1. Cardiac Rehabilitation Programme Stress Management Andrea Papitsch-Clark Clinical Health Psychologist

2. Stress in everyday life What does it feel like to be stressed? What does it feel like not to be stressed? What causes YOU stress?  Emergencies (e.g. fall, emergency stop, being startled by something etc.)  Life events (e.g. bereavement, illness, marriage, holiday, change job)  Daily hassles (e.g. stuck traffic jam, arguments, queue in supermarket etc.)

3. What is stress? What is stressful differs from one person to the next, and also how we experience stress may differ from person to person. Definition of stress: “stress is a condition or feeling, experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilize” (according to Richard S Lazarus)

4. Symptoms of stress Physical Muscle tension, aches Tension headaches Breathlessness Change in appetite Tiredness, sleeplessness Increased blood pressure Behavioural Smoking Drinking more alcohol Poor concentration Putting things off Inability to finish things Avoiding people Thoughts Intrusive, unwanted thoughts Worrying obsessively Inability to make a decision Self-criticism Being critical of others Lapses in memory Feelings Irritability Anger or resentment Loss of temper Anxiety Feeling tearful Loss of sense of humour Feeling guilty

5. Physiological effects of stress Adrenaline is released when our brains perceive we are under threat or in danger. Evolutionary fight or flight response. Body's reaction:The effect: Pupils dilate Heart rate increases to send o2 to muscles Blood pressure rises Breathing faster Digestion slows down Muscles tense, ready for action Blurred vision Palpitations, heart pounding Light-headed Dry mouth, short of breath Indigestion, butterflies, nausea Tremor, jelly legs Useful in real emergency…but not in everyday hassles

6. Stress thermometer Excited Alert Wide awake Calm Sleepy Very relaxed Panic Fear Worried Bad tempered Tense Some adrenaline = Good Too much adrenaline = Bad Most people have raised adrenaline levels after a cardiac event - normal to feel worried. Any other worries or events can be enough to put adrenaline levels even higher

7. Does stress cause heart disease? It is recognised that stress contributes to CHD, but we can’t say for certain whether stress directly causes CHD. …. BUT Long-term stress can make us feel miserable, drained and unwell. It can affect our attitude or ‘state of mind’ and make us rely on ‘short-term fixes’ like smoking, drinking, not exercising, unhealthy eating, all of which DO contribute to heart disease…

8. Does stress cause heart disease? ….ALSO stress can affect the heart by releasing certain hormones that increase blood pressure and can encourage clotting of the arteries. Stress can also make us feel less motivated to spend time on healthy behaviours such as relaxation or exercise.

9. Unhelpful thoughts/interpretations Being under stress can lead to unhelpful thoughts such as: “There’s nothing that will help me” “I’m not getting better, I’m getting worse” “It’s dangerous for people with heart problems to argue” “I should be able to cope” This can lead to a vicious cycle, with unhelpful thoughts raising adrenaline and producing unpleasant physical effects, which leads to more worrying thoughts, in turn leading to more stress and so on…

10. Physical effects: e.g. increase adrenaline (increase HR, faster breathing, tension etc.) Behaviour: Stop what doing, reduce overall activity, lose fitness etc. VICIOUS CIRCLE OF STRESS/ANXIETY Feelings: Raised anxiety, fear, frustration Thoughts: “There’s not much you can do about heart problems” “There’s something wrong with my heart” Trigger stimulus Internal external

11. Coping with stress

12. 1. Learning to spot when stress levels are building up Feeling stressed and tense can become a habit Be aware of daily hassles and strains increasing stress levels What was I thinking about, or doing or what had happened just before I started to feel like this? Are there other ways of looking at the situation? Panic Scared Worried Bad tempered Tense Excited Alert Wide awake Calm Relaxed

13. Challenging unhelpful thoughts Remember that unhelpful thoughts can raise adrenaline levels, and in turn increase stress. BUT: can try to challenge unhelpful thoughts Ask yourself:  Is this thought really true/true all the time?  Am I considering all the evidence?  Am I ignoring any strengths or positives?  Am I jumping to conclusions?

14. 2. Challenge unhelpful thoughts “ Having considered these questions, can you come up with a different, more balanced, more positive thought? “My heart is not worn out” “Most people make a full recovery after a heart attack” “There are many things I can do to prevent CHD” “It was a blockage in an artery – not the heart that caused the problem” “Relaxation is not just being lazy it’s important for health and well-being”

15. Physical effects: More relaxed Behaviour: Healthy lifestyle changes, active, see friends, set goals BREAK THE VICIOUS CYCLE Feelings: Positive, calm, optimistic, motivated Thoughts: “There are many things I can do to fight CHD”

16. 3. Problem-solving For example…. Are you managing your time effectively? Can you cut back on some things if you’ve taken on too much? Are your goals/expectations realistic? Can you speak to somebody about it? Can you prioritise the most important things that need to be done? Can you say NO to some things?

17. Adopting ‘Low stress’ ways of living and working Making time for enjoyable activities Switching off from thoughts/worries Slowing down, taking your time Taking a break Being relaxed; practising relaxation Thinking about what you have achieved, not worrying about what you haven’t Talking about how you’re feeling Leading a healthy lifestyle

18. 4. Relaxation Important for everyone to have times when they relax during the day – stick to them – it doesn’t mean you’re being lazy. Lowers adrenaline Reduces stress Lowers blood pressure Increases feelings of being in control Reduces pain Improves sleep Reduces tension Helps us feel better able to cope with problems Helps reduce fears and anxieties Improves well-being Rest and relaxation are as important as work. Relaxation is more than just watching TV!

19. Things you can do… 1. Learn to recognise when you are stressed before it becomes a long-term problem. Be aware of daily hassles keeping adrenaline levels high. 2. Be aware of unhelpful thoughts and how they can increase adrenaline. Try and replace with more balanced alternative ways of thinking. 3. Make time for yourself for relaxation and enjoyable activities and stick to them. Practice breathing exercises everyday 4. Change ways of doing things to lower stress levels and anxiety 5. If things are too much to cope with, remember there is help and support available. Talk to the CR team.

20. THANK YOU! Any questions?