Burnout and Stress Related Illness

CHAPTER 3: Stress Management Stress is a feeling you get when faced with a challenge. In small doses, stress can be good for you because it makes you more alert and gives you a burst of energy. For instance, if you start to cross the street and see a car about to run you over, that jolt you feel helps you to jump out of the way before you get hit. But feeling stressed for a long time can take a toll on your mental and physical health. Even though it may seem hard to find ways to de-stress with all the things you have to do, it’s important to find those ways. Your health depends on it.

Section 3.1 Chronic Stress

We all have stress sometimes. For some people, it happens before having to speak in public. For other people, it might be before a first date. What causes stress for you may not be stressful for someone else. Sometimes stress is helpful – it can encourage you to meet a deadline or get things done. But long-term stress can increase the risk of diseases like depression, heart disease and a variety of other problems. A stress-related illness called post-traumatic stress disorder (PTSD) develops after an event like war, physical or sexual assault, or a natural disaster.

If you have chronic stress, the best way to deal with it is to take care of the underlying problem. Counseling can help you find ways to relax and calm down. Medicines may also help.

Section 3.2 The Effects of Stress on the Body

Not all stress is bad. All animals have a stress response, which can be lifesaving in some situations. The nerve chemicals and hormones released during such stressful times prepares the animal to face a threat or flee to safety. When you face a dangerous situation, your pulse quickens, you breathe faster, your muscles tense, your brain uses more oxygen and increases activity—all functions aimed at survival. In the short term, it can even boost the immune system.

However, with chronic stress, those same nerve chemicals that are life-saving in short bursts can suppress functions that aren’t needed for immediate survival. Your immunity is lowered and your digestive, excretory, and reproductive systems stop working normally. Once the threat has passed, other body systems act to restore normal functioning. Problems occur if the stress response goes on too long, such as when the source of stress is constant, or if the response continues after the danger has subsided.

Section 3.3 Stress and the Brain

Stress has many definitions, but according to Richard Lazarus, stress is a state of anxiety produced when events and responsibilities exceed one’s coping abilities. In this way, stress relies not only on environmental factors, but on cognitive appraisals of these factors

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(Myers, 2004). The cerebral cortex perceives the stressor, the hypothalamus stimulates the pituitary gland to release epinephrine and norepinephrine. This in turn stimulates the adrenal glands to release the hormone cortisol (Myers, 2004). Stress affects many other areas of the body, such as the amygdala, which produces a fear response. It seems to hardwire the brain differently. Middle-aged rats that had undergone early life stress had abnormal brain-cell activity and memory loss (Brunson et. al., 2005). The sources of stress are numerous: from catastrophes such as Hurricane Katrina, significant life changes, poverty and inequality, to daily hassles like traffic tie-ups and demanding jobs (Myer, 2004). Especially in urban and overcrowded environments, psychologist s see links between everyday stressors and hypertension, and unhealthy behaviors such as lack of sleep and alcoholism (Lazarus & Folkman, 1984). In fact, the leading causes of death today in America are linked to lifestyle and stress. According United Nations Security Council, about half of the world’s children grow up in extremely stressful environments (poverty, violence, war, abuse), which means that these children may have impaired cognitive abilities later on in life.

According to research by Janet Rodin, the less perceived control of a situation, the greater the stress. The elderly that lived in nursing homes, were lonely, and had to be fed, dressed, and changed, felt significantly more stress and had shorter lifespans than their independent, active counterparts. Females seem to be more susceptible to stress and depression. After experiencing traumatic events, females are twice as likely as men to develop Post Traumatic Stress Disorder, where humans develop maladaptive behaviors such as avoidance, reduced responsiveness and guilt (Myers, 2004).

However, mindful exercise, such as Tai Chi, meditation, and aerobic exercise decrease stress response and promote overall well-being (Sandlund and Norlander, 2000). In a University of Wisconsin study, participants who did meditative exercises showed more electrical activity in the left side of the frontal lobe, indicating that they had a lower anxiety and a more positive emotional state (Davidson, 2003). Meditation, yoga, and other relaxation exercises also assist in autonomic reflexes. This is called conscious control. Through these practices, it is possible to gain control over the sphincter muscles in the anus and bladder. Yoga has been shown to help control heart rate, blood pressure, and other autonomic functions. These are learned behaviors – they involve the formation of new pathways in the brain.

Researchers have also found the correlation between a social support network of close friends and family and less physiological stress effects (Brown and Harris, 1978). Stress Inoculation Training and Hardiness Training are cognitive behavioral techniques that work to improve stress resistance through analyzing stressors, teaching coping techniques, and changing behavior so that the patient feels more assertive and in control (Kobasa, 1986). Drugs, such as beta-blockers, which reduce stress arousal, anxiolytic drugs, such as minor tranquilizers, and anti-depressant drugs, which treat severe anxiety, can also be used to combat stress.

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Section 3.4 Your Bodies Response to Stress

Fight or Flight Response

When we experience excessive stress, either from internal worry or external circumstance, a bodily reaction called the “fight-or-flight” response will be triggered. Harvard physiologist Walter Cannon originally defined it. The response system represents the genetic impulse to protect ourselves from bodily harm, but also can result in negative health effects. According to Cannon’s theory, during stress-response processes, the sympathetic nervous system increases the heart rate and releases chemicals to prepare our body to either fight or flee. When the fight-or-flight response system get activated, it tends to perceive everything in the environment as a potential threat to survival.

In modern life, we do not get the option of “flight” very often. We have to deal with those stressors all the time and find a solution. When you need to take an SAT test, there is no way for you to avoid it; sitting in the test room for five hours is the only choice. Lacking the “flight” option in stress-response process leads to higher stress levels in modern society.

Section 3.5 General Adaptation Syndrome

Selye’s Concept of General Adaptation Syndrome

Hans Selye (1907-1982) started the modern era of research into something called stress. In 1950, Selye addressed the American Psychological Association convention. He described a theory of stress-induced responses that become the standard model of stress, the one people usually refer to (or criticize) in academic journal articles about stress. How did Selye discover the stress response? Selye’s discovery of the stress response was an accident. He was doing research on the effect of hormone injections in rats. Initially he thought he detected a harmful effect from the hormones, because many of the rats became sick after receiving the injections. But when Selye used a control group of rats, injected only with a neutral solution containing no hormones, he observed that they became sick, too. As it turned out, the rats responded more profoundly to the trauma of being injected than they did to the hormones. The experience of being handled and injected led to high levels of sympathetic nervous system arousal and arousal and eventually to health problems such as ulcers. (Note that stress was not found to directly cause ulcers by Selye.) Selye coined the term “stressor” to label a stimulus that had this effect.

What is a stressor for rats? For lab assistants? The immediate response to stress is the release of adrenaline into the blood plasma (the liquid part of the bloodstream). “Mild stressors such as opening a cage door or handling a rat produces an eightfold increase in plasma epinephrine [adrenaline] concentrations” (Axelrod and Reisine, 1984). The sentence is ambiguous; does the rat or the human experience the eightfold increase in adrenaline? In this case, it is the rat which is having its

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adrenaline (plasma epinephrine) measured. However, many lab assistants probably experience a burst of adrenaline, too, when handling a rat for the first time.

What were the three stages of Selye’s General Adaptation Syndrome?

Selye proposed a three-stage pattern of response to stress that he called the General Adaptation Syndrome (GAS) . He proposed that when the organism first encountered stress, in the form of novelty or threat, it responded with an alarm reaction. This is followed by a recovery or resistance stage during which the organism repairs itself and stores energy. If the stress-causing events continue, exhaustion sets in. This third stage is what became known popularly as burn-out. Classic symptoms of burn-out include loss of drive, emotional flatness, and (in humans) dulling of responsiveness to the needs of others.

Hans Selye’s Study of Stress Response

In 1934, Hans Selye at McGill University discovered a new type of hormone. He gave rats daily injections of ovarian extract and found that the rats had enlarged adrenals and shrunken spleens, thymus, lymph nodes, and intestinal ulcers. “Multiple organs in the body generate this hormone, and thus he announced that it is a nonspecific response of body to noxious agents. (Evan-Martin, 2007) In 1936, Selye defined these series of symptoms in the experiments with the rats as the General Adaptation Syndrome, which consists of three stages: the alarm stage, the resistance stage, and the exhaustion stage (Evan-Martin, 2007). The alarm stage is similar to the fight-to-flight response, and the body mobilizes resources to react to the incoming noxious agent. The resistance forces will be built up when the noxious challenge is detected as continuing. The exhaustion stage will cause death if the body is unable to overcome the threat.

For example, your mom told you that you are going to take the SAT next month. The first reaction is shock, starting complaints and feelings of stress, which represent the beginning of the first stage. In the resistance stage, you will try your best to do practice tests, reviewing vocabulary, studying any type of study aids that are available. Finally, you will feel like you are doomed to fail this test and feel desperate, feel constantly anxious, have difficulty falling asleep and waking up in the morning. The exhaustion of this stage will have deleterious effects on your health by depleting your body resources which are crucial for the maintenance of normal functions. Your immune system will be exhausted and function will be impaired. Also, the decomposition which is a functional deterioration of body may happen as the exhaustion stage extends. Selye believed that one becomes sick at that point because stored hormones secrete during the stress response are depleted (Sapolsky, 1998).

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Section 3.6 Distress may be destructive to health

Hans Selye’s research that led to the concept of the General Adaptation Syndrome (GAS) demonstrated that stress that is perceived as a threat (distress) may be debilitating if it is continuous. But even “flow” could go on too long and the person would need a break. But “flow” only develops in activities that are freely engaged in. Negative stress, or distress, is often part of activities that we perceive we cannot escape. Our bodies and minds seem to have evolved to cope well with sudden and brief stressors, such as escaping attack by a predator. We do not seem to be designed to handle chronic stress even if it is mild, like driving in heavy traffic. Our society has created many conditions that produce chronic stress and are associated with stress related illnesses. We have time pressures, work pressures, relationship pressures, crowding, noise, crime, to many things to do in too little time, achievement pressures, and even education-related pressures in this course. It is this detrimental effect of ongoing stress that underlies the GAS and the concepts of stress- induced health problems.

Section 3.7 Eustress

Hans Selye originally defined stress as the body’s response to challenges. He was dismayed by the implication that all challenging events in life were unhealthy and undesirable. Stress was not always bad, he pointed out. Sometimes a challenge is a good thing. Indeed, one could argue that nothing useful in life can be accomplished without some degree of stress.

“Good stress,” Selye pointed out, is “the spice of life.” To combat the notion that all stress was bad, Selye developed the idea of eustress, which is a person’s ideal stress level. Selye proposed that different people needed different levels of challenge or stimulation (stress) in their lives. Some people (“turtles”) need low levels of stress. Others (“racehorses”) thrive on challenges.

In the long run, the popular conception of stress as something bad proved to be more durable and accurate than Selye’s notion of stress as a challenge to the system. In other words, the word stress continues to mean something bad (not something challenging) to most people. That seems to make the most sense, because psychologists found that only unpleasant stressors produced the harmful stress reaction identified by Selye (corticosteroid secretion). Challenges were not harmful in themselves. A person could be a busy executive or engage in strenuous exercise without experiencing negative stress- related symptoms, as long as the person enjoyed the challenge.

Section 3.8 Burnout and Stress Related Illness

Burnout syndrome is considered an important work-related illness in welfare societies. It was through observations by German psychologist Herbert Freudenberger inside a detoxification clinic in the mid-1960s that the first scientific descriptions came to light of staff affected by this disorder. It was only in the 1980s that evaluation criteria for the

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syndrome became available, through the design of a standard measurement instrument, the Maslach Burnout Inventory or MBI.

Burnout is a psychosocial syndrome. It involves feelings of emotional exhaustion, depersonalization and diminished personal accomplishment at work. Emotional exhaustion is a situation where, owing to lack of energy, workers perceive they are no longer able to participate on an emotional level. Depersonalization entails the development of negative attitudes and feelings towards persons for whom work is done, to the point where they are blamed for the subject’s own problems. Diminished personal accomplishment is a tendency in professionals to negatively value their own capacity to carry out tasks and to interact with persons for whom they are performed, and feeling unhappy or dissatisfied with the results obtained.

The MBI questionnaire has been adapted for application not only to human services professions but to all types of occupations in general. An updated definition of burnout, constructed using the latest version of the MBI, is that proposed by Maslach et al. In their description, it is “a prolonged response to chronic emotional and interpersonal stressors on the job, and is defined by the three dimensions of exhaustion, cynicism, and inefficiency.” Exhaustion is the feeling of not being able to offer any more of oneself at an emotional level; cynicism is contemplated as a distant attitude towards work, the people being served by it and among colleagues; ineffectiveness is the feeling of not performing tasks adequately and of being incompetent at work.

Burnout is generally considered a response by a person to chronic work-related stress in an attempt to adapt or protect oneself from it. From a transactional approach, stress is defined as “the result of a relationship with the environment that the person appraises as significant for his or her well-being and in which the demands tax or exceed available coping resources.” This is the case because a life event is not what produces stress; rather, it is caused by the appraisal the affected person makes of it. According to Lazarus and Folkman, coping is “cognitive and behavioral efforts to manage specific internal and/or external demands that are appraised as taxing or exceeding the resources of the person.” A person will be psychologically vulnerable to a determined situation if he or she does not possess sufficient coping resources to handle it adequately, and if at the same time, he or she places considerable importance on the threat implicit in the consequences of this inadequate handling. From this perspective, burnout syndrome may be seen as a progressively-developed process resulting from the use of the relatively ineffective coping strategies with which professionals try to protect themselves from work-related stress.

Burnout has also been described as an experience where the worker is aware of considerable discrepancy between his or her efforts and the results, between the invested efforts and the rewards obtained at work. This phenomenological analysis framework is introduced into the subjective experience of those affected, and the conclusion is reached that the burnout process is triggered when the worker feels that his or her efforts are disproportionate to the gratification achieved, and consequently is no longer able to justify or cope with further investment of effort. Burnout syndrome may be seen as the

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continuous perception that efforts made to carry out tasks are not effective, because expected gratitude, recognition or success at work are not being achieved.

This tool can help you check yourself for burnout. It helps you look at the way you feel about your job and your experiences at work, so that you can get a feel for whether you are at risk of burnout. Resource: MindTools, http://www.mindtools.com/pages/article/newTCS_08.htm

Section 3.9 Common Causes of Stress

Stress happens when people feel like they don’t have the tools to manage all of the demands in their lives. Stress can be short-term or long-term. Missing the bus or arguing with your spouse or partner can cause short-term stress. Money problems or trouble at work can cause long-term stress. Even happy events, like having a baby or getting married can cause stress. Some of the most common stressful life events include:

• Death of a spouse • Death of a close family member Divorce • Losing your job • Major personal illness or injury • Marital separation • Marriage • Pregnancy • Retirement • Spending time in jail

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Section 3.10 Common signs and symptoms of stress

Everyone responds to stress a little differently. Symptoms may vary person to person. Here are some of the signs to look for:

• Not eating or eating too much • Feeling like you have no control • Needing to have too much control • Forgetfulness • Headaches • Lack of energy • Lack of focus • Trouble getting things done • Poor self-esteem • Short temper • Upset stomach • Back pain • General aches and pains

These symptoms may also be signs of depression or anxiety, which can be caused by long- term stress.

Section 3.11 Do women react to stress differently than men?

One recent survey found that women were more likely to experience physical symptoms of stress than men. But we don’t have enough proof to say that this applies to all women. We do know that women often cope with stress in different ways than men. Women “tend and befriend,” taking care of those closest to them, but also drawing support from friends and family. Men are more likely to have the “fight or flight” response. They cope by “escaping” into a relaxing activity or other distraction.

Section 3.12 Can Stress Affect My Health?

The body responds to stress by releasing stress hormones. These hormones make blood pressure, heart rate, and blood sugar levels go up. Long-term stress can help cause a variety of health problems, including:

• Mental health disorders, like depression and anxiety • Obesity • Heart disease • High blood pressure • Abnormal heart beats • Menstrual problems • Acne and other skin problems

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Section 3.13 The Effect of Stress on the Immune System

Psychoneuroimmunology (PNI) is defined as the examination of the interactions among psychological, behavioral, and social factors with immunological and neuroendocrine outcomes. It is now well established that psychological factors, especially chronic stress, can lead to impairments in immune system functioning in both the young and older adults. In several studies of older adults, those who are providing care for a relative with dementia report high levels of stress and exhibit significant impairments in immune system functioning when compared with noncaregivers. Stress-induced changes in the immune system may affect a number of outcomes, including slowing the wound healing process and increasing susceptibility to infections.

Section 3.14 Does stress cause ulcers? NO

A bacterium called Helicobacter pylori (H. pylori) is a major cause of peptic ulcers. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen, are another common cause. Rarely, cancerous or noncancerous tumors in the stomach, duodenum, or pancreas cause ulcers. Peptic ulcers are NOT caused by stress or eating spicy food, but both can make ulcer symptoms worse. Smoking and drinking alcohol also can worsen ulcers and prevent healing.

Section 3.15 Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a type of anxiety disorder that can occur after living through or seeing a dangerous event. It can also occur after a sudden traumatic event. This can include:

• Being a victim of or seeing violence • Being a victim of sexual or physical abuse or assault • The death or serious illness of a loved one • Fighting in a war • A severe car crash or a plane crash • Hurricanes, tornadoes, and fires

You can start having PTSD symptoms right after the event or symptoms can develop months or even years later. Symptoms may include:

• Nightmares • Flashbacks, or feeling like the event is happening again

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• Staying away from places and things that remind you of what happened • Being irritable, angry, or jumpy • Feeling strong guilt, depression, or worry • Trouble sleeping • Feeling numb • Having trouble remembering the event

Women are 2 to 3 times more likely to develop PTSD than men. Also, people with ongoing stress in their lives are more likely to develop PTSD after a dangerous event.

Section 3.16 Stress is in the Eye of the Beholder

The process by which we influence the emotion we experience in a situation by the interpretation or cognitions we select in the experience is described by Lazarus’s theory of appraisal as influencing our stress experience. This theory may be beneficial to our understanding of the differences between individual’s stress levels. The theory’s main points are:

  1. When we experience a situation or event we first determine if it is a threat, a challenge, or is neutral.
  2. We then assess our inventory of resources to cope with the event. If we do not perceive we are adequate to the task, we must be able to withdraw or we will feel trapped in a situation with aversive consequences coming. That induces distress and all the physiological processes that harm our health. If we perceive that we have the resources to successfully cope with the situation, we feel challenged and optimistic. Note that challenge and optimism are related to enhanced health and sense of well- being.

This second stage of appraisal impacts the first stage in a loop process. If we at first perceive a threat but then realize we can handle it, it reduces the distress and may even create a perception of challenge. If at first we perceive a challenge but then realize that we don’t have what it takes to be successful, we may begin to experience distress as we see the aversive outcome of failure looming ahead. Depending on the meaning of the outcome to us, the distress may be mild or severe. If the situation is always hanging over us and we always feeling inadequate to it and anxious about negative outcomes, we are always under distress. Our health and well-being take a beating in that scenario.

Next, we must select from our repertoire of coping resources. There are two types of coping resources:

• Instrumental • palliative (emotion-focused)

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Instrumental coping solves the problem and removes the stressor from our experience as in working out a conflict with someone to reduce the distress or by getting a better job to reduce financial pressures.

Palliative coping alters our physiological reactions to stress that will not go away and cannot be escaped. These include relaxation skills, reinterpretation of the meaning or effects of the stressor, acceptance of the situation, or optimism about future improvements in the situation. Palliative skills would include relaxing in the traffic jam even though you have an important appointment that is being missed. You realize you cannot do anything about it, so you may as well relax because anger and tension will not make the cars move any faster, but it will hurt you, so you choose to relax instead.

As we go to our repertoire of coping skills to select one or more, we may become more optimistic of success and reappraise the situation in the first step. It may become less threatening and hence less distressful. We could find that our coping resources will be less adequate than we initially thought and we would become more threatened now. Even a challenge might be converted into a threat as in traveling to a another country for the first time and finding your credit cards are missing and you have no money for anything and no way to get any.

This interactive appraisal and coping process is at the heart of the impact of stress on us. If we interpret a situation as stressful, it has the stress-related effects on us. If we have few coping sources, more situations will be perceived as distressing. If we have many coping resources, more situations will be perceived as challenging or at least neutral.

As I am driving down the road and have a flat tire, I could be annoyed at the trouble it causes or highly threatened by the memory of Bill Cosby’s son’s murder a few years ago as he changed his tire. If I don’t know how to change a tire and it is night time, I may feel very threatened as I perceive helplessness and vulnerability to someone’s attacking me. If I assure myself that this is unlikely, and I do know how to change a tire, I may decide that I will get this done in ten minutes and be on the road safely. But then I find that my spare tire is flat. Now I feel threatened for sure. But if I have a good spare, have a good flashlight, have a handgun and the skill to use it, and have changed many tires, I may only feel annoyed at the hassle and not feel threatened (many instrumental skills). I may have none of these things but have a cell phone and a close friend who will quickly be here to solve the problem for me (social support). My distress is much less then.

These factual situations are part of the appraisal and coping process. Perception is also critically important. If I have little confidence in myself to handle a flat tire even though I have been taught how to do it and have the tire, I may feel more threatened. If I have the cell phone but don’t believe I should bother anybody to come here, or don’t believe they would want to help me, the facts do not determine my reaction as much as my perception of the facts determines it.

A second example of the role of coping skills and perception could involve getting started in this course. If you are a computer whiz and have taken several college courses including

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online courses before, you got started with little problem. Learning to use Etudes, to take online quizzes probably did not cause much distress. But if you were new to using the Internet, had never taken an online course, and had low self-confidence, you may have been quite distressed. Same situation, different coping resources. Some of our community colleges go to great effort to be sure new online students have the knowledge and coping skills to begin a course with little stress.

Now add pure perception. If you perceive college as a supportive environment that will find a way to assist you to get through as long as you put forth the effort, and perceive instructors as willing to be flexible when circumstances are beyond all of our control, like getting started on the three programs we use and getting books late, you may be hassled but not threatened about failing the course because of these factors. But if you see colleges and instructors as money-hungry and deliberately placing obstacles in your path to cause you to fail and drop out, you have been very distressed when you had these difficulties as you would see no support or flexibility to allow you to adapt to the new situation and have the time to catch up. You might even feel quite angry at this new ploy to get your tuition and frustrate you into quitting. The reality of the college and instructor’s intent make no difference in your initial perception and resultant choices. It is your perception of reality that determines what you will do.

The appraisal and coping process underlies the statement that “stress is in the eye of the beholder.” Any event of situation may be perceived differently by different individuals due to past experience with it, learned skills, personality traits like Type A and optimism, and the amount of distress being experienced already. Social support may be instrumental in helping cope with problem as in coming to help with the flat tire, or being eager to listen and be supportive with your sharing your experiences. Both reduce the distress levels.

Section 3.17 Managing Stress

Everyone has to deal with stress. There are steps you can take to help you handle stress in a positive way and keep it from making you sick. Try these tips to keep stress in check:

Develop a new attitude

• Become a problem solver. Make a list of the things that cause stress. From your list, figure out which problems you can solve now and which are beyond your control for the moment. From your list of problems that you can solve now, start with the little ones. Learn how to calmly look at a problem, think of possible solutions, and take action to solve the problem. Being able to solve small problems will give you confidence to tackle the big ones. And feeling confident that you can solve problems will go a long way to helping you feel less stressed.

• Be flexible. Sometimes, it’s not worth the stress to argue. Give in once in a while or meet people halfway.

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