Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 1
Stress Management Skills for Pharmacy Practice
Cynthia Knapp Dlugosz, BSPharm, ACCCertified Integrative Health Coach
1
Accreditation Information
“Stress Management Skills for Pharmacy Practice” is accredited by ACPE for pharmacists and techniciansACPE #0154-0000-16-014-L04-P ACPE #0154-0000-16-014-L04-T
Cynthia Knapp Dlugosz has not disclosed any financial or conflicts of interest in relation to this program
2
Learning Objectives At the end of this activity, participants should be able
to: Identify common sources of stress for pharmacy
professionals and possible effects on physical health, mood, and behavior
Contrast the body's stress response and relaxation response
Demonstrate practices for eliciting the relaxation response, including proper breathing, progressive muscle relaxation, and mindfulness meditation
Use simple cognitive techniques to transform stressful thoughts
Formulate a personal list of “in-the-moment” strategies that can be employed when stressful situations arise in pharmacy practice
3
WHAT IS STRESS?
4Image: Shutterstock.com
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 2
What Is Stress?
Hans Selye (“Father of Stress Research”)“Non-specific response of the body to any
demand for change” (1936)“The rate of wear and tear in the human
machinery that accompanies any vital activity” (1964)“Everyone knows what stress is, but nobody
really knows”
5
Stressor vs Stress
Stressor = stimulus (trigger)EnvironmentalSocialPhysiologicalCognitive
Stress = response
6
The Problem With Definitions
How we experience stress depends on:Our view of the stressor Threatening: dangerous, difficult, painful, unfair? Overwhelming?
Our reaction to events/circumstances Events are not inherently stressful!
7
Source: Hesson O, Stress Management for Life
Activating event (potentially stressful situation)
Beliefs, thoughts, perceptions
Consequence (stress or lack of stress)
8
Source: Elkin A, Stress Management for Dummies
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 3
Yerkes-Dodson Principle
Source: Stress Management (Harvard Medical School Special Health Report)9
Stress is not inherently bad
Is It Good Stress or Bad Stress?
EustressPositive, desirable
stress
Feels exciting
Motivates, focuses energy
Short-term
Perceived as within our coping abilities
DistressNegative, undesirable
stress
Feels unpleasant
Causes anxiety or concern
Short-term or long-term
Perceived as outside of our coping abilities
10
Stress Management Action Plan
What are your stress triggers?
11Image: Shutterstock.com
THE STRESS RESPONSE
12Image: Shutterstock.com
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 4
13
The stress response is designed to help us survive physical danger
Fight Flight
Source: Hesson O, Stress Management for Life
Freeze
RecognitionAppraisal
14
Sympathetic nervous system
Adrenal medulla
EpinephrineNorepinephrine
Pituitary gland
Hypothalamus
ACTH
Adrenal cortex
Cortisol
Fight or flight effects
CRH
Fight or Flight Effects
heart rate cardiac output blood pressure respiratory rate pulse rate O2 consumption muscle tension coagulation metabolic activity
Hepatic release of:Glucose
Free fatty acids
Cholesterol
Vasoconstriction (selective)
Blood shunted to periphery
Decreased GI activity
15
The Modern Dilemma
Our body does a poor job of distinguishing
between life-threatening events and day-to-day
stressful situations
16
Source: Stress Management (Harvard Medical School Special Health Report)
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 5
“We end up pumping high-energy chemicals for low-
energy needs”
Robert Eliot, MD
17
Chronic Stress
State of continued sympathetic nervous system activation
“Constant emergency mode”Decreases stress thresholdStress response kicks in sooner or more
frequently
Wears down our ability to adapt and copeStress becomes a “habit”
18
Effects of Chronic Stress
Medium-termMuscle tension and
pain
Headaches
Fatigue
Upset stomach
Difficulty sleeping
Grinding or clenching teeth
Infection
Long-termCardiovascular disease
Hypertension
GI disorders
Impaired immunity
Premature aging
Chronic inflammation
Central adiposity
…and many, many others!
19
Symptoms of Stress
20
Source: Stress in America 2015, American Psychological Association
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 6
Stress Management Action Plan
How does stress affect you?
21Image: Shutterstock.com
THE RELAXATION RESPONSE
22
After the Stress Response…
Parasympathetic nervous system (“rest and digest”)Reverses effects of stress responseRestores homeostasis
23
Rest and Digest Effects
heart rate cardiac output blood pressure respiratory rate pulse rate O2 demand muscle tension coagulation metabolic activity
Blood shunted to internal organs
Normal GI function resumes
24
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 7
The Relaxation Response
Herbert Benson, MDMind-Body Medical
Institute, Massachusetts General Hospital (now the Benson-Henry Institute for Mind Body Medicine)
25
1975
26
When we invokethe Relaxation Response,
we switch from the fight-or-flight responseto parasympathetic activity
BREATHINGChange the Consequences
27Image: Shutterstock.com
Fight or Flight Breathing
Chest (thoracic) breathingChest expands, shoulders riseShallow breaths (upper portion of lungs)Rapid breathing
28
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 8
Relaxation Response Breathing
Source: Stress Management (Harvard Medical School Special Health Report)29
Relaxation Response Breathing
Diaphragmatic (abdominal) breathingBelly expands out; chest remains stationaryDeep breathsSlow breaths Stimulates vagus nerve “There is no threat—return to homeostasis”
30
31
Breathing is the only process regulated by the
autonomic nervous systemthat can be controlled consciously
Stress Toolkit for Pharmacy Practice
Option 1Breathe in deeply
Pause for a count of three
Breathe out slowly
Pause for a count of three
Option 2Breathe in —
“Calm…”
Breathe out —“down…”
32Image: Shutterstock.com
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 9
PROGRESSIVE MUSCLE RELAXATION
Change the Consequences
33Image: Shutterstock.com
Progressive Muscle Relaxation
Tightening and releasing all major muscle groups in an exaggerated fashionTeaches what muscle tension feels likeReduces muscle tension through focused
attentionActivates parasympathetic nervous system
34
Stress Toolkit for Pharmacy Practice
The 5-second “scrunch”Sit comfortably
Clench both fists, bend both arms, tense both biceps
Scrunch up face (close eyes, furrow brow, clench jaw, purse lips
Bring shoulders to ears
Tense stomach muscles
Hold 5 seconds
Release fully
35Image: Shutterstock.com
MINDFULNESS MEDITATION
Change the Consequences
36Image: Shutterstock.com
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 10
MINDFULNESS
“The awareness that arises from paying attention on purpose, in
the present moment, and nonjudgmentally”
Jon Kabat-Zinn
37
—James BarazAwakening Joy: 10 Steps to Happiness
Mindfulness Is…
• Simply being aware of what is happening right now without wishing anything were different
• Enjoying pleasant experiences without holding on to them when they pass (which they will)
• Remaining present with unpleasant experiences without fearing they will always be this way (which they won’t)
38
“…consciously placing the mind”
Sakyong Mipham
Mindfulness Meditation Is…
39
Where Are You Right Now?
40
Image: Shutterstock.com
What might happen
What has already happened
What is happening right now
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 11
Most stressful thoughts concern the past or the future
41
Image: Shutterstock.com
“Monkey Mind”
42Image: Shutterstock.com
“…allows you to see what’s going on in your head without getting carried away by it”
Dan Harris
Mindfulness Meditation…
43
Image: http://cbicounseling.com/mindfulness-101/44
Active, open, intentional attention on the present—
not an “empty” mind
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 12
Meditation Practice
Focus attention
Get distracted
Notice the distraction
Release and return
45
Stress Toolkit for Pharmacy Practice
Practice “returning”Select a cue (e.g., telephone, chime)Stop and noticeConsciously practice mindful breaths
46Image: Shutterstock.com
Practice While You Drive
47
Image: Shutterstock.com
There’s an App for That
48
10% Happier: Meditation for Fidgety Skeptics
7-day free introduction
$9.99/month
Calm
7-day free introduction
$9.99/month, $39.99/year
Buddhify
$4.99
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 13
COGNITIVE STRATEGIES
Change Your Perception
49
Is It…
The stress?
How we relate to the stress?
or
50
Maybe It’s How We Relate
…exposure to daily stressors may be less important for cardiac autonomic control than how people perceive and respond to those stressors, as well as their overall daily experiences of negative affect.
51
Sin N et al. Psychosom Med. 2016 Jun;78(5):573-82.
“Between stimulus and response there is a space. In that space is our power to choose our response.”
Victor E. Frankl, MD, PhD
52
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 14
Source: Tim’s Printables http://timvandevall.com/human-brain-diagram/
Prefrontal cortex
Amygdala
53
How Mindfulness Helps
54
Mindlessness (you don’t notice)
Stressor Fight or flight
Mindfulness (you notice)
Mindful response Automatic response
Stress reduces Stress increases
Better able to deal with next stressor
Stress cycle continues
Alidina S, The Mindful Way Through Stress
Don’t bite the hook
55
Image: Shutterstock.com
The STOP Technique
Stop what you’re doing Initial step that helps break the
autopilot stress cycle
Take a few deep breaths Observe your
experience just as it is Proceed
56
Stress Management Skills for Pharmacy Practice© 2016, CKD Associates, LLC 15
The PRO Technique
PauseInitial step that helps break
the autopilot stress cycle
Relax your body Open to what matters in
the momentFocus on the task at hand
P
R
O
57
Practice While You Drive
58
Image: Shutterstock.com
Someone cuts you off
You think, “I’m
angry!”
You actually become angry
OR…you stop or pause
Stress Toolkit for Pharmacy Practice
Choose a different thought“I don’t need to be stressed about this—I’m
not in any danger”“I can’t control how others behave, but I can
control the way I think about it”“I choose ease”
59Image: Shutterstock.com
Your Stress Toolkit
Stress Management Practices “In the Moment” Practices
Relaxation response breathing
Progressive muscle relaxation
Mindfulness meditation
STOP technique
PRO technique
Breathe in, pause, breathe out, pause
Breathe in “calm,” breathe out “down”
5-second scrunch
Practice returning
Choose a different thought
60
-1-
My Stress Management Action Plan
My biggest sources of stress in pharmacy practice are:
-2-
How stress affects me
Anxiety, worry, panic
Dizziness
Fatigue, lethargy
Headaches
Muscle tension (e.g., tight neck or shoulders, back pain)
Decreased libido
Difficulty falling asleep
Insomnia
Irritability, impatience
Bouts of anger or hostility
Moodiness
Sadness or depression
Eating too much
Eating too little
Heartburn, indigestion
GI symptoms (e.g., diarrhea, gas, cramps, constipation)
Rashes, hives, itching
Cold sores
Restlessness
Fidgeting
“Nervous habits” (e.g., nail biting, hair-twirling)
Frequent urination
Grinding teeth, clenching jaw while sleeping
Difficulty concentrating
“Fuzzy” thinking
Trouble remembering things
Heart palpitations
Shakiness, tremors, tics, twitches
Loss of sense of humor
Overly critical attitude
Feeling overwhelmed
Increased use of alcohol or drugs
Increased smoking
Other:
-3-
Stress management practices I liked
Relaxation response breathing
Progressive muscle relaxation
Mindfulness meditation
STOP technique
PRO technique
How I will manage stressful situations “in the moment”
Breathe in, pause, breathe out, pause
Breathe in “calm,” breathe out “down”
5-second scrunch
Practice returning
Choose a different thought