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Stress, Burnout, and Happiness David Mays, MD PhD

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1 Stress, Burnout, and Happiness David Mays, MD PhD

2 The Chronobiology of Getting Sick – 12 - Gout – 1 AM - Gallbladder – 2 AM - GERD, peptic ulcer – 3 AM - Congestive heart failure, pulmonary edema – 4 AM - Cluster and migraine headaches – 5 AM - Asthma attacks

3 6 AM - Death, all causes 7 AM - Allergic rhinitis, colds, flu, rheumatoid arthritis, depression 8 AM to Noon - Angina, MI, sudden cardiac death, TIA, stroke 1 PM - Stomach ulcer perforation 4 PM - Tension headache

4 5 PM - Intestinal ulcer perforation, osteoarthritis 7 PM - Cholesterol rises 8 PM - Backache 9 PM - Restless legs syndrome 10 PM - Menopausal hot flashes

5 Stress 50-75% of routine medical practice is devoted to complaints related to stress. Problems at work are more strongly associated with health complaints than any other life stressor. 29% of workers report that they feel “quite a bit or extremely stressed at work.” (Yale Univ. Survey, 1997) Healthcare expenditures are 50% greater for workers who report high levels of stress (J of Occ Env Med, 1998)

6 Stress Response: LC/NE Pathway LC/NE: The locus coeruleus (LC) secretes norepinephrine (NE - related to adrenaline) in the cortex, thalamus, limbic system, hypothalamus, spinal cord. NE acts as a neuromodulator. It also activates the autonomic nervous system for fight or flight. Heart rate, respiration, and blood pressure increase.

7 Stress Response: HPA Axis Hypothalamic: When stress is perceived, corticotropin-releasing hormone (CRH) and vasopressin are secreted by neurons in the hypothalamus. CRH causes the pituitary to secrete ACTH. ACTH stimulates the adrenal gland to release cortisol which increases glucose levels and suppresses the inflammatory/immune response. This is the hypothalamus-pituitary adrenal axis (HPA.)

8 Cortisol The levels of glucocorticoids in the blood typically follow a daily rhythm - high early in the morning, low later in the day. They increase glucose in the blood, control its metabolism, and regulate the sleep wake cycle. High levels of cortisol have many deleterious effects on the body (Cushing’s disease).

9 Stress: Memory Effects Short term stress can enhance memory. But chronic stress can impair attentional states and learning later on. Ultimately, even amnesia can be result. High levels of glucocorticoids lead to impaired memory and neuronal cell death. Cortisol dissolves the brain.

10 Common Physical Symptoms of Stress Headache Back, shoulder, neck pain Sleep problems Difficulty concentrating GI problems Palpitations Skin problems Tics Low energy

11 Common Emotional Symptoms of Stress Job dissatisfaction Burnout Irritability Anxiety Depression Isolation, withdrawal

12 Stress or Depression Stress – Difficulty falling asleep – Poor concentration and memory, and significantly lower brain activity during memory tests Depression – Early morning awakening – Poor concentration and memory, but higher brain activity during tests

13 Stress Reduction You can reduce stress by either reducing your exposure to stressful situations (amygdala management which effects the autonomic nervous system), or learning better skills for coping with them (strengthen your prefrontal cortex – cognitive restructuring.)

14 Best Evidence for Stress Reduction Exercise Meditation Caffeine reduction Get enough sleep Reappraisal

15 News Flash! Proceeds of the National Academy of Science, Nov 23, 2010: – Rats were placed on a stress increasing paradigm and then given sugar. The sugar lowered cortisol levels, improved heart rate variability, increased friendly behavior toward unfamiliar animals, and increased exploration in a maze test. These positive effects lasted for 7 days.

16 The Dimensions of Burnout Exhaustion: individual stress component - feeling overextended, depleted of one’s emotional and physical resources Cynicism: interpersonal component -negative or callous, excessively detached response to job Reduced efficacy/accomplishment: feelings of incompetence and lack of achievement and productivity

17 Burnout Effects Burnout is associated with various forms of job withdrawal: absenteeism, turnover For people who stay on at work, burnout leads to lower productivity and effectiveness, poor job satisfaction, reduced commitment. Burnout has a negative impact on coworkers, creating more interpersonal conflict and disruption. It is contagious.

18 Burnout in the Mental Health Workforce A 2010 review shows that almost all “research” in this area is informal, anecdotal and survey-based. Findings: – There are consistently high levels of exhaustion, but cynicism and feelings of reduced efficacy are usually low. – We know nothing about the impact of interventions on burnout.

19 Leadership The mood of a leader is more powerful than the mood of members of the group. In several studies that have measured leaders and workers moods before and after a task, the leaders mood has proven to be very contagious. Interestingly, “negative” contagion seems to be stronger than “positive” contagion.

20 Symptoms of Burnout Physical Symptoms: fatigue, cognitive impairment, sleep disruption, GI problems, headache, inflammatory changes Emotional Symptoms: alienation, cynicism, powerlessness Behavioral Symptoms: impatience, negativism, frustration, irritability

21 Job/Situational Causes Overload: exhaustion Role Conflict: competing demands Role Ambiguity: lack of training Severity of Client’s Problems Lack of Support from Supervisors (more so than coworkers)

22 Job/Situational Causes Lack of Feedback Lack of Control Lack of Autonomy Lack of Reciprocal Loyalty Lack of Perceived Fairness

23 Job/Situational Causes The psychological contract:When we first begin working for an organization, we have certain expectations about what that employment will entail - the job we will be doing, workload, resources, career advancement, job security, etc. Larger social and economic forces can bring about significant changes in these things.

24 Personal Causes Personal causative factors are not as strong as situational factors Younger, unmarried Gender neutral (although males tend to rate higher in cynicism)

25 The Mismatch Paradigm of Burnout Burnout arises from mismatches between the person and the job in six domains. The greater the mismatch, the greater the chance of burnout. The better the match, the greater the likelihood of job engagement. Mismatches arise when the initial psychological contract was not clear, or the job changes. The six areas are: workload, control, reward, community, fairness, and values.

26 1) Workload – Energy can be exhausted to the point that the person can no longer recover. – Mismatch can also result from the wrong kind of work in terms of skills or inclination. – Work is especially draining when it requires people to display emotions inconsistent with their feelings.

27 2) Control – Mismatches occur most often when workers feel they do not have control over resources needed to do their job most effectively. – Workers may also feel overwhelmed by their responsibility and feel that their responsibility exceeds their authority.

28 3) Reward – Financial rewards – Social rewards are even more important to most people. Feeling lack of appreciation and having one’s hard work ignored devalues the work and the worker. – Lack of intrinsic reward (pride in work) is also critical for burnout.

29 4) Community – People can lose a sense of positive connection with others at work. People thrive when they share praise, comfort, happiness, and humor with those they like and respect. They have a shared sense of values. – Jobs may isolate workers from one another, but what is most destructive is chronic, unresolved conflict.

30 5) Fairness – Fairness communicates respect and confirms people’s self-worth. – Inequity of pay, workload, when there is cheating or when promotions and evaluations are mishandled, or when grievances are not handled appropriately all increase cynicism and emotional exhaustion. – This dimension is the most predictive of future burnout when it appears.

31 6) Values – Employees may feel that their job requires them to act unethically (lie). – They may feel that their personal values are at odds with their workplace, or that their workplace has contradictory goals (maintain a high case load, be culturally sensitive.)

32 Job Mismatch Individuals may place different importance on these six factors. If you really support the values of the organization, you may be able to tolerate problems with reward, for example. Investigating job mismatch is a very fruitful way to help supervisors and employees concretely discuss burnout and encourage engagement.

33 Individual Interventions People can learn new coping skills, but it has not been shown that they can apply it at work At best, there may be a reduction in exhaustion, but generally there is no change in cynicism or self-efficacy. The most effective change requires integration of workplace and individual needs.

34 Detachment From Work A recent longitudinal study of 309 human services employees showed that high job demands predicted emotional exhaustion, psychosomatic complaints, and low work engagement over time. Psychological detachment from work during off-job time was an important factor in protecting employee well-being and work engagement.

35 Reducing 10 Common Stressors 1) Lateness: Consider priorities and get rid of unnecessary tasks. Give yourself 15 extra minutes travel time. Map out the day. 2) Anger: Do you magnify problems and make up stories about them? Take time to stop, breathe, reflect. 3) Unsure of your abilities: Don’t worry alone. Get help.

36 Reducing 10 Common Stressors 4) Overextended: What is truly essential right now? Get help with the household chores from family or hire help. 5) No time for stress relief: Single task. Try mini-relaxations. Cut back commitments. 6) Feeling tense: Try massage, sauna, mini- relaxations, a walk, exercise

37 Reducing 10 Common Stressors 7) Pessimism: recognize cognitive distortions. Exercise your sense of humor. Practice gratitude. 8) Conflict: State needs directly. Practice assertiveness. 9) Burned out: Eat well, engage in creative, productive leisure activities. Set priorities.

38 Reducing 10 Common Stressors 10) Loneliness: work at being friendly. Volunteer. Join a group. Take an interesting class

39 Biological Research – Where Does It Feel Good? The Biology of Drug Euphoria – The ventral tegmentum – nucleus accumbens – prefrontal cortex – Dopamine driven – Animal studies indicate this is probably a system of “wanting” more than pleasure. Salience. Animals will do this until they die. – Cocaine stimulates this pathway The Biology of Pleasure – Endorphins, widely scattered throughout the brain – Positive and negative emotions activate different parts of the brain and deactivate each other – EEG’s show the left prefrontal cortex is more active in happy people, the right prefrontal cortex when people experience negative emotions

40 Biological Research Happiness and unhappiness are not on a continuum. We seem to have a positive system and a negative system that operate separately, but can stifle each other.

41 The Positive and Negative Systems Negative – Like Velcro – Very sensitive – Bitter 1:2,000,000 – I HATE to lose – Triggered by poverty – 1 negative remark – Stronger reaction to negative language – Strong and damaging stress response – Harder to adapt to Positive – Like Teflon – Not sensitive – Sweetness 1:200 – Winning is OK – Money has no effect – 5 positive remarks – Weaker response to positive language – Pleasure response not very physically active – Fast adaptation

42 Defining Happiness The Pleasant Life: Pleasure and Enjoyment The Good Life: Feeling Happy and Flow The Meaningful Life: Purpose

43 The Pleasant Life The pleasant life consists of experiencing as many pleasures as possible and learning to amplify and savor them Pleasure may range from the basic to the very refined The ability to experience pleasure seems to be very genetic (about 50%.) People who are very social tend to also experience a lot of this kind of happiness. Unfortunately, we tend to habituate/adapt very rapidly to pleasure.

44 US Citizens: Necessities Item Second car20%59% Second TV 3%45% More than 1 telephone 2%78% Car air conditioning11%65% Home air conditioning22%70% Dishwasher 8%44%

45 The Good Life There are two different experiences that contribute to the good life: – being in a good mood – the experience of “flow.” This kind of happiness is usually what is referred to when writers talk about our happiness “set point.” We may be born a cheerful person, or someone who easily becomes engages in “flow.” Studies show that people who are happy most of the time also tend to be: – Optimistic – Appreciative – Social

46 A Rather Dumb Question... Would you rather win the lottery or become disabled in this coming year?

47 The Data Researchers at UC studied both lottery winners and individuals who sustained a physical injury. Immediate levels of happiness were higher (lottery winners), or lower (physically injured), but after eight weeks or less, people returned to the level of happiness they had before the event. The data tell us, with a few exceptions, that if it happened over three months ago, it has no significance to us in terms of happiness.

48 The Effect of Disability on Happiness Able-bodied Univ. Ill students: – Happy - 50% of the time – Unhappy- 22% of the time – Neutral - 29% of the time Univ Ill students with disabilities: – Happy - 50% of the time – Unhappy - 22% of the time – Neutral - 29% of the time

49 Dan Gilbert’s “Happiness Synthesizer” Dan Gilbert, Harvard psychologist, says that we create our own happiness “synthetically” if bad things happen to us. We unconsciously, and automatically make lemonade when life gives us lemons. This keeps us within a certain range of positive affect – our set point. The range differs among individuals.

50 The Good Mood: A Summary Some people just feel happier than others, no matter what happens to them. They tend to be more social, optimistic, and grateful than those who are less happy. It almost seems as though people are “stuck” at a certain level of feeling happy, as though they had a happiness thermostat. Whether you win the lottery or have an accident, you tend to recover to your usual state of mind within 3 months. This happens because our minds create a certain amount of “synthetic” happiness, especially in uncontrollable situations, that bring us back to our “normal.”

51 The Good Life: Flow Another kind of “happiness” that people experience, besides a good mood, is the experience of “flow.” This experience is different than the experience of pleasure, or a sense of well-being. In many respects, it is the lack of feeling, or emotion that defines this kind of contentment. It is best captured by the experience of “flow” – a feeling of absorption/concentration where time seems to stop and you are completely engaged with what you are doing.

52 Flow Flow experiences lead to to positive emotions in the short run and over the long term, people who more frequently experience flow are generally happier. People vary in how much they value having flow experiences and how easily they can do it.

53 Flow Recent scans investigating brain-activation patterns have compared sensory stimulation to self-reflection. Brain regions active during self-reflection are suppressed during perception and vice versa. We can be aware of about 110 bits/sec of information. A person talking to us takes about 60 bits/sec. In flow, there is no capacity left for attention to monitor the body, think about family or problems. The ego disappears. Existence is suspended.

54 Characteristics of Flow Effortless concentration Experience outside of everyday reality Inner clarity Knowledge that you are capable of doing the task Sense of serenity/calm Timelessness Not thinking about yourself Intrinsic motivation – the activity is its own reward You want to repeat the experience

55 The Meaningful Life The meaningful life seems to arise when people both know their strengths and use them in the service of something “larger” than themselves.

56 Generosity Increase in happiness by having a income increase from $20,000 to $80,000: 16% Increase in happiness from never volunteering to volunteering once a week: 16% study: employees who gave more of their bonus money to charity reported greater happiness than those who gave less. Participants were given $5 or $20 to spend on themselves or others. Spending even $5 on others made participants happier than spending $20 on themselves.

57 What Makes for an Overall Satisfying Life? After interviewing thousands of subjects, it appears that “pleasure” has only a marginal contribution to overall life satisfaction. “Flow” contributes much more strongly. “Meaning” has the largest contribution. A survey of 30,000 American households found that those who gave to charity were 43% more likely to say they were “very happy” than those who did not give.

58 Where We Go Wrong 1) Money 2) Family 3) Not taking into account impact bias and adaptation – nothing will be as good as we hoped 4) Not taking into account our psychological immune system – nothing will be as bad as we were afraid of 5) Trying to maximize our options 6) The self-esteem movement 7) The comparing mind

59 Can Money Buy Happiness? The historical research says money can buy happiness and it already has. Throughout history, most people have been racked by illness, the desperate hunger of their children, continual drudgery, and the threat of violent animals. However, data suggests that once you have enough, more money does not make much difference.

60 Money and Happiness People who make $50,000/yr are a lot happier than those who make $10,000. But people who make $5 million/year aren’t that much happier than those who make $100,000/yr. The data says that if you are poor, a little money can buy a lot of happiness. But if you are rich, a lot of money can only buy you a little more happiness.

61 Does Money Buy Happiness? People with lots of money are not happier than those with enough. Wealth is like health: its absence breeds misery, but having it is not guarantee of happiness. If people don’t worry about money, they worry about something else.

62 Why People Have Children (Pew Research, 2010)

63 What Would Make You Happy? Most people believe that having children would make them happy. As far as children are concerned, most parents would say that some of their best moments of happiness involved their children, but on a day-to-day level, people aren’t particularly happy when they’re interacting with their children. Women looking after their children are significantly less happy than when they’re watching TV. (Children are hard work!)

64 Marital Satisfaction: 4 Studies

65

66 Are Options Good For Us? The more choices we have, the more likely we are to regret our choice. It is easy to idealize the choice we did not take. We experience an “escalation of expectations.” Some psychologists have concluded that our current abundance of choices often leads to depression and feelings of loneliness. We have only ourselves to blame if we are unhappy with what we get.

67 Can We Be Happier? Freud says, no. – But we can turn “hysterical misery into ordinary human unhappiness” Madison Avenue says, yes. – “Life is short. Let us spend.” (inscription on an ancient Sumerian coin) David Mays says, yes, but... – We can be happier in the same way we can be more physically fit. We can do it, but we have to work at it, not just wish for it. And some of us have to work harder than others.

68 Happiness as a byproduct of living your life is a great thing. But happiness as a goal is a recipe for disaster. Barry Schwartz, Swarthmore College

69 Increasing Pleasure Learn to savor what is happening now. Single task: you can’t fully pay attention to multiple things. (People who multitask are not doing anything as well as people who single task.) Plan to take time for yourself and do those things that make you feel good. Like taking a walk...The natural world makes most humans happy. More money is spent worldwide on visiting zoos than any other recreational activity. Or listening to music you enjoy. Listening to music causes dopamine release in the nucleus accumbens, and causes people to synchronize their movements together.

70 Increasing Pleasure Let yourself be happy when you have a good moment! Research shows that humans are hard- wired to scan for the bad. Aversive events get stored more quickly in memory, and are more rapidly recalled. Positive events are stored through the standard memory systems and need to be held in conscious awareness for seconds for them to be coded and held onto. Help positive events become positive experiences by paying extra attention to them. Hold them in consciousness longer. Savor them so they sink in.

71 Increasing Pleasure Frequent small events have a bigger impact than occasional large events. This means spending fifteen minutes every evening of your life with a relaxed drink and a sympathetic friend will make you happier than winning the lottery.

72 Increasing Pleasure Slow down: time affluence predicts happiness better than monetary affluence. Eliminate some of the less enjoyable ways you spend your time. Be active: set new goals and plan new activities. The boost in happiness you get from a new undertaking lasts longer than that brought on by simply new circumstances. Simplify: too many choices makes us unhappy

73 Improving the Good Life Recall, the qualities of people who were found to be happy most of the time were: – Extroverted/Social – Optimistic – Appreciative

74 Expanding the Social World People with 5+ friends outside of immediate family are happier than those with fewer friends. Work toward spending more time socializing. Can pets increase your happiness? – Absolutely!

75 Increasing Optimism Pessimists who spent one week writing down experiences when they felt good about themselves and others were happier than controls 6 months later.

76 Increasing Gratitude At the end of the day, write down three things that went well during the day. Do this every night for a week. After each positive event on your list, think about why this good thing happened.

77 Increase the Capacity for Flow People vary in how much they value having flow experiences and how easily they can do it. Learn to recognize your strengths and interests and re-craft your life (work, play, love) to utilize these strengths. Cultivate concentration – e.g. meditation Balance challenge with skill Recognize the paradox that most people tend to choose relaxation activities that do not lead to flow (e.g. TV)

78 Re-setting our “Set Point” Meditation – In 2003, a study at UW Madison studied the effects of an 8 week course of Mindfulness Based Stress Reduction on 41 subjects. The results demonstrated an increase in pre-frontal left anterior brain activation (relative to right side) and increases in immune response to flu vaccination. Left side activation has been related to better positive mood states as opposed to more negative mood states associated with right frontal activation. These changes continued through an 8-month follow up brain scan.

79 Meditation The right prefrontal cortex is believed to be responsible for the hypervigilance typical of people under stress. One of the characteristics of people with depression is an excessive self-focus, an exaggerated negative self- representation, and a tendency to confuse one’s negative perceptions with actual external reality. It is possible that the meditative state is in part a state where the meditator has taught himself/herself to dampen right frontal activity and cultivate left frontal activity (consistent with the goal of losing the self.)

80 Meditation Recent studies have shown that subjects who focus on their emotional state, rather than just thinking globally about themselves, show reduced activity in the amygdala and create a calming effect. This sort of awareness buffers the brain’s emotional responses to events.

81 Meaningful Life Exercise Write a eulogy for yourself that describes how you spent your life, what your best accomplishments were, and what was most satisfying to you. Think about any gaps between how you would like to be remembered and what you have done. Take active steps to reach some new goals. A 2006 study showed that simply counting the number of kind acts that you perform each day for a week made participants feel happier. (The number of kind acts increased as well!)

82 Take Care of Yourself! Exercise, sleep, diet Avoid violent TV, media, and movies Get yourself into a positive frame of mind before your sessions. People who feel good perform better and are better liked by others. End sessions with compliments or positive remarks. That’s what people remember. Your friends: your happiness depends on the happiness of others with whom you are connected


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