Anxiety Disorders

Stress Management for Patient and Physician

By David B. Posen, MD
The Canadian Journal of Continuing Medical Education, April 1995


One of the most important things we can do for patients is teach them about stress management. Even better, we can learn these lessons ourselves and then model them for our patients. Although there are many approaches to stress management, this article lists 10 ways for reducing stress that are practical, beneficial and which even busy physicians can start implementing in their patients' and their own lives.

Main Article

Stress is the most common cause of ill health in our society, probably underlying as many as 70% of all visits to family doctors. It is also the one problem that every doctor shares with every patient. This presents physicians with two advantages:

As my mentor, Dr. Matthew Budd of Harvard University, told me at our first meeting in 1982, "If you want to help your patients deal with their stress, you're going to have to learn to handle your own." Therefore, when I talk to physicians, I invite them to listen on two channels: one for their patients and one for themselves. The material is much more meaningful if you can connect with it on a personal level.

The manifestations of stress are legion. Early in this century, medical students were taught that, "if you know syphilis (the great masquerader), you know medicine." One could say the same about stress. It can contribute to or mimic just about any symptom you can think of. However, the main presentations can be summarized under four headings: physical, mental, emotional and behavioral (see Patient Information sheet.)

The causes of stress are multiple and varied but they can be classified in two general groups: external and internal. External stressors can include relatives getting sick or dying, jobs being lost or people criticizing or becoming angry. However, most of the stress that most of us have is self-generated (internal). We create the majority of our upsets, indicating that because we cause most of our own stress, we can do something about it. This gives us a measure of choice and control that we do not always have when outside forces act on us.

This also leads to my basic premise about stress reduction: to master stress, you must change. You have to figure out what you are doing that is contributing to your problem and change it. These changes fall into four categories: change your behavior, change your thinking, change your lifestyle choices and/or change the situations you are in. By getting to the root causes of your stress, you can not only relieve current problems and symptoms but you can also prevent recurrences. For example, if you keep becoming frustrated over arguments with your children, you might discover that the cause of your upset is not their behavior but your unrealistic expectations. By modifying your standards, you might find the children's actions no longer bother you.

There are many ways to relieve stress, from going for a walk to quitting your job. What follows is a list of 10 practical and down-to-earth strategies which I have found helpful over the years for both myself and my patients. Some are simple and can be implemented quickly; others are a bit more involved. All are feasible and beneficial.

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1. Decrease or Discontinue Caffeine

In terms of "bang for the buck," it is hard to beat this simple intervention. Most patients do not realize that caffeine (coffee, tea, chocolate and cola) is a drug, a strong stimulant that actually generates a stress reaction in the body. I tell patients that the best way to observe the effect of caffeine is to get it out of the system long enough to see if there is a difference in how they feel. Three weeks is adequate for this purpose and all my patients accept this suggestion, especially when I frame it as an experiment. ("If you dont notice a difference, you can go back to it; but if you feel better without it, you will probably want to stay off it.") I would guess that 75% to 80% of my patients notice a benefit. They feel more relaxed, less jittery or nervous, sleep better, have more energy (a paradox, since you are removing a stimulant), less heartburn and fewer muscle aches. Many patients feel dramatically better and cannot believe the difference.

One warning, however. Patients must wean themselves gradually or they will get migraine-type withdrawal headaches. I suggest decreasing by one drink per day until they are down to zero, then they should abstain for three weeks. When they feel better, they will thank you. In fact, you will be a hero because it is such an easy thing to do and delivers a big payoff. Incidentally, I do not believe caffeine is a highly addictive substance. I have never met a patient in 10 years who could not give it up within one week.

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2. Regular Exercise

As a way of draining off stress energy, nothing beats aerobic exercise. To understand why, we need to review what stress is. People often think of stress as pressure at work, a demanding boss, a sick child or rush-hour traffic. All these may be triggers but stress is actually the body's reaction to factors such as these. Stress is the fight-or-flight response in the body, mediated by adrenaline and other stress hormones, and comprised of such physiologic changes as increased heart rate and blood pressure, faster breathing, muscle tension, dilated pupils, dry mouth and increased blood sugar. In other words, stress is the state of increased arousal necessary for an organism to defend itself at a time of danger.

The 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. There is only one problem: unlike a caveman being attacked by a wild animal or warring tribesman, 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. It is what our bodies are trying to do when we pace around or tap our legs and fingers. It is much better to channel it into a more complete form of exercise like a brisk walk, a run, a bike ride or a game of squash. During times of high stress, we could benefit from an immediate physical outlet - but this often is not possible. However, regular exercise can drain off ongoing stress and keep things under control. I recommend physical activity every day or two. At the very least, it is important to exercise three times per week for a minimum of 30 minutes each time. Aerobic activities like walking, jogging, swimming, bicycling, racquet sports, skiing, aerobics classes and dancing are suitable. Choose things you like or they will feel like a chore and you will begin to avoid them. It is also beneficial to have a variety of exercise outlets. I have never met a patient who did not feel better with some form of regular exercise - and I know I could not exist without it. For chronic or acute stress, exercise is an essential ingredient in any stress reduction program.

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3. Relaxation/Meditation

Another way to reduce stress in the body is through certain disciplines which fall under the heading of relaxation techniques. Just as we are all capable of mounting and sustaining a stress reaction, we have also inherited the ability to put our bodies into a state of deep relaxation which Dr. Herbert Benson of Harvard University has named "the relaxation response." In this state, all the physiologic events in the stress reaction are reversed: pulse slows, blood pressure falls, breathing slows and muscles relax.

Where the stress reaction is automatic, however, the relaxation response needs to be brought forth by intention. Fortunately, there are many ways of doing this. Sitting quietly by a lake or fireplace, gently petting the family cat, lying on a hammock and other restful activities can generate this state. There also are specific skills that can be learned which are efficient and beneficial. A state of deep relaxation achieved through meditation or self-hypnosis is actually more physiologically restful than sleep. These techniques are best learned through formal training courses which are taught in a variety of places. Books and relaxation tapes can be used when courses are not available or are beyond the patient's budget.

I can attest to the benefits of regular meditation from personal experience. And on days when exercise is not possible, relaxation techniques are an excellent way to bring down the body's stress level. Whereas exercise dissipates stress energy, relaxation techniques neutralize it, producing a calming effect. As little as 20 minutes once or twice per day confers significant benefit.

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4. Sleep

As mundane as it sounds, sleep is an important way of reducing stress. 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. These dynamics can create a vicious cycle. When distressed patients get more sleep, they feel better and are more resilient and adaptable in dealing with day-to-day events. I always ask patients how much sleep they are getting, whether they wake up rested or tired, and how much sleep they generally need to function well. Most people know what their usual sleep requirement is (the range is five to 10 hours per night; the average being seven to eight), but a surprisingly large percentage of the population is chronically sleep deprived.[1] I urge patients to go to bed 30 to 60 minutes earlier and to monitor the results after a few days or a week. If they are still tired, I suggest a bedtime 30 minutes earlier than this. Eventually, they find what works for them. The three criteria of success are waking refreshed, good daytime energy and waking naturally before the alarm goes off in the morning.

Sleeping-in is fine but if you sleep too long, it throws off your body rhythms during the following day. It is better to go to bed earlier. Daytime naps are an interesting phenomenon. They can be valuable if they are short and timed properly (i.e., not in the evening). The "power nap" or catnap is a short sleep (five to 20 minutes) that can be rejuvenating. A nap lasting more than 30 minutes can make you feel groggy. Patients with insomnia should be discouraged from daytime naps. Beyond these cautionary notes, sleep can be key in reducing stress and helping patients cope and function better.

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5. Time-outs and Leisure

No one would expect a hockey player to play an entire game without taking breaks. Surprisingly though, many otherwise rational people think nothing of working from dawn to dusk without taking intermissions, and then wonder why they become distressed. The two major issues are pacing and work/leisure balance.

Pacing has two components: monitoring your stress and energy level, and then pacing yourself accordingly. It is about awareness and vigilance; knowing when to extend yourself and when to ease up. It is also about acting on the information your body gives you. The best visual tool I have seen to understand this is a diagram I learned from Dr. Peter Nixon, a British cardiologist (Figure 1). The diagram illustrates some important points:

I show this diagram to my patients at their first visit and ask them where they are on the curve. I tell my patients to monitor where they are on this curve on a daily basis and to take appropriate action (either speed up or slow down). I then use it periodically to check their progress. It is a helpful guide (for me and for them) of how they are doing.

The other key to pacing is taking periodic time-outs. Too many patients (and doctors) go far too long without breaks. Dr. Ernest L. Rossi wrote The 20-Minute Break, an excellent book extolling the virtues of a short recess every couple of hours throughout the day. Just as we all have cycles of deep sleep and dream sleep throughout the night (at roughly 90- to 120-minute intervals), we also have cycles through the day (peaks of energy and concentration interspersed with troughs of low energy and inefficiency) (Figure 2). These cycles are called "ultradian rhythms" because they happen many times per day (as opposed to the 25-hour circadian rhythm with which we are all familiar). The main point of the book is that we need to watch for these troughs and take 20 minute "ultradian healing breaks" when they occur, as opposed to working through them and building up stress.

It is not always convenient for people to take time-outs when nature tells us to but we can all become better at this. A mid morning break, lunch, a mid afternoon break and supper divide the day into roughly two hour segments. These time-outs can include power naps, meditation, daydreaming, a social interlude, a short walk, a refreshment break, a change to low-concentration tasks or listening to music. Since I (and some of my patients) have started to work with this biologic pattern (instead of resisting it), the results have been pleasing. Like the catnap, it is simply a good investment of time that pays itself back quickly in increased productivity and reduced stress.

Work-leisure balance. Despite all our labor-saving devices, leisure is still an elusive commodity for most people. Statistics show that the average American (and probably Canadian) is working an extra three hours per week compared with 20 years ago.1 That translates into an extra month of work each year. Add to that the phenomenon of the two career family (which makes family and leisure time even more scarce) and you start to get a picture of society on an accelerating treadmill.

Leisure time and levels of distress are inversely proportional - the less leisure, the more stress. I ask patients to fill in a chart so we can both see what their work/ leisure ratio looks like. I ask them to think of their lives (excluding sleep time) in four compartments (work, family, community and self) and then to assess what percentage of their time and energy in an average week goes into each part. There is no normal range but I become concerned when work is over 60% and/or when self is less than 10%. 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. The word leisure is derived from the Latin word licere which means "permission." The main reason so many people do not have enough leisure is that they are not giving themselves permission to make the time to enjoy it.

Leisure is one of the most pleasant stress relievers ever invented. It is strange that people resist it so much (e.g., feeling selfish, guilty). I am not preaching hedonism - just a healthy amount of necessary respite from the day's pressures. We as doctors can give patients permission if they will not give it to themselves. Once they experience a payoff, the benefits will reinforce the behavior. After that, they are usually able to give themselves permission.

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6. Realistic Expectations

A common source of stress is unrealistic expectations. People often become upset about something, not because it is innately stressful, but because it does not concur with what they expected. Take, for example, the experience of driving in slow-moving traffic. If it happens at rush hour, you may not like it but it will not surprise or upset you. However, if it occurs on a Sunday afternoon, especially if it makes you late for something, you are more likely to be stressed by it.

When expectations are realistic, life feels more predictable and therefore more manageable. There is an increased feeling of control because you can plan and prepare yourself (physically and psychologically). For example, if you know in advance when you have to work overtime or stay late, you will take it more in stride than when it is dropped on you at the last minute.

There is much we can do to help patients by letting them know when their expectations (of themselves and others) are unrealistic. I remember a patient berating himself and feeling guilty because he did not love his stepdaughter as much as his own biologic children. Blended families are common and I suspect many people struggle with this issue of love and loyalty. I asked this man where he got the idea that he would love his second wife's children as if they were his own. He did not know. I suggested to him that his expectation was probably unrealistic, especially early in the new marriage. He felt relieved by this idea and stopped putting pressure on himself to feel something he did not feel.

As for expectations of others, another patient said: "Expect less from people who cannot give you what you want. It makes it easier - not great, just less upsetting."

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7. Reframing

This is one of the most powerful and creative stress reducers of which I know. Reframing is a technique used to change the way you look at things in order to feel better about them. We all do this inadvertently at times. For example, many people viewed the baseball strike as a personal disaster whereas others immediately realized they were going to save a lot of time and money by not hotfooting it down to the ballpark whenever the Blue Jays or Expos were in town.

The key to reframing is to recognize that there are many ways to interpret the same situation. It is like the age-old question: Is the glass half empty or half full? The answer of course is that it is both or either, depending on your point of view. As Dr. Joel Goodman put it at The Power of Laughter and Play Conference, Toronto, 1986: "There is more than one meaning to the same reality." However, if you see the glass as half full, it will feel different than seeing it as half empty because the way we feel almost always results from the way we think. The message of reframing, then, is that there are many ways of seeing the same thing - so you might as well pick the one you like.

One of the things we can do with patients is help them reframe stressful situations. This most often involves helping them see positives in a negative situation and assisting them in understanding the behavior of other people. It is best to get the patient to provide the input first (to which you can add later) by asking certain questions. The information is more meaningful when it comes from them. For example, I had a patient who lost her job because of a chronic, though not life-threatening illness. I asked if anything positive had come out of this experience and she came up with several things, including "It will make me a stronger person," "I never liked the work I was doing before. This gives me the chance to do what I really want to do," "It has made my marriage stronger," "It has brought me closer to my family," and "I have learned to watch my money and spend more carefully, which I never had to do before." I then asked her to focus on what is there (what she can still do) rather than what is missing (due to the restrictions of her illness). She replied, "Most things - my hobbies, watch television, go to the cottage, socialize, go out; although some things are still (physically) uncomfortable." By asking her to think about her illness from a different perspective, she was encouraged to reframe the situation and she felt better emotionally as a result.

In terms of reframing the behavior of other people, ask patients why they think someone did what they did. For example, a woman's boss was acting critical and domineering towards her. I said, "Assuming your boss is not just evil or malicious, why do you think she might be acting like this?" Answers included, "She is probably insecure," "She is under a lot of pressure,' and "She is having personal problems." Performing this exercise helped the patient step outside herself and look at other possible interpretations of her boss's behavior. After that, her upset was considerably
decreased. In fact, after such a discussion some patients feel more compassion than anger for the person who is bothering them.

Notice that reframing does not change the external reality but simply helps people view things differently (and less stressfully). It should be done with a bit of preamble to explain the premise (e.g., using the glass half empty as an illustration) and only after you have acknowledged the validity of the patient's initial (stressful) interpretation. 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.

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8. Belief Systems

A lot of stress results from our beliefs. We have literally thousands of premises and assumptions about all kinds of things that we hold to be the truth - everything from, "You can't fight City Hall" and "The customer is always right," to "Men shouldn't show their emotions" and "Children should make their beds." We have beliefs about how things are, how people should behave and about ourselves ("I can never remember people's names"). Most of our beliefs are held unconsciously so we are unaware of them. This gives them more power over us and allows them to run our lives.

Beliefs cause stress in two ways. The first is the behavior that results from them. For example, if you believe that work should come before pleasure, you are likely to work harder and have less leisure time than you would otherwise. If you believe that people should meet the needs of others before they meet their own, you are likely to neglect yourself to some extent. Several patients tell me, "If you want something done right, you have to do it yourself." They do not delegate well and tend to get overloaded.

In the above three cases, the beliefs are expressions of people's philosophy or value system, but all lead to increased effort and decreased relaxation - a formula for stress. There is no objective truth to begin with. These are really just opinions but they lead to stressful behavior. Helping patients uncover the unconscious assumptions behind their actions can be helpful in getting them to change.

The second way beliefs cause stress is when they are in conflict with those of other people. One of my patients had a fight with his son because the child wore the same clothes several days in a row. I asked why it bothered him and he replied, "Because you should change your clothes every day." I asked him where this idea originated: "Well, my mother taught me that. Everyone knows you should change your clothes every day." I told him that this was not "the truth," but merely his opinion based on the way he was raised. I said I had lived in cultures where people did not change clothes often and nothing bad happened to them. I helped him see that this was a premise he held but one which was not shared by his son. The argument was not over the clothes themselves but merely about a difference of opinion. Once he recognized his belief was not "true," his anger diminished.

We can do much for patients by getting them to articulate their beliefs and then to label them as such. Next, we need to help them acknowledge that their assumptions are not truth but rather opinions and, therefore, they can be challenged. Lastly, we can help patients revise their beliefs or at least admit that the beliefs held by the other person may be just as valid as their own. This is a mind-opening exercise and usually diminishes the upset the patient was experiencing.

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9. Ventilation/Support System

We have all had patients who come into the office upset, talking incessantly about a problem, and feeling better when they are finished. They have told their story, cried or made some admission, and the act of doing so in the presence of a trusted and empathic listener has been therapeutic. We often do not have to say much. We just have to be there, listen attentively and show our concern and caring. On other occasions we might offer validation, encouragement or advice. But the combination of the patient being able to ventilate and our support can be profoundly beneficial.

There is an old saying that "a problem shared is a problem halved." People who keep things to themselves carry a considerable and unnecessary burden. We can do much for patients by allowing them to ventilate or encouraging them to do so. We can also help by urging them to develop a support system (a few trusted relatives, co-workers or friends to talk to when they are upset or worried).

Another form of ventilation that many patients find helpful is writing, for example in a private journal at home. Former tennis star Guillermo Vilas once said: "When my life is going well, I live it. When it's not going well, I write it." When patients are angry, I often suggest they write a letter to the person at whom they are vexed. These letters are not for sending; they should be destroyed once they are written - unread. The value is in expressing the feelings and getting them out. Rereading the letter just reinforces the upset and fans the flames of anger all over again.

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10. Humor

Humor is a wonderful stress reducer, an antidote to upsets. Laughter relieves tension. In fact, we often laugh hardest when we have been feeling most tense.

One of my patients was lamenting the 15 pounds she gained over the winter and the fact that she could not get into her bathing suit. She had always been sensitive about her weight. While talking about her upset she suddenly stopped, her face softened and a smile came to her lips. "You know what? I've just decided," she said. "I'll swim in the dark this year." Another case involved a man who worked in a busy company dealt with customers at the counter, customers on the phone and staff members who needed his help. He felt besieged often from several directions at once.. He told me he started using a phrase which helped him cope and gave him a laugh; "I love it when they fight over me." In both cases, patients generated their own humor and reduced their upset.

Humor is an individual thing - what is funny to one individual may be hurtful to another. It is wonderful when patients can poke fun at themselves. We can also do this with patients, but we have to be careful and respectful in what we say. If you think of something funny that may help the patient, say it if you feel it will ease their tension and not be offensive. I will often throw in a quip or joke when I think it is appropriate. When it is done sensitively, laughter is a great gift to people you care about.

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One of the most important things we can do for patients is teach them about stress management. Even better, we can learn these lessons ourselves and then model them for our patients. Although there are many approaches to stress management, this article has listed 10 ways for reducing stress that are practical, beneficial and which even busy physicians can start implementing immediately - for their patients and for themselves.

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1. Schor, JB: The Overworked American. Basic Books, New York, 1991, p. 11.

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Suggested Reading

1. Watzlawick, P, Weakland, J, Fisch, R: Change. Norton, New York, 1974.

2. Selye, H: Stress Without Distress. Signet, Scarborough,1975.

3. Benson, H: The Relaxation Response. Avon, New York,1975.

4. Freudenberger, HJ: Burn-Out. Bantam, NewYork,1980.

5. Eliot, RS: Is it Worth Dying For? Bantam, New York, 1984.

6. Borysenko, J: Minding the Body, Mending the Mind. Addison-Wesley, 1987.

7. Schor, JB: The Overworked American. Basic Books, New York,1991.

8. Dominguez, J, Robin, V: Your Money or Your Life. Viking, New York, 1992.

9. Prochaska, J, Norcross, J, DiClemente, C: Changing For Good. Morrow, New York, 1994.

10. Rainham, DC: Winning Your Battle With Stress. Optimum Health Resources, 900 King Street W., Kitchener, Ontario, N2G 1G5,1994.

11. Posen, DB: Always Change a Losing Game. Key Porter, Toronto, 1994.

Presented at Tri-University Winter Medical Symposium St. Petersburg, Florida March 11 ,1995

Dr. Posen practiced family medicine in Oakville, Ontario until 1985, when he gave up his family practice to devote his time exclusively to stress management, lifestyle counseling and psychotherapy. He has given seminars for IBM, Motorola, Bell Canada, Peat Marwick and the Royal Bank of Canada. His first book, Always Change a Losing Game, was published in 1994 by Key Porter Books, and became a Canadian best seller. He also presents seminars about stress management for McMaster University medical school and has given presentations for the Ontario Medical Association and the Ontario College of Family Physicians. He received his medical degree from University of Toronto in 1967.

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Information For Patients - Stress Management

What Is Stress?

Dr. Hans Selye, the father of stress theory, defined stress as "the nonspecific response of the body to any demand made upon it." The "demand" can be a threat, a challenge or any kind of change which requires the body to adapt. The response is automatic, immediate. Stress can be good (called "eustress") when it helps us perform better, or it can be bad ("distress") when it causes upset or makes us sick.

What Does the Stress Reaction Consist of?

The stress reaction results from an outpouring of adrenaline, a stimulant hormone, into the blood stream. This, with other stress hormones, produces a number of changes in the body which are intended to be protective. The result often is called "the fight-or-flight response" because it provides the strength and energy to either fight or run away from danger. The changes include an increase in heart rate and blood pressure (to get more blood to the muscles, brain and heart), faster breathing (to take in more oxygen), tensing of muscles (preparation for action), increased mental alertness and sensitivity of sense organs (to assess the situation and act quickly), increased blood flow to the brain, heart and muscles (the organs that are most important in dealing with danger) and less blood to the skin, digestive tract, kidneys and liver (where it is least needed in times of crisis). In addition, there is an increase in blood sugar, fats and cholesterol (for extra energy) and a rise in platelets and blood clotting factors (to prevent hemorrhage in case of injury).

What Are Common Symptoms of Stress?

Manifestations of stress are numerous and varied but they generally fall into four categories (this is only a partial list of most common symptoms):

Physical: fatigue, headache, insomnia, muscle aches/stiffness (especially neck, shoulders and low back), heart palpitations, chest pains, abdominal cramps, nausea, trembling, cold extremities, flushing or sweating and frequent colds.

Mental: decrease in concentration and memory, indecisiveness, mind racing or going blank, confusion, loss of sense of humor.

Emotional: anxiety, nervousness, depression, anger, frustration, worry, fear, irritability, impatience, short temper.

Behavioral: pacing, fidgeting, nervous habits (nail-biting, foot-tapping), increased eating, smoking, drinking, crying, yelling, swearing, blaming and even throwing things or hitting.

What Are the Causes of Stress?

Dr. Selye called the causes of stress "stressors" or "triggers." There are two kinds of stressors: external and internal.

External stressors include:

Internal stressors include:

It is important to note that most of the stress that most of us have is actually self-generated. This is a paradox because so many people think of external stressors when they are upset (it is the weather, the boss, the children, the spouse, the stock market). Recognizing that we create most of our own upsets, however, is an important first step to dealing with them.

What Are Some Ways to Master Stress?

The following are some categories that can be helpful in mastering stress:

Change lifestyle habits.

Change stressful situations.

Change your thinking.

Diversion and distraction. Take a time-out (anything from a short walk to a vacation) to get away from the things that are bothering you. This will not resolve the problem, but it gives you a break and a chance for your stress levels to decrease. Then, you can return to deal with issues feeling more rested and in a better frame of mind.

[Prepared by Dr. David B. Posen Lifestyle Counselor and Psychotherapist, and Author of "Always Change a Losing Game" Oakville, Ontario. May be copied and distributed to patients]

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