Stress, Burnout, Humor, and Happiness David Mays, MD, PhD dvmays@wisc Stress, Burnout, Humor, and Happiness David Mays, MD, PhD dvmays@wisc.edu

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

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

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

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)

Stress Obviously, there is an adaptive component to the fight or flight phenomenon. There may also be an adaptive feature to being afraid of loneliness, or shutting down when we are afraid/depressed, which can save energy or elicit concern from others. Just as obviously, there is a physical cost from being stressed. Not so obvious is defining exactly what stress is.

What is a stressful experience? The experience must be unpleasant. (Would you avoid this experience if you could?) The experience must lead to a heightened degree of arousal. The experience must be out of the subject’s control. This determines the intensity of the response. And it is the intensity of the response that determines the degree of stress-induced problems on the organism.

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.

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.)

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).

Stress: Memory Effects The amygdala is a central brain structure that processes fearful stimuli. It is directly connected to the hippocampus. The hippocampus is primary structure involved in memory formation. 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.

Chronic Stress Chronic stress results in hypertrophy of the adrenal gland and persistent elevations of cortisol. The LC also fires faster at lower levels of stimulation. These changes result in depression of reproductive functioning, reductions in growth hormone, vagus nerve blockade (GI shutdown), insulin resistance, depression, panic, and anxiety. Uncontrollable stress produces reductions in LC-NE levels - depression, learned helplessness.

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

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

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

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.

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.

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

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)

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

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.

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

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.

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.

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.

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.

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.

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.

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.)

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.

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.

Goals of Complaining venting prevents internal rumination communicates saves face diffuse negative emotional experiences helps develop insight expresses solidarity socialization

Negative Effects of Complaining people find it annoying it affects how people perceive you it makes others more dissatisfied

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.

People high in negative affect are no less healthy and do not have a higher mortality than positive people. They just complain a lot.

Defensive Pessimism, Strategic Optimism Defensive pessimism - a strategy that anxious individuals may use by setting low expectations and rehearsing negative outcomes. Strategic optimism - a strategy of setting optimistic expectations for outcome and avoiding extensive reflection.

Who Does Better? Both groups do equally well on tasks and both show performance decrements when not allowed to use their preferred strategies. Optimists tend to feel better and be more satisfied. You can cheer the pessimists up, but a positive mood impairs their performance and does not make them feel more satisfied.

The Power of Negative Thinking In the elderly and the sick, defensive pessimism may improve outcome and adaptation. Unrealistic optimism may blind people to feedback and prevent normal precautionary measures. There is little empirical evidence that people can change their coping styles, and there is ample evidence that their performance deteriorates when they try.

Life is not being dealt a good hand. It is playing a poor hand well. Anonymous

Laughter Nobody understands humor. The biggest laugh getters at social occasions are not jokes (99% of people can’t remember a joke) but remarks like “see you later” or “must be nice.” The speaker laughs more than the listeners. Laughter is not necessarily linked to humor. We seldom laugh at funny things when we are alone, for example, but we laugh quite quickly when meeting an old friend.

Laughter Robert Provine, Univ Maryland, traveled streets of Baltimore with a video camera, asking people to laugh. They couldn’t facing the camera, but when they turned to a person next to them, they could. Often we’re not even aware we’re laughing. It is very much out of our conscious control. It is located in the brainstem (stroke victims). Chimps laugh and tickle each other throughout life.

The Physical Effects of Laughter The Physical Act of Laughing: Increases respiration and oxygen exchange Activates muscles - and then relaxes intercostals, abdominals, diaphragm, muscles of neck and shoulders. A hearty belly laugh effects almost all muscle groups. Stimulates cardiovascular system Stimulates sympathetic nervous system Raises blood pressure during laughter, lowers it after Body temperature increases Increases release of endorphins and enkephalins Increases salivary immunoglobulin A

Function of Laughter All of these things make sense if we regard laughter as a facilitator of human bonding, which is a necessary component of health. “The shortest distance between two people is a laugh.” Victor Borge

Development of Humor Babies smile around 6 weeks, and later chuckle when their mother plays with them. At 10 weeks, a baby smiles at surprises and relief. At 16 weeks, the baby is smiling about 1x per hour. By 10 months, visual and social stimuli are beginning to elicit smiles, like when mom crawls on the floor like a baby. Around 11-12 months, the baby begins to take the initiative in fun: peek-a-boo. Around 4 years old, we see the first signs of kids laughing at themselves.

Humor Test The neighbor approached Mr. Smith at noon on Sunday and inquired, “Say, Smith, are you using your lawnmower this afternoon?” “Yes, I am,” Smith replied warily. The neighbor answered: A. “Oops,” as the rake he walked on hit him in the face. B. “Oh, well. Can I borrow it when you’re done?’ C. “You won’t be wanting your golf clubs. I’ll borrow them.”

Richard Wiseman Two thousand jokes, generally 4 themes: Trying to look clever and messing up Husband and wife conflict Doctors being insensitive to imminent death God making a mistake The funniest animal is a duck The funniest joke…

Why are things funny? More than 100 theories Superiority theory (aggression): Plato, Aristotle Incongruity theory: Pascal 17th Century (surprise - coherence, tension release) Release theory: Freud, Jokes and Their Relation to the Unconscious “A quota of psychical energy which has earlier been used for cathexis of psychical paths and become unusable so that it can find free discharge.”

Criteria for Humor 3 criteria for determining appropriateness of humor: 1) Timing 2) Receptivity 3) Content Genuineness of the interpersonal relationship. The relationship must be non-exploitive, respectful, tolerant.

Criteria for Humor Impediments to humor: confusion depression paranoia offensiveness

Humor and Psychotherapy Inhibitions are released, aids clients feeling relaxed, letting go of defenses Aids diagnosis May facilitate moments of insight Helps build perspective

Concerns Humor reduces distress, but is this always desirable? Humor can be a form of denial in the client and may perpetuate inaction. Inappropriate humor can create more tension and block communication. Inappropriate humor may represent a destructive countertransference. Therapists may be using humor aggressively in an attempt to develop rapport or to avoid anxiety provoking themes.

Requirements Accurate empathy in clinician. There is usually a subtle context of permission to use humor. Awareness of your own feelings (countertransference) Avoid sarcasm, abusive humor Be aware that clients may not feel you are taking them seriously. Some things are not funny.

Who’s Happy? Apparently Everybody. 90% of Americans describe themselves as very/fairly happy. Everyone thinks they are happier than the average person. Almost everyone puts themselves near the maximum of possible happiness. This has been true throughout history, as far as we have available records. Individuals may have ups and downs, but the level of happiness remains very stable from childhood. Like blood pressure, happiness fluctuates around a certain level for each of us. Or so it seems…

A Happiness Thermostat? Although happiness levels are moderately stable throughout life, large and lasting changes can occur. In some people, big events like a bad divorce, unemployment, or severe illness and disability did seem to effect them throughout their life, changing their level of happiness. But how we react plays a crucial role.

What Would Make You Happy? Most people believe that having more money and 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!)

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. Most of us believe that just “a little more” money, a little bigger house, five less pounds, etc…we would be happier.

Predictors of Happiness Strong Influence on Happiness High self-esteem Optimistic and outgoing Close friendships/good marriage Work and leisure that engages skills (usually less expensive - gardening, social contact, etc) Meaningful religious faith “Satisficers” (those who aim for good enough)

Predictors of Happiness Weak Influence (less than 2% of the variance) Gender Race Educational level Parenthood (frequently negative)

Predictors of Unhappiness Strong Influence on Unhappiness Hunger Disease Poverty Oppression Dangerous environment “Maximizers” (those who want the best)

The Pursuit of Happiness Impact Bias Psychological Defense Mechanisms Adaptation Comparing Mind

The Pursuit of Happiness: Impact Bias Our actions are based on our predictions of the emotional consequences, but when it comes to predicting how we will feel in the future, we are most likely going to be wrong. This is because our memories of events are really very sketchy. Consequently, our brains tend to fill in the details based on how we are feeling in the present moment. If we are exhausted right now for instance, we do not want to plan an active weekend.

The Pursuit of Happiness: Impact Bias We overestimate the intensity and the duration of our emotional reactions to future events - the good and the bad. This is called “Impact Bias.”

The Pursuit of Happiness: Defense Mechanisms Another reason we cannot estimate the emotional consequences of our actions is the powerful roles that psychological defenses play in coping with very big problems. These end up causing us less discomfort than the ordinary minor annoyances in our lives (Toothpaste cap left off). People with cancer are more optimistic about their future than people in good health. We also cope with what we’re stuck with.

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: Unhappy - 22% of the time

The Pursuit of Happiness: Adaptation Impact bias makes sense biologically. Soon after a major event, we return to our set point, so we can be motivated again. This is called “Adaptation.” Our brains are not trying to make us happy. They are trying to regulate us. The problem is that we seem unable to to learn that we adapt, and we keep being driven by the same desires and pleasures. Our unimaginably successful consumer driven culture is based on this phenomenon.

The Pursuit of Happiness: The Comparing Mind Satisfaction, success and failure are all relative. We seem unable to not compare ourselves with other people. Sometimes, we can increase our happiness by looking at people less fortunate than ourselves. But most of the time, we feel that we deserve more. (When Oakland athletics outfielder Jose Conseco was offered $4.7 million annual salary, his fellow outfielder Rickey Henderson refused to show up to spring training because he only made $3 million annually.)

“I wish I came in first more often.” Michael Jordan Newsweek 2/17/1992

“I have also learned why people work so hard to succeed: It is because they envy the things their neighbors have. But it is useless. It is like chasing the wind…It is better to have only a little, with peace of mind, than be busy all the time with both hands trying to catch the wind.” Ecclesiastes 4:4

Can We Be Happy? Freud says, no. Madison Avenue says, yes. Science says, maybe.

The Three Faces of Happiness Pleasure The good mood (set at birth, right vs. left brain) Overall quality of life, satisfaction and contentment (more about ethics and values)

Some Suggestions for Finding Happiness Find ways to think less about yourself and more about others. Spend time with friends. Be physically active. Be actively engaged in your activities. Cultivate a spiritual life.

Some Suggestions for Finding Happiness Work on being a “Satisficer” rather than a “Maximizer.” Restrict your options (two stores, e.g.) Realize when a choice has met your core requirements Consciously limit the time spent on wondering about other options that you have missed.

Some Suggestions for Finding Happiness Live longer. The 70’s are the best time of life. (The 20’s and 30’s are among the least happy decades for adults.) The shift begins around age 50. They are faster to react to a smiling face than to a sad or distressed face, the amygdala calms faster during stressful emotions, the prefrontal cortex more actively quiets negative emotions. Older people think less about doing things as an investment, and more about what makes them happy now. They are also more skilled at avoiding bad experiences.

Some Suggestions for Finding Happiness Stop looking. Total happiness is not attainable. By pursuing happiness, we cause it to recede farther away from us. True happiness comes when we are focused on living a life of generosity and integrity.