University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Stress

It seems that everyone is feeling stressed out these days. With uncertainty in social and economic issues here in America and difficult worldwide problems such as violence, pollution, contagious diseases, and the effects of poverty, you could say that it's a stressful world we live in. Our personal lives are filled with stress also: making ends meet, getting education for ourselves or our children, keeping our homes and selves safe from crime, maintaining our health in the face of "epidemic" rates of obesity and related illnesses like diabetes and heart disease, trying to find "quality time" to spend on the people and activities that are most meaningful to us. The worst part of stress is that it can make us physically sick. For people with spinal cord injuries, stress can even make it more likely that a pressure ulcer (which means the same thing as "pressure sore" or "bedsore") will develop.

Stress can be divided into two categories: acute, that is, one-time or sudden sources of stress, lasting for a matter of minutes or hours, and chronic, that is, ongoing or long-term stress that lasts for extended periods every day for weeks or months, even years 1. But both forms can be equally damaging to your health. When it comes to acute stress, probably the term that would best describe the cause is life events, that is, unexpected happenings that have a major impact on us. Two researchers from the University of Washington, Thomas Holmes and Richard Rahe, identified some of the most common and most powerfully upsetting life events. They used that information to create a way to estimate how stressful a person's life is by giving a certain number of points to each event, based on how difficult that event was for most people to deal with. The result was called the Holmes and Rahe stress scale.

Chronic stress can come from any number of sources. Think of subjects that can cause ongoing or lasting worries, such as money, family conflicts, relationships, and community or local issues. For people with spinal cord injuries, there can be extra stresses just in everyday activities, which can be more difficult to carry out than before the injury occurred. One study points out that some of the sources of stress for people with spinal cord injury include physical changes, family and other personal relationships and work responsibilities 2. While many people are concerned about getting good medical insurance for their families, or how they will get by without insurance, the health complications that can come with spinal cord injuries make health care coverage a must. But just having coverage doesn't automatically bring medical treatment; there is still the need to negotiate the system (that is, figure out the rules and follow them), and deal with anything else that might limit access to health care, such as cultural or language barriers, distance from a specialized facility, or other obstacles. There might also be stress caused by dealing with care attendants if a person has not yet found a helper they can trust over the long-term. And, not surprisingly, if a person's health condition is not stable or steady, that can also cause a lot of worry.

Many people, whatever the status of their health, experience chronic stress from their jobs. When businesses ask employees to take on a heavier load because co-workers have been fired or laid off, the stress piles on. This problem can be so bad that, for example, in Japan, the term "karoshi" has been created to refer to "death from overwork!" Experts also point out that when you spend too much time working, you miss out on activities that would probably be most beneficial to your peace of mind and well-being, such as spending time with family and friends or participating in hobbies and relaxation. Strangely, career consultants also say that sometimes it's not the boss that's asking people to work long hours; some employees feel like they can't leave until they've completed a big project, or that the way to get ahead is to stay on the job from morning to night 3. Sometimes workers take double-shifts just to earn enough money to make ends meet. And the problems of work stress might be even greater for a person with a spinal cord injury, since long hours up in the wheelchair also add to the risk of developing a pressure ulcer.

So it's clear that stress is a common problem today, but how exactly does stress lead to getting a pressure ulcer? There are four ways this can happen. One connection between stress and pressure ulcers comes from the physical effect stress can have on the immune system, which is the body's way of protecting against disease. Stress has been proven in many medical studies to lessen the immune system's power and performance; this effect is called immunosuppression, or "lowering your resistance." 1 When your resistance is low, you are less able to fight bacteria (which cause the infections that often go along with pressure ulcers). Bacteria can then take hold in the tissue, or flesh, that is under any part of your skin that is under pressure or even slightly damaged, like from a cut or scrape. The result: a pressure ulcer appears. That's what happened to Ken, one of our study participants, who felt very stressed out when his mother left town and he had trouble hiring a care attendant; sometimes his new attendants quit after only a few days. Ken wound up with urinary tract infections, and pressure ulcers due to the stress, and to the poor level of care he received when his mother was gone. Another study participant, Aaron, felt chronic stress due to financial problems and worries about the safety of family members living in a high-crime neighborhood.

Another road from stress to pressure ulcers is a little less direct, but just as likely to cause trouble: when a person feels stressed out, they are more likely to skip usual habits, including the habits of pressure ulcer prevention such as using lotion, double-checking that clothing and bedding are completely smooth, skin checks, pressure reliefs, and so on. An example of this comes from study participant Brenda's life; when she learned she might have breast cancer, her stress at this terrible news caused her to stop taking care of a small, new pressure ulcer while she waited to hear the results of the series of tests she had. Another study participant, Frank, was feeling stressed out by a number of issues that were happening in his family, so he stopped doing his daily skin checks; the result was that he got a pressure ulcer that needed surgery. As Frank himself described it:

"I got a little careless at the end, I guess.... I had a lot of problems at the time. I remember I had the attitude I didn't care at the time. I stop even treating myself a little bit and I paid for it."

A third link between stress and pressure ulcers comes from the way people deal often with stress. To escape stress, people often unwind by drinking or using drugs, and substance abuse also makes it more likely to get a pressure ulcer. Dave, who participated in our study, found this out when he would party with friends to relax from the stress of dealing with financial reversals at the company where he worked. The combination of all these factors led to a pressure ulcer that eventually required surgery.

Another possible cause of pressure ulcers is the overall damaging effect stress has on a person. Studies have found that extreme chronic stress can actually lead to a physical aging effect on the genes of the body's cells; this is sometimes noticed when a person who is under a lot of emotional stress looks tired and worn out 4. For example, sometimes if you look at a photo of a President of the United States before his term started, and then at a photo of the same man after he left office, they often look much, much older in the second picture. Even if you are not the president, stress can make your body seem to age, and an aging body can make a person more likely to develop a pressure ulcer.

The good news is, there are a number of things you can do to reduce or prevent stress. For example, there are many healthy stress reduction practices you can try, including relaxation and deep breathing techniques, guided imagery and visualization, listening to pleasing music, receiving massages (which you would have to check with your doctor about, but which could also help to relieve any problems you might be having with chronic pain), meditation and prayer. Medical professionals, such as an occupational therapist, can help you with suggestions and instructions in these and other stress reduction techniques. Participating in your favorite activities can also reduce stress, as can spending time with supportive family and friends. Many experts recommend ways of dealing with stress, especially work-related stress, that also help make your immune system stronger: specifically, getting plenty of sleep, quitting cigarettes, cutting down on or stopping drinking alcohol, quitting any recreational drugs, eating well and exercising. 3 This is really a time for you to think about your lifestyle and decide how to balance your need to get work done, with your need to protect your health.

Another way to battle stress is to change your attitude. Although this is not always easy and might take a while, you can create a more positive attitude about your ability to cope with stress, or about your self-efficacy (that is, ability to achieve goals), just as our study participant Ken did when he changed the depression he felt in the hospital into a commitment to get involved with his church and better himself by becoming a counselor. A person's emotions or attitudes can even influence their health; in fact, studies have found that having a positive, "can-do" attitude - what psychologists and others who deal with the science of human behavior call "the hardy personality" - can lead to better health, better on-the-job performance and a higher ability to handle stress and find a positive way to react when something unexpected happens 5 6. (To find out more about how your emotions and attitude can affect your health, see the section in this publication called "Emotions, Attitudes and Self-Efficacy".)

If stress is a serious problem for you, your doctor can give you a referral, that is, a prescription for specialized medical services, to talk with a counselor or mental health therapist. For example, one type of counseling called cognitive therapy helps people learn to react to stress in a different way, and can often be very effective in helping people to change their attitude toward stressful events 4. Anti-stress medications are another possibility for some people. Talking to a non-medical counselor, such as a leader in your religious congregation or trusted family friend, might also be helpful in reducing your level of worries or stress.

During World War II, President Franklin Roosevelt helped give courage to the American people by telling them that "we have nothing to fear but fear itself." In a similar way, you could say that the way to handle stress, is not to stress about stress! Of course it's true that the problems in someone's life don't magically melt away, but worrying about those problems, or letting problems cause stress, only makes things worse because of the harm stress can do to a person's health. Letting go of stress might be one of the best things you can do for yourself!

There are many good websites on the Internet where you can get more information about stress. Understanding and Managing Stress is an excellent article, on the website of Craig Hospital in Denver, Colorado, which talks about what causes stress, the problems that stress might create, and suggestions for reducing stress. There are also a lot of web pages with good ideas about how to help yourself deal with stress or let go of it, which is sometimes called stress management. One article with good advice about coping skills and support is on the website of the Mayo Clinic, a well-respected health care and research center in Rochester, MN. This page also has links to other topics that are important to people with spinal cord injuries, and you can search the website for reliable information about many illnesses and medical conditions. An online newsletter from the University of Michigan Medical School includes an article, Forgiveness and Spinal Cord Injury, about a study by Dr. Claire Z. Kalpakjian, Dr. Jon R. Webb and others that found something very interesting: people who have had a serious accident or injury but who are willing to forgive themselves and forgive others tend to feel better about their lives and to have better health than people who hold onto anger and stress. (Look for the article on page 7 of the newsletter.)

Coping With Life's Stressors is an article on the website of the Cleveland Clinic Health System (CCHS). You might also like another article by CCHS, The Phases of Stress, which explains the phases of stressors as their effects increase, and offers solutions to contend with each phase. CCHS even has an article, Coping With Holiday Stress, with suggestions for dealing with the stresses that come up at holiday time. And, in very technical language, Forgiveness linked to spinal cord injury rehab is an abstract of Dr. Webb's research into forgiveness and stress reduction.

1 Dhabhar, F. S. (2002). A hassle a day may keep the doctor away: Stress and the augmentation of immune function. Integrative and Comparative Biology, 42, (3), 556-564.

2 Galvin, L. R., & Godfrey, H. P. D. (2001). The impact of coping on emotional adjustment to spinal cord injury (SCI): Review of the literature and application of a stress appraisal and coping formulation. Spinal Cord, 39, 615-627.

3 Schwartz, J. (2004, September 5). Always on the job, employees pay with health. The New York Times. Retrieved September 5, 2004 http://www.nytimes.com/2004/09/05/health/05stress.html

4 Carey, B. (2004, November 30). Too much stress may give your genes gray hair. The New York Times. Retrieved November 30, 2004 http://www.nytimes.com/2004/11/30/health/30age.html

5 Harris, S. M. (2004). The effect of health value and ethnicity on the relationship between hardiness and health behaviors. Journal of Personality, 72, (2), 379-412.

6 Maddi, S. R. (2004). Hardiness: An operationalization of existential courage. Journal of Humanistic Psychology, 44, (3), 279-298.