Leonardi A. Goenawan

Impaired pumping efficiency ~ myocardial ischemia 1

Physician who had had the highest scores on a test of hostility while still in medical school were seven times as likely to have died by the age of fifty as were those with low hostility scores 2

Those who had been rated as easily roused to anger were three times more likely to die of cardiac arrest than those who were more even-tempered 3

Being angry more than doubled the risk of cardiac arrest in people who already had heart disease; the heightened risk lased for about two hours after the anger was aroused 4

1. Gail Ironson et al: Effects of anger on left ventricular ejection fraction in coronary artery disease, The American Journal of Cardiology, 70 – 1992.

2. Redford Williams: Hostility & heart disease, The trusting heart, New York Times Books, 1989

3. Linda H.: Emotional arousal as a predictor of long-term mortality and morbidity in Post MI men, Circulation, vol 82, no.4, Supplement III, Oct 1990.

4. Murray A.M.: Triggering of myocardial infarction onset by episodes of anger, Circulation, vol.82, no.2, 1994

Anger

more fact about anger....Anger is a normal human emotion, which is a

problem when it is too intense, occurs too frequently, lasts too long, is harmful to one’s health, leads to person-directed aggression or damages interpersonal relationships.

Anxiety helps us prepare to deal with some danger (a presumed utility in evolution).

In modern life anxiety is more often OUT of proportion and OUT of place – distress comes in the face of situations that we must live with or that are CONJURED by the mind, NOT REAL dangers we need to confront.

Anxiety – the distress evoked by life’s pressure.Perhaps the emotion with the greatest weight

of scientific evidence connecting it to the onset of sickness and course of recovery.

Anxiety

Compromising immune function to the point that it can speed the metastasis of cancer

Increasing vulnerability to viral infectionsExacerbating plaque formation leading to

atherosclerosis and blood clotting leading to myocardial infarction

Accelerating the onset of Type I diabetes and the course of Type II diabetes

Worsening or triggering an asthma attackLeading to ulceration of the gastrointestinal tractTriggering symptoms in ulcerative colitis & in

inflammatory bowel diseaseThe brain itself is susceptible to the long-term effects

of sustained stress, including damage to the hippocampus.

more bad news about Angst

1. Bruce McEwen & Eliot Stellar: Stress and metastasis, Stress and the Individual mechanism leading to disease, Archives of Internal Medicine 153 (Sept 1993)

2. M Robertson & J Ritz: Biology and Clinical Relevance of Human Natural Killer Cells, Blood 76 (1990)

DefinitionA state of mental exhaustion that affectshuman service professionals, like educators,job nurses and physicians, due to chronic emotionaland interpersonal job related stressors.1

Encompasses three aspects: exhaustion, depersonalization, and lack of personal accomplishment.2

1. Freundenberger H. Staff burnout. J Soc Issues 1974;30:159–65.

2. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397–422.

about self.....Exhaustion

Exhaustion corresponds to feelings of being emotionally overwhelmed and exhausted by one’s work and is generally referred to as emotional exhaustion

Physicians are required to deal DAILY with the powerful emotions of human existence: pain, death, life, sexuality, anger, abuse

Its parameters often somatic (GI symptoms, rapid breath, headache, etc), emotional (sadness, negativism, decrease creativity, increase cynism) & interpersonal manifestations (quickness to anger, defensiveness, edgy and ready to blame others, family problems and a negative world–view)

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397–422.

about self.....Depersonalization

Refers to an impassive and impersonal response toward recipients of one’s service, care, treatment, or instruction

Depersonalization of patients and distancing develop in patient/staff relations

Manifests as Apathy and CynicismIncrease IneffectivenessTheory behind Genocide Participants

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397–422.

about self.....Loss of Personal AccomplishmentLoss of feeling of competence and

successful achievement in one’s work with people

Most ominous symptom.

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397–422.

Decreased job performance and commitmentLower career satisfaction, which can lead to

worse quality of care when health professionals are affected.

Potentially very serious for health workers, as burnout can lead to stress-related health problems, low morale, physical exhaustion, insomnia, increased use of alcohol and drugs, and increased family problems.

1. Leiter MP, Harvie P, Frizzell C. The correspondence of patient satisfaction and nurse burnout. Soc Sci Med 1998;47:1611–7

2. Goldberg R, Boss RW, Chan L, Goldberg J, Mallon WK, Moradzadeh D, et al. Burnout and its correlates in emergency physicians: four years’ experience with a wellness booth. Acad Emerg Med 1996;3:1156–64.

3. Gundersen L. Physician burnout. Ann Intern Med 2001;135: 145–8.

Burnout differs from depression because it involves only a person’s relationship to his or her work, whereas depression globally affects a person’s life

About one third of Swiss primary care physicians presented a moderate or a high degree of burnout, which was mainly associated with extrinsic work-related stressors.1

Burnout is frequent among physicians, with rates ranging from 25% to 76%, depending on the working conditions and medical specialty.2-61. Goehring, C., Gallacchi, MB. Künzi, B., Bovier, P.: Swiss Med Wkly, 2005;135:101–108

2. Ramirez AJ, et al.: Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996;347:724–8

3. Grassi L, Magnani K.: Psychiatric morbidity and burnout in the medical profession: an Italian study of general practitioners and hospital physicians. Psychother Psychosom 2000;69:329–34.

4. Shanafelt TD, et al.: Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–67

5. Kirwan M, et al.: Investigation of burnout in a sample of British general practitioners. Br J Gen Pract 1995;45:259–60.

6. Visser MR, Smets EM, Oort FJ, de Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. CMAJ 2003;168:271–5

A survey of British consultants in gastroenterology,surgery, radiology and oncology showed a frequencyof burnout varying from 27% (surgeons)to 35% (oncologists) for emotional exhaustion,from 19% (surgeons) to 28% (gastroenterologists)for depersonalization, and from 32% (surgeons) to49% (radiologists) for low personal accomplishment

Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM.Mental health of hospital consultants: the effects of stress andsatisfaction at work. Lancet 1996;347:724–8.

Decrease / Discontinue CaffeineCaffeine is a strong stimulant that actually

generates a stress reaction in the bodyMore relaxed, less jittery or nervous, sleep

better, have more energy (a paradox, since you are removing a stimulant), less heartburn and fewer muscle aches

Migraine-type withdrawal headachesCaffeine is NOT a highly addictive substance

Regular ExerciseThe stress reaction is IN us, not "out there." It

provides us with the strength and energy to either fight or run away from danger and is therefore self-protective.

The only problem: fighting and running away are rarely appropriate responses to stressful situations in the modern world. The result is that our bodies go into a state of high energy but there is usually no place for that energy to go; therefore, our bodies can stay in a state of arousal for hours at a time.

Exercise is the most logical way to dissipate this excess energy.

Exercise three times per week for a minimum of 30 minutes each time.

Relaxation / MeditationWe have also inherited the ability to put our

bodies into a state of deep relaxation Where the stress reaction is automatic,

however, the relaxation response needs to be brought forth by intention

Whereas exercise dissipates stress energy, relaxation techniques neutralize it, producing a calming effect.

20 minutes once or twice per day confers significant benefit.

Use mind to change physiology

Inborn set of physiological changes that offset flight or fight response

The physiological responses are reductions in HR, BP, RR, & muscle tension

Used to counteract harmful effects of stress.

Practice diaphragmatic breathing (i.e., slowly & deeply)

1. Pick a focus word, phrase, image, or prayer; or focus on breathing.

2. Sit quietly in comfortable position.

3. Close eyes & relax muscles

4. Breathe slowly & naturally – as you do, repeat focus word or phase as you exhale.

5. When other thoughts come to mind, just go back to repetition of word or breathing.

6. Do this 5-10 minutes qd or bid

SleepVicious Cycle: Chronically stressed patients almost

all suffer from fatigue (in some cases resulting from stress-induced insomnia), and people who are tired do not cope well with stressful situations.

When distressed patients get more sleep, they feel better and are more resilient and adaptable in dealing with day-to-day events.

Usual sleep requirement is 5 to 10 hours per night; the average being 6 to 8.

The three criteria of success are waking refreshed, good daytime energy and waking naturally before the alarm goes off in the morning.

Catnap (five to 20 minutes) can be rejuvenating.

Time-outs & LeisureThe two major issues are pacing and

work/leisure balance.Monitoring your stress and energy level, and

then pacing yourself accordingly.We all require time to meet our own needs

(self-care, self-nurturing, etc.) and when that is neglected, trouble usually follows.

Self directed activities can include exercise or recreation, relaxation, socializing, entertainment and hobbies.

Hedonism vs healthy amount of self-indulge

Realistic ExpectationsWhen expectations are realistic, life feels more

predictable and therefore more manageable.An increased feeling of control because you

can plan and prepare yourself (physically and psychologically).

Expect less from people who cannot give you what you want. It makes it easier - not great,

just less upsetting

ReframingOne of the most powerful and creative stress reducers A technique used to change the way you look at things in

order to feel better about themThe key to reframing is to recognize that there are many

ways to interpret the same situationStep outside of yourself and look at other possible

interpretations Reframing does not change the external reality but

simply helps people view things differently (and less stressfully)

You are not trying to disrespect their point of view but only to suggest there are other, less stressful ways of looking at the same thing

"There is more than one meaning to the same reality."

Belief SystemWe have literally thousands of premises and

assumptions about all kinds of things that we hold to be the truth.

We have beliefs about how things are, how people should behave and about ourselves.

The beliefs are expressions of people's philosophy or value system, but all lead to increased effort and decreased relaxation - a formula for stress.

Opinion OR truth?

Ventilation/Support System“Talking cure”“A problem shared is a problem halved”The presence of a trusted and empathic

listener has been therapeuticBe there, listen attentively and show our

concern and caringValidation, encouragement or advice

HumorHumor is a wonderful stress reducer, an

antidote to upsets.Humor is an individual thing Be careful and respectful in what we say