Stress

Stress is not harmful when managed effectively. With the increased awareness of the impact of stress on the body has come a variety of stress-reducing techniques derived from behavior therapy. Stress management training enables the patient to condition his or her body to cope more adaptively with stress or anxiety. As part of a comprehensive treatment program, the primary care physician may choose to train the patient in one or more of the self-regulatory procedures. Relaxation training is by far the most effective of the procedures.

Before proceeding to train the patient in relaxation as a self-control procedure, the physician should advise reduction or elimination of caffeine from the patient’s diet, because relaxation training is aimed at lowering the patient’s autonomic arousal level and caffeine augments arousal.

Progressive deep muscle relaxation, autogenic training, and diaphragmatic breathing represent the major techniques practical for use in the primary care setting.

Progressive deep muscle relaxation is probably the most extensively used and most effective relaxation technique today for the treatment of anxiety and stress-related problems. A brief modified version can be taught to the patient in one session. The rationale for the technique is the view that anxiety and relaxation are mutually exclusive; that is, anxiety cannot be experienced when the muscles are relaxed.

Progressive deep muscle relaxation is a simple procedure contrasting tension with relaxation. Because a person generally has very little awareness of the sensation of relaxation, one is asked first to tense a set of muscles as hard as one can until they can feel tension in the muscles. Then one allows those muscles to relax and tries to become aware of (“to feel internally”) the difference between tension and relaxation.

This relaxation technique entails the systematic focus of attention on specific gross muscle groups throughout the body. The patient is instructed to actively tense each muscle group for 10 to 15 seconds, after which they are told to let go of the tension in the muscles, observe the difference, and relax the muscles. The sequence of tensing the muscles, letting go of the tension, and noting the difference between tension and relaxation is systematically applied to a host of muscle groups starting at the head and ending at the toes

Autogenic training is a relaxation technique composed of a set of exercises that are intended to induce heaviness and warmth in the muscles through mental imagery.

Autogenic training typically involves the patient sitting comfortably in an armchair in a quiet room with the eyes closed. Verbal formulas are introduced (e.g., “my arm is heavy”), and the patient is instructed to visualize and feel the relaxation of the muscle being focused on while silently repeating and passively concentrating on that formula. The formulas, which consist of verbal somatic suggestions, are intended to facilitate concentration and “mental contact” with the parts of the body indicated by the formula.

Training consists of six psychophysiologic exercises, which are practiced several times a day. The training begins with the theme of heaviness (e.g., “my arm feels heavy and relaxed”). The second group of formulas involve warmth (e.g., “my arm feels warm and relaxed”). After warmth training, the patient continues with passive concentration on cardiac activity (e.g., “my heartbeat feels calm and regular”). The fourth exercise focuses on breathing and respiration. In the next exercise, the patient focuses on warmth in the chest and abdomen, and in the last exercise the focus is passive concentration on cooling of the forehead.

In modern practice, the time and the six standard exercises have been condensed so that a whole round can be practiced in a very brief period of between 5 and 10 minutes. In this condensed version, the autogenic training phrases are focused primarily on the physiologic aspect used in the training, interspersed with general suggestions for relaxation. Each phrase is said slowly, allowing time for the patient to begin to feel some awareness of the effect of the suggestion.
DIAPHRAGMATIC BREATHING

The quickest and simplest method of relaxation is to breathe slowly and deeply from the belly. Diaphragmatic breathing is an effective means of coping with and reducing stress.

For centuries, students of yoga and zen have been aware that a mastery of breathing could slow heart rate, lower blood pressure, and calm the body. Diaphragmatic breathing involves parasympathetic nervous system stimulation. Diaphragmatic breathing prevents the possibility of hyperventilation and, after 50 to 60 seconds of such breathing, brings a feeling of quiescence to the body and reduction in bodily symptoms of stress.

Training in diaphragmatic breathing can be done either sitting or lying down. In either position, a pillow should be placed at the small of the back to force the belly out. Breathing should begin by pushing the stomach out as inhalation takes place slowly and deeply. Care should be taken to minimize the movement of the chest with each inhalation. The word “relax” should be said silently before exhaling, and the stomach should fall with exhalation.