Evidence-Based Procedures That Reduce Stress and Promote Health

HEALTH SCIENCE JOURNAL ® VOLUME 5, ISSUE 2 (2011)

Stress Management Techniques: evidence-based procedures that reduce stress and promote health

Liza Varvogli1, Christina Darviri1

1. Postgraduate Program of Stress management and Health Promotion, Athens Medical School, University of Athens.

Abstract

Purpose: According to the World Health Organization, stress is a significant problem of our times and affects both physical as well as the mental health of people. Stress is defined as a situation where the organism‘s homeostasis is threatened or the organism perceives a situation as threatening. Stress coping methods are the cognitive, behavioral and psychological efforts to deal with stress. Method: After a thorough literature review in major databases (MEDLINE, Scopus, Science Direct) the following techniques were identified and are presented and briefly discussed here: progressive muscle relaxation, autogenic training, relaxation response, biofeedback, emotional freedom technique, guided imagery, diaphragmatic breathing, transcendental meditation, cognitive behavioral therapy, mindfulness-based stress reduction and emotional freedom technique. Conclusion: These are all evidence-based techniques, easy to learn and practice, with good results in individuals with good health or with a disease.

Key words: stress, stress management techniques, evidence based techniques

Corresponding author:

Varvogli Liza, Postgraduate Program of Stress management and Health Promotion, Athens Medical School, Agamemnonos 4, Chalandri 152 31 Athens, Greece Tel: 6937392530 Email: [email protected]

Introduction

ife exists through the maintenance of a perceived by the individual as threatened complex dynamic equilibrium, termed homeostasis and it is re-established by a L homeostasis, that is constantly complex repertoire of behavioural and physiologic adaptive responses of the challenged by internal or external adverse 1 forces, termed stressors, which can be organism . Neuroendocrinic hormones have emotional or physical in nature. Thus, stress a crucial role in coordinating basic as well as is defined as a state of threatened or threatened homeostasis; also, they intervene

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in pathogenesis of dyshomeostatic or one of the main approaches to health cacostatic situations of disease1. enhancement, can serve this multiple role by The Stress System located both in the designing and applying interventions to central and peripheral nervous system, reduce or prevent distress and adequately generically activated whenever a threshold contribute to future health and wellness. of any stressor is exceeded, plays a major coordinator role in the re-establishment of Evidence-based stress management homeostasis by eliciting a complex techniques behavioral and physical adaptive response. This response is defined as the stress Progressive Muscle Relaxation (PMR) syndrome and represents the unfolding of a relatively stereotypic, innate program of the Origins: Progressive muscle relaxation (PMR) organism that has evolved to coordinate is a technique for reducing stress and anxiety homeostasis and protect the individual by alternately tensing and relaxing the during stress1. muscles12. It was developed by American physician Edmund Jacobson in the early Stress, health and illness 1920s. Jacobson argued that since muscle tension accompanies anxiety, one can reduce According to the World Health anxiety by learning how to relax the Organization 2 stress, especially that relating muscular tension. PMR entails a physical and to work, is the second most frequent health mental component 13. problem, impacting one third of employed Method/Pathophysiology: The physical people in the European Union. component involves the tensing and relaxing There is a substantial body of research of muscle groups over the legs, abdomen, connecting stress to cardiovascular disease 3, chest, arms and face. In a sequential the future manifestation of hypertension pattern, with eyes closed, the individual related to the individual‘s response to stress places a tension in a given muscle group 4, metabolic syndrome5, obesity6, emotional purposefully for approximately 10 seconds overeating 7, while stress fuels and then releases it for 20 seconds before approximately 50% of depression cases continuing with the next muscle group. The through disturbance of the HPA axis 8 and mental component requires that the increased cortisol levels. individual focuses on the distinction between Furthermore, biological markers the feelings of the tension and relaxation. associate the immunoendocrinological With practice, the patient learns how to disturbance brought by stress to infertility 9. effectively relax in a short period of time. There are also research data pin pointing the Relaxation must be attempted in order role of stress in infectious disease10 and to reduce pain or pain perception and cancer 11. Given the negative impact of tension, create a pleasant mental state, stress at intrapersonal and somatic level, it reduce anticipatory anxiety, reduce anxiety is important for healthcare professionals to as a response to stress, increase master a repertoire of stress management parasympathetic activities, increase techniques and teach them to their patients. knowledge concerning muscle tension and It should be noted that stress autonomous stimuli, improve concentration, management techniques are applicable not increase the feeling of control, improve the only to people who manifest a disease or ability to block inner talk, energize and disorder, but also to healthy people, when improve sleep, decrease the cardiac index, added to daily routine practice as an lower blood pressure, warm or cool body effective tool for health enhancement and parts, enhance performance of physical protection over the life span, serving thus as activities and help in the relationship with a valuable intervention for the ―healthy others 14. Therefore, the individual is population‖ as well. Health promotion, as taught by a trained professional, manual or

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audio how to progressively relax major counterbalancing mechanism to the stress muscle groups and performs the sequence 2- response: just as stimulating an area of the 3 times daily for 15-20 minutes per session. hypothalamus can cause the stress response, Results/Benefits: Among PMR long-term so activating other areas of the brain results benefits the following are included: in its reduction. He defined this opposite reduction of salivary cortisol levels and state the "relaxation response."22- 24. generalized anxiety 13, decreased blood Method/Pathophysiology: RR is a simple pressure 13, 15 and heart rate 15, decreased practice that once learned takes 10 to 20 headaches 16 better management of cardiac minutes a day to achieve relaxation. The rehabilitation 17, improvement of quality of important characteristics of a relaxation life of patients after bypass surgery 18 and program are: α) repetition of a word, sound, improvement of quality of life of patients prayer, thought, phrase or muscular with multiple sclerosis 19. movement, through which concentration is achieved β) passive return to the repetition Αutogenic Training (AT) when other thoughts intrude. When an organism is stressed its Origins: Autogenic training (AT) is a self- physiological response is the fight-or-flight relaxation procedure by which a response, whereas when the body is no psychophysiological determined relaxation longer in perceived danger, and the response is elicited. This relaxation autonomic nervous system functioning technique was developed by Johannes returns to normal, the relaxation response Heinrich Schultz 20. AT aims to achieve deep (RR) occurs. During RR, the body moves from relaxation and reduce stress. a state of physiological arousal, including Method/Pathophysiology: In AT the increased heart rate and blood pressure, individual learns a set of directions/exercises slowed digestive functioning, decreased that command the body to relax and control blood flow to the extremities, increased breathing, blood pressure, heartbeat, and release of stress hormones, and other body temperature. AT consists of six responses preparing the body to fight or standard exercises that -with the use visual flight, to a state of physiological relaxation, imagination and verbal cues- make the body where blood pressure, heart rate, digestive feel warm, heavy, and relaxed. The person functioning and hormonal levels return to learns each exercise by reading about it or their normal state. watching a teacher, then practicing it for a Results/Benefits: The RR can reduce systolic few minutes several times a day. Mastering hypertension25, improve cardiac the exercises, either from an instructor or on rehabilitation26 and relieve medical one‘s own, usually requires 4 to 6 months. symptoms 27. Results/Benefits: A meta-analysis of clinical There is compelling evidence that the RR outcome studies in AT found that it is useful elicits specific gene expression changes in in a range of diverse disorders including people who practice either short-term or tension headache/migraine, mild-to- long-term. The study results suggest moderate essential hypertension, coronary consistent and constitutive changes in gene heart disease, asthma bronchiale, expression resulting from RR. These changes somatoform pain disorder (unspecified type), may relate to long term physiological Raynaud's disease, anxiety disorders, mild- effects28. to-moderate depression/dysthymia, and functional sleep disorders 21. Βiofeedback

Relaxation Response (RR) History: Biofeedback has its roots in the concept of homeostasis and cybernetic Origins: In the 1960's, Herbert Benson of theory, proposing that systems are controlled Harvard University found that there is a by monitoring their resultsits. A team of

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researchers in a landmark conference in 1969 History: GI is not a new approach to at the Surfrider Inn in Santa Monica coined helping, but is well established in Native the term biofeedback from Weiner's American and other indigenous traditions, in feedback. The conference resulted in the Hinduism, Judeo-Christian, and other founding of the Bio-Feedback Research religious traditions as well as traditional Society, which permitted normally isolated Chinese medicine 37. In the late 1960s, researchers to contact and collaborate with Joseph Wolpe introduced several imagery- each other, as well as making the term related techniques in behaviour-modification ―biofeedback‖ popular 29. therapy: systematic desensitization, Training/Psychophysiology: Biofeedback is a aversive-imagery methods, symbolic- process that enables an individual to learn modelling techniques and implosive therapy. how to change physiological activity for the Since that time there have been many purposes of improving health and advocates of guided imagery 37. In 1982, Drs. performance. Precise instruments measure Bresler and Rossman presented their initial physiological activity such as brainwaves, findings at a conference sponsored by heart function, breathing, muscle activity, Marquette University and the University of and skin temperature. These instruments San Francisco called The Power of rapidly and accurately 'feed back' Imagination. During this conference, leading information to the user. The presentation of clinicians and researchers introduced more this information — often in conjunction with than 1,400 health professionals nationwide changes in thinking, emotions, and behavior to the practical applications of imagery work — supports desired physiological changes. 38. Over time, these changes can endure without Method/Pathophysiology: The GI method is continued use of an instrument 30. taught by a trained professional, an audio or Biofeedback training is done in the written script in the course of 4-8 weeks, presence of qualified biofeedback therapists. requiring 10 minutes practice per day. GI The therapists work with their patients and utilizes the subject‘s personalized images to explain to them the process of reading and promote health through several then responding to the physiological standardized, yet adaptable, techniques, information relating to their body using including relaxation/stress reduction. The GI various biofeedback devices. When patients facilitator‘s goal is to enable the subject to understand and practice this concept, after engage his/her own images that are symbolic several sessions spanned in 3-6 months, they of his/her specific health or life issues, in are then able to take control of their order to develop health-directed insights, physiological functions like heart beat rate, health-promoting behaviour changes, or blood pressure, etc. They can also learn to direct physiologic changes. A facilitated observe the changes that happen when they exploration of an image of a safe, apply the learning from the training. Sensor comfortable place specific to the participant modalities include: the electromyograph, is involved including sensory recruitment feedback thermometer, electrodermograph, (visual, auditory, olfactory, tactile, and electroencephalograph, electrocardiograph, kinesthetic), particularly focusing on linking pneumograph, capnometer, and the elements of relaxation in the image to the hemoencephalography30. physiologically relaxed state simultaneously Results/Benefits: Biofeedback has been used being experienced by the subject39. successfully for the treatment of headaches Results/Benefits: GI has been used 31, the control of high blood pressure 32- 34 successfully in stress reduction 40, in the and type II diabetes 34- 35 and cardiac disease prevention of smoking relapse 41 , in the 36 . treatment of depression 42, as an adjuvant cancer therapy 43, as an anxiety treatment Guided Imagery (GI) prior to diagnostic cardiac catheterization 44 on surgical stress and wound healing 45and in

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patients undergoing coronary artery bypass significant effect on improvement of the graft surgery 46, in the management of hemodynamic changes following the acute patients undergoing bone marrow stressful tasks. Furthermore, it has been transplantation 47, for cancer pain and used to influence autonomic functions in management 48- 49, for asthma management patients with essential hypertension and thus 50, for pain management 51- 52, for overweight reduce it 58-59, in the management of male adolescents 53. adolescent aggressive behaviour 60, in long term prophylaxis of migraine 61, in stress Diaphragmatic Breathing related to dental visits 62.

Origin: The natural act of breathing has been Transcendental Meditation ™ used as a means of relaxation intuitively, has been traditionally part of different yoga History: The TM technique, a simple, traditions and is now incorporated in many psychophysiological stress reduction relaxation programs. procedure, was introduced to the West by Method/Pathophysiology: Diaphragmatic Maharishi Mahesh Yogi, a scholar of the breathing, or abdominal or belly or deep ancient Vedic tradition of India 63. breathing is marked by expansion of the Method/Pathophysiology: The TM technique abdomen rather than the chest when is simple and easily learned, requiring to be breathing. practiced for 20 minutes twice daily while Diaphragmatic breathing is defined as a sitting with eyes closed and repeating a manipulation of breath movement, ‗mantra‘, a meaningless sequence of sounds contributing to a physiologic response specific to each individual, to promote a characterized by (a) the presence of natural shift of awareness to a wakeful but decreased oxygen consumption, decreased deeply restful state 64. TM is not a religion heart rate and blood pressure, and (b) or philosophy and is taught through a seven- increased theta wave amplitude in EEG step course of instruction by a certified TM recordings, increased parasympathetic teacher. During the TM practice, a reduction activity accompanied by the experience of in mental and physical activity occurs and alertness and invigorating 54. that is the result of the individual‘s It is hypothesized that voluntary slow experience of a mental state called deep breathing functionally resets the ―transcendental consciousness,‖ which is autonomic nervous system through stretch- different from usual waking, dreaming, or induced inhibitory signals and sleep states. This experience is deemed hyperpolarisation currents propagated responsible for the restoration of normal through both neural and non-neural tissue function of various bodily systems, especially which synchronizes neural elements in the those involved in adapting to environmental heart, lungs, limbic system and cortex 54. ―stressors‖ or challenges 63. TM increases Patients are taught by a trained frontal and alpha central activity 64 and professional, manual or audio how to inhale neuroimaging studies indicate increased and exhale deeper and slower. They need to regional cerebral blood flow measures during practice several times a day, or as needed, meditation 65. for a few minutes to see immediate benefits. Studies show that regular practice of TM Results/Benefits: Deep breathing has been has an impact on the brain‘s successfully used to decrease the fatigue electrophysiologic characteristics, improving associated with haemopoietic stem cell brain functioning 66- 69 and attention70- 71. transplantation patients 55, to reduce the During TM practice there is improved cortical anxiety and asthma signs/symptoms of coherence between and within children with asthma56, in the management hemispheres72- 73. Regular practice of TM of acute stressful tasks 57 showing that the leads to reduced medical care utilization and slow-breathing technique can have a expenditures74- 77. Additionally, research data

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shows that TM helps patients become more complete homework assignments98. resilient under stressful situation, reducing Cognitive change and the resulting the more concrete pathophysiologic signs or behavioural change relate to cognitive symptoms of cardiovascular disease. restructuring, which proposes that people Results/Benefits: The TM technique appears are directly responsible for generating to be distinctively effective in modifying dysfunctional emotions and their resultant several clinically relevant physiological and behaviours, like stress, depression, anxiety, psychological outcomes in different something that can be prevented by changing disorders. There is substantial evidence thought patterns. Cognitive restructuring is indicating that psychological stress the process of learning to refute cognitive contributes to hypertension and distortions, aiming to replace one's cardiovascular disease and that TM can irrational, counter-factual beliefs with more lower blood pressure 78- 84. A recent meta accurate and beneficial ones. This is analysis concluded that TM shows clinical and established by helping the individual gain statistical changes in lowering blood awareness of detrimental thought habits, pressure, and it should be recommended to learn to challenge them and substitute life- patients in preventing or treating enhancing thoughts and beliefs99. hypertension. There are documented CBT-related TM can also help in reduced neurobiological changes showing that it can atherosclerosis/stroke 85- 87 , can lead to modify the dysfunctional neural activity reduced congestive heart failure 88, lower related to anxiety disorders in the patients components of the metabolic syndrome and who responded to treatment100. pre-diabetes 89 , provide adjunctive non- Results/Benefits: CBT has been used pharmacological analgesia for invasive successfully in the management of medical procedures 90. Clinical effects of TM cardiovascular disorder 101-104,of diabetes105- impact a broad spectrum of physical and 107, of chronic fatigue syndrome108 , of Pain psychological symptoms and syndromes, management109, of Headaches110- 111, of including reduced anxiety, pain, and overweight and obesity112 , of depression and depression, enhanced mood and self- stress related to infertility 113- 114, of anxiety esteem91, decreased stress 92-96, and faster disorders115 and stress management116- 117. recovery from stress Cognitive Behavioral Therapy (CBT) Mindfulness-Based Stress Reduction (MBSR) Origins: Cognitive behaviour therapy (CBT) Origins: Mindfulness–Based Stress Reduction was developed through a merging of was pioneered by Jon Kabat-Zinn, Ph.D. and behaviour therapy with cognitive therapy assisted by Saki Santorelli, Ph.D. and and though rooted in different theories, colleagues in 1979 at the University Of these two traditions share a common Massachusetts Medical Center. MBSR classes focusing on the present time and on are usually taught by physicians, nurses, alleviating symptoms 97. social workers, and psychologists, who are Method/Pathophysiology: CBT is an seeking to reclaim and deepen some of the established; evidence based structured and unique reciprocity inherent in the doctor- time-limited psychological treatment for caregiver/patient-client relationship. several health conditions such as anxiety Mindfulness-Based Cognitive Therapy (MBCT) disorders, major depression, and health is a form of MBSR that provides information problems such as insomnia, headache, and about depression and cognitive therapy- tinnitus among others. Briefly, CBT is a based exercises that link thinking and its treatment approach that encompasses resulting impact on feeling 118. assessment strategies, cognitive and Method/Pathophysiology: MBSR is a behavioural treatment techniques, and relies structured 8-week group program employing on collaboration between clinician and mindfulness meditation in order to alleviate patient, who has the responsibility to mental and physical suffering, associated

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with physical, psychosomatic and psychiatric and counterconditions anxiety and traumatic disorders. MBSR is not a religion or dogma memories. Exposure therapies like EFT first and is based upon a systematic procedure to elicit the midbrain's anxiety reflex and then develop enhanced awareness of moment-to- replace it with a relaxation response, in moment experience of one‘s own mental order to ―reciprocally inhibit‖ anxiety139. It is process. The technique assumes that greater also indicated that manual stimulation of awareness of the here-and-now will provided acupuncture points produces opioids, clearer and more accurate perception, serotonin, and gamma-aminobutyric acid reduce negative affect and improve energy (GABA), and regulates cortisol, the stress and coping119- 121 . Systematic mindfulness hormone139. These neurochemical changes training can influence brain areas involved in lead to reduction of pain, slowing of the regulating attention, awareness, and heart rate, decreased anxiety, shuting off emotion122. the fight of flight response, and regulation of Results/Benefits: MBSR has been used the autonomic nervous system, as well as to successfully on mood and cardiovascular the creation of a sense of calm139. variables123, in the management of Results/Benefits: EFT leads to reduced pain diabetes124- 125, in chronic disease126, in perception, increased acceptance, coping chronic pain127. MBSR may improve patients‘ ability and health-related quality of life in psychosocial adjustment to cancer 128 and individuals with fibromyalgia has an offer psychological and health benefits to immediate effect on specific phobias 140-141 cancer patients129- 130, it increases natural on anxiety and depression142-143, on killer cells activity131, it can control severe psychological trauma and PTSD144-145 as well headaches132 it helps reduce stress in as in the trauma following coronary heart patients with aneurismal haemorrhage133 and disease145. is effective for anxiety and depression in individuals134- 135 and groups136-137. Conclusion

Emotional Freedom Technique (EFT) It is established that via complex neuroendocrinological mechanisms stress Origins: EFT, introduced by Gary Craig in the contributes to the aetiopathogenesis, 90‘s, a brief exposure therapy that combines initiation and continuation, aggravation of a cognitive and a somatic element, is based the disease, or quality of life of patients. on the discovery that emotional trauma Current research findings support the notion contributes greatly to disease. Scientific that evidence-based stress reduction studies have shown that EFT is able to techniques can lower stress levels of the rapidly reduce the emotional impact of organism, resulting in reduction of disease memories and incidents that trigger symptoms, lowering of biological indicators emotional distress. Once the distress is of disease, prevention of disease and/or reduced or removed, the body can often improvement of patient‘s quality of life. As rebalance itself, and accelerate healing138. stress is universal and of relevance to all, a Method/Pathophysiology: EFT works by a more thorough understanding of stress person tapping on nine of acupoints, while management techniques is essential for speaking aloud a specific, meaningful short preventing stress related disease and phrase. A key part of the therapy is enhancing health overall. Thus, it should be calibrating the intensity of either physical or incorporated into all levels of prevention, emotional pain, which allows both therapist addressing the need of different populations and patient a tangible scale by which to and in different settings. measure progress in pain or emotional In the present paper we attempted a distress reduction138. According to the review of some of the most commonly used, literature, imaginal exposure, paired with evidence-based stress reductions techniques acupressure, reduces midbrain hyperarousal for health related problems such as

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cardiovascular disease, high blood pressure, symptoms can benefit from the programs diabetes, obesity, and headaches. However, presented in this paper. With proper there is extensive well-documented training, health visitors, nurses, physicians literature for the use of the same techniques and other health professionals can safely and for other medical issues, such as cancer, effectively use these interventions in a gastrointestinal problems, pregnancy, to variety of patient and healthy populations. mention a few. In addition, stress management is effective for preventing Bibliography behaviors such as smoking, unhealthy eating habits, sedentary lifestyle choices to name a 1. Chrousos G. P., Gold P. W. The concepts few-, behaviors that serve as risk factors for of stress and stress system disorders: the majority of the aforementioned disease overview of physical and behavioral and disorders. The selection of the homeostasis. Journal of American Medical techniques presented reflects those that are Association, 1992; 267, 1244- 1252. being taught in our program and used in our 2. WHO. Facing the Challenges, Building research. Solution. Report from the WHO European It is concluded that progressive muscle Ministerial Conference. The Regional relaxation, autogenic training, relaxation Office for Europe of the World Health response, biofeedback, guided imagery, Organization Retrieved January 21 2011, diaphragmatic breathing, transcendental from meditation, cognitive behavioral stress http://www.euro.who.int/__data/assets reduction and mindfulness-based stress /pdf_file/0008/96452/E87301.pdf. reduction are all effective treatment 3. Lambert G, Schlaich M, Lambert E, methods for reducing stress and anxiety that Dawood T, Esler M. Stress reactivity and accompanies daily life and chronic illness. its association with increased The stress reduction techniques reviewed in cardiovascular risk: a role for the this paper also improve the quality of life of sympathetic nervous system? patients and in many cases contribute in the Hypertension, 2010; 55(6):e20. reduction of disease symptoms. The same 4. Spruill T.M. Chronic psychosocial stress techniques are also therapeutic for and hypertension. Curr Hypertens Rep, healthcare providers, enhancing their 2010; 12(1), 10-16. interactions with patients. No negative side 5. Kyrou I., Tsigos C. Hypothalamic- effects from any of those techniques have pituitary-adrenal axis, cytokines and been documented. metabolic syndrome. Obesity and However, the literature shows that there Metabolism, 2006; 2, 116-126. is a need for more extensive randomized 6. Brunner E.J., Chandola T., Marmot M.G. control trials of the aforementioned stress- Prospective effect of job strain on reduction techniques in order to establish general and central obesity in the their usefulness in the prevention and Whitehall II study. American Journal of management of disease. There is also a Epidemiology, 2007; 165, 828-837. need to include more biological measures in 7. Adam T. C., Empel E. S. Stress eating and order to quantify symptom reduction and the reward system. Physiology & investigate the pathophysiological Behavior, 2007; 91, 449-458. mechanisms connecting stress, disease and 8. Nemeroff C.B., Vale, W.W. The health. neurobiology of depression: In roads to treatment and new drug discovery. IMPLICATIONS FOR PRACTICE: Stress Journal of Clinical Psychiatry, 2005; 66, reduction techniques constitute a safe and 5-13. effective approach for reducing stress. 9. Li X.H., Ma, Y.G., Geng, L.H., Qin, L., Patients and healthcare providers Hu, H., & Li, S.W. Baseline psychological experiencing stress or stress-related stress and ovarian norepinephrine levels

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