:77-110. doi:10.1196/annals.1367.008
[7] Tsigos C, Kyrou I, Kassi E, et al. Stress: Endocrine Physiology and Pathophysiology. [Updated 2020 Oct 17]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278995/
[8] Tsigos C, Kyrou I, Kassi E, et al. Stress: Endocrine Physiology and Pathophysiology. [Updated 2020 Oct 17]. In: Feingold KR, Anawalt B, Boyce A, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK278995/
[9] Brownley, K. A., Hurwitz, B. E., & Schneiderman, N. (2000). Cardiovascular psychophysiology In: Cacioppo JT, Tassinary LG, Berntson GG, editors. Handbook of psychophysiology.
[10] Goodhart AK. Hypertension from the patient’s perspective. Br J Gen Pract. 2016;66(652):570. doi:10.3399/bjgp16X687757
[11] Vingerhoets AJ, Van Huijgevoort M, Van Heck GL. Leisure sickness: a pilot study on its prevalence, phenomenology, and background. Psychother Psychosom. 2002;71(6):311-317. doi:10.1159/000065992
[12] Vingerhoets AJ, Van Huijgevoort M, Van Heck GL. Leisure sickness: a pilot study on its prevalence, phenomenology, and background. Psychother Psychosom. 2002;71(6):311-317. doi:10.1159/000065992
[13] Kendler KS, Hettema JM, Butera F, Gardner CO, Prescott CA. Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of onsets of major depression and generalized anxiety. Arch Gen Psychiatry. 2003;60(8):789-796. doi:10.1001/archpsyc.60.8.789
[14] Widiger TA, Oltmanns JR. Neuroticism is a fundamental domain of personality with enormous public health implications. World Psychiatry. 2017;16(2):144-145. doi:10.1002/wps.20411
[15] Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and biological determinants. Annu Rev Clin Psychol. 2005;1:607-628. doi:10.1146/annurev.clinpsy.1.102803.144141
[16] Schneiderman N, Ironson G, Siegel SD. Stress and health: psychological, behavioral, and biological determinants. Annu Rev Clin Psychol. 2005;1:607-628. doi:10.1146/annurev.clinpsy.1.102803.144141
[17] Başoğlu M, Paker M, Paker O, et al. Psychological effects of torture: a comparison of tortured with nontortured political activists in Turkey. Am J Psychiatry. 1994;151(1):76-81. doi:10.1176/ajp.151.1.76
