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An in-depth report on the causes, diagnosis, treatment, and prevention of stress.

Lifestyle Changes

A healthy lifestyle is an essential companion to any stress-reduction program. General health and stress resistance can be enhanced by regular exercise, a diet rich in a variety of whole grains, vegetables, and fruits, and by avoiding excessive alcohol, caffeine, and tobacco.

Of interest, a 2003 study suggested that fish oil, which has been associated with a lower risk for heart disease and stroke, may blunt some of the harmful effects of mental stress on the heart.

In one 2002 study, high doses of vitamin C reduced stress levels and blood pressure. The doses given were higher than the recommended upper limit of 2000 mg/day. High doses may cause headaches and diarrhea. Long-term use increases risk for kidney stones and has other adverse effects in specific individuals.


Exercise in combination with stress management techniques is extremely important for many reasons, including the following:

  • Exercise is an effective distraction from stressful events.
  • Exercise may directly blunt the harmful effects of stress on blood pressure and the heart. (Exercise protects the heart in any case.)

Usually, a varied exercise regime is more interesting, and thus easier to stick to. Start slowly. Strenuous exercise in people who are not used to it can be very dangerous and any exercise program should be discussed with a physician. In addition, half of all people who begin a vigorous training regime drop out within a year. The key is to find activities that are exciting, challenging, and satisfying. The following are some suggestions:

  • Sign up for aerobics classes at a gym.
  • Brisk walking is an excellent aerobic exercise that is free and available to nearly anyone. Even short brisk walks can relieve bouts of stress.
  • Swimming is an ideal exercise for many stressed people including pregnant women, individuals with musculoskeletal problems, and those who suffer exercise-induced asthma.
  • Yoga or Tai Chi can be very effective, combining many of the benefits of breathing, muscle relaxation, and meditation while toning and stretching the muscles. The benefits of yoga may be considerable. Numerous studies have found it beneficial for many conditions in which stress is an important factor, such as anxiety, headaches, high blood pressure, and asthma. It also elevates mood and improves concentration and ability to focus.

As in other areas of stress management, making a plan and executing it successfully develops feelings of mastery and control, which are very beneficial in and of themselves. Start small. Just 10 minutes of exercise three times a week can build a good base for novices. Gradually build up the length of these every-other-day sessions to 30 minutes or more. [See also Well-Connected Report #29, Exercise.]

Cognitive-Behavioral Techniques

Cognitive-behavioral techniques (CBTs) are the most effective ways to reduce stress. A CBT typical approach includes identifying sources of stress, restructuring priorities, changing one's response to stress, and finding methods for managing and reducing stress.

CBT may particularly helpful when the source of stress is chronic pain or other chronic diseases. In fact, in one study of HIV patients, it was more helpful even than support groups for improving well-being and quality of life.

Identifying Sources of Stress. One key component in most CBT approaches is a diary that keeps an informal inventory of daily events and activities. While this exercise might itself seem stress producing (and yet one more chore), it need not be done in painstaking detail. A few words accompanying a time and date are usually enough to serve as reminders of significant events or activities.

The first step is to note activities that put a strain on energy and time, trigger anger or anxiety, or precipitate a negative physical response (e.g., a sour stomach or headache).

Also note positive experiences, such as those that are mentally or physically refreshing or produce a sense of accomplishment.

After a week or two, try to identify two or three events or activities that have been significantly upsetting or overwhelming.

Questioning the Sources of Stress. Individuals should then ask themselves the following questions:

  • Do these stressful activities meet their own goals or someone else's?
  • Have they taken on tasks that they can reasonably accomplish?
  • Which tasks are in their control and which ones aren't?

Restructuring Priorities: Adding Stress Reducing Activities. The next step is to attempt to shift the balance from stress-producing to stress-reducing activities. Eliminating stress is rarely practical or feasible, but there are many ways to reduce its impact.

Consider as many relief options as possible. Examples include the following:

  • Listen to music. Music an effective stress reducer in both healthy individuals and people with health problems. In a 2001 study, for example, students who listened to a well-known gentle classical piece of music during a stressful task had reduced feelings of anxiety, heart rate, and blood pressure.
  • Take long weekends or, ideally, vacations.
  • If the source of stress is in the home, plan times away, even if it is only an hour or two a week.
  • Replace unnecessary time-consuming chores with pleasurable or interesting activities.
  • Make time for recreation. (This is as essential as paying bills or shopping for groceries.)
  • Own a pet. In a 2001 study of people with high blood pressure, pet owners had much lower blood pressure increase in response to stress than non-owners. (Pet owning was beneficial only for people who like animals to begin with.)

Discuss Feelings. The concept of communication and letting your feelings out has been so excessively promoted and parodied that it has nearly lost its value as good psychologic advice. Nevertheless, feelings of anger or frustration that are not expressed in an acceptable way may lead to hostility, a sense of helplessness, and depression.

Expressing feelings does not mean venting frustration on waiters and subordinates, boring friends with emotional minutia, or wallowing in self-pity. In fact, because blood pressure may spike when certain chronically hostile individuals become angry, some therapists strongly advise that just talking, not simply venting anger, is the best approach, especially for these people.

The primary goal is to explain and assert one's needs to a trusted individual in as positive a way as possible. Direct communication may not even be necessary. Writing in a journal, writing a poem, or composing a letter that is never mailed may be sufficient.

Expressing one's feelings solves only half of the communication puzzle. Learning to listen, empathize, and respond to others with understanding is just as important for maintaining the strong relationships necessary for emotional fulfillment and reduced stress.

Keep Perspective and Look for the Positive. Reversing negative ideas and learning to focus on positive outcomes helps reduce tension and achieve goals. The following steps using an example of a person who is alarmed at the prospect of giving a speech may be useful:

  • First, identify the worst possible outcomes (forgetting the speech, stumbling over words, humiliation, audience contempt).
  • Rate the likelihood of these bad outcomes happening (probably very low or that speaker wouldn't have been selected in the first place).
  • Envision a favorable result (a well-rounded, articulate presentation with rewarding applause).
  • Develop a specific plan to achieve the positive outcome (preparing in front of a mirror, using a video camera or tape recorder, relaxation exercises).
  • Try to recall previous situations that initially seemed negative but ended well.

Use Humor. Research has shown that humor is a very effective mechanism for coping with acute stress. Keeping a sense of humor during difficult situations is a common recommendation from stress management experts. Laughter not only releases the tension of pent-up feelings and helps keep perspective, but it appears to have actual physical effects that reduce stress hormone levels. It is not uncommon for people to recall laughing intensely even during tragic events, such as the death of a loved one, and to remember this laughter as helping them to endure the emotional pain.

Relaxation and Other Alternative Techniques

Relaxation Methods. Since stress is here to stay, everyone needs to develop methods for invoking the relaxation response, the natural unwinding of the stress response. Relaxation lowers blood pressure, respiration, and pulse rates, releases muscle tension, and eases emotional strains. This response is highly individualized, but there are certain approaches that seem to work.

Combinations are probably best. For example, in a study of children and adolescents with adjustment disorder and depression, a combination of yoga, a brief massage, and progressive muscle relaxation effectively reduced both feelings of anxiety and stress hormone levels.

No one should expect a total resolution of stress from these approaches, but if done regularly, these programs can be very effective.

Acupuncture. Some evidence suggests that acupuncture may also be helpful. It might even improve some physical factors associated with stress and health problems. For example, in a study of heart failure patients acupuncture improved stress-related heart muscle activity, which could be an important benefit in these patients. (Acupuncture had no effect on stress-related blood pressure or heart rate.)

Hypnosis. Hypnosis may also benefit some people with severe stress. In one study of patients with irritable bowel, stress reduction by hypnosis correlated with improvement in many IBD symptoms.

Relaxation Methods

Specific Procedure

Deep Breathing Exercises. During stress, breathing becomes shallow and rapid. Taking a deep breath is an automatic and effective technique for winding down. Deep breathing exercises consciously intensify this natural physiologic reaction and can be very useful during a stressful situation, or for maintaining a relaxed state during the day.

  • Inhale through the nose slowly and deeply to the count of ten.
  • Make sure that the stomach and abdomen expand but the chest does not raise up.
  • Exhale through the nose, slowly and completely, also to the count of ten.
  • To help quiet the mind, concentrate fully on breathing and counting through each cycle.
  • Repeat five to ten times and make a habit of doing the exercise several times each day, even when not feeling stressed.

Muscle Relaxation. Muscle relaxation techniques, often combined with deep breathing, are simple to learn and very useful for getting to sleep. In the beginning it is useful to have a friend or partner check for tension by lifting an arm and dropping it; the arm should fall freely. Practice makes the exercise much more effective and produces relaxation much more rapidly. Small studies have reported beneficial effects on blood pressure in hypertensive patients who employ this technique.

  • After lying down in a comfortable position without crossing the limbs, concentrate on each part of the body.
  • Maintain a slow, deep breathing pattern throughout this exercise.
  • Tense each muscle as tightly as possible for a count of five to ten and then release it completely.
  • Experience the muscle as totally relaxed and lead-heavy.
  • Begin with the top of the head and progress downward to focus on all the muscles in the body.
  • Be sure to include the forehead, ears, eyes, mouth, neck, shoulders, arms and hands, fingers, chest, belly, thighs, calves, and feet.
  • Once the external review is complete, imagine tensing and releasing internal muscles.

Meditation. Meditation, used for many years in Eastern cultures, is now widely accepted in this country as a relaxation technique. The goal of all meditative procedures, both religious and therapeutic, is to quiet the mind (essentially, to relax thought). Small studies have suggested that regular meditation can benefit the heart and help reduce blood pressure. Better research is needed, however, to confirm such claims.

Some recommend meditating for no longer than 20 minutes in the morning after awakening and then again in early evening before dinner. Even once a day is helpful. Note: Meditating before going to bed may cause some people to wake up in the middle of the night, alert and unable to return to sleep.

New practitioners should understand that it can be difficult to quiet the mind, and should not be discouraged by lack of immediate results

A number of techniques are available. A few are discussed here.

The only potential risks from meditating are in people with psychosis in whom meditating may trigger a psychotic event.

Mindfulness Meditation. Mindfulness is a common practice that focuses on breathing. It employs the basic technique used in other forms of meditation.

  • Sit upright with the spine straight, either cross-legged or sitting on a firm chair with both feet on the floor, uncrossed.
  • With the eyes closed or gently looking a few feet ahead, observe the exhalation of the breath.
  • As the mind wanders, one simply notes it as a fact and returns to the "out" breath. It may be helpful to imagine one's thoughts as clouds dissipating away.

Transcendental Meditation (TM). TM uses a mantra (a word that has a specific chanting sound but no meaning). The meditator repeats the word silently letting thoughts come and go. In one study, TM was as effective as exercise in elevating mood.

Mini-Meditation. The method involves heightening awareness of the immediate surrounding environment. Choose a routine activity when alone. For example:

  • While washing dishes concentrate on the feel of the water and dishes.
  • Allow the mind to wander to any immediate sensory experience (sounds outside the window, smells from the stove, colors in the room).
  • If the mind begins to think about the past or future, abstractions or worries, redirect it gently back.
  • This redirection of brain activity from your thoughts and worries to your senses disrupts the stress response and prompts relaxation. It also helps promote an emotional and sensual appreciation of simple pleasures already present in a person's life.


  • During biofeedback, electric leads are taped to a subject's head.
  • The person is encouraged to relax using methods such as those described above.
  • Brain waves are measured and an audible signal is emitted when alpha waves are detected, a frequency which coincides with a state of deep relaxation.
  • By repeating the process, subjects associate the sound with the relaxed state and learn to achieve relaxation by themselves.

Massage Therapy. Massage therapy appears to slow down the heart and relax the body. Rather than causing drowsiness, however, massage actually increases alertness. A number of massage therapies are available and some are listed here.

Many massage techniques are available, such as the following:

Swedish massage is the standard massage technique. It uses long smooth strokes and kneading and tapping of the muscles.

Shiatsu applies intense pressure to the same points targeted in acupuncture. It can be painful, but people report deep relaxation afterward.

Reflexology manipulates acupuncture points in the hands and feet.

Herbal and Natural Remedies

Some people who experience chronic stress seek herbal or natural remedies. It should be strongly noted, however, that just as with standard drugs, so-called natural remedies can cause problems, sometimes serious ones.

Probiotics. Probiotics are helpful bacterial strains that by themselves may provide a barrier against harmful bacteria, possibly through various mechanisms, such as by excreting certain acids (e.g., lactate, acetate) that inhibit harmful bacteria or competing with them for nutrients. Stress reduces levels of these bacteria, and it has been suggested that probiotics may help maintain remission in patients with IBD. In one small 2002 study, at the end of six months people suffering from stress and exhaustion who took a probiotic supplement experienced significant reductions in stress symptoms and gastrointestinal complaints. The specific bacterial strains that might be beneficial, however, are not fully known. The most well-known probiotics are the lactobacilli strains, such as acidophilus, which is found in yogurt and other fermented milk products. Others, however, may prove to be more important, such as bifidobacteria and GG lactobacilli. Other probiotics include the lactobacilli rhamnosus, casel, plantarium, bulgaricus, and salivarius, and also Enterococcus faecium and Streptococcus thermophilus.

Aromatherapy. The smell of lavender has long been associated with a calming effect. In a Japanese study, 14 women who were put in a room with a lavender scent experienced reduced mental stress. A number of aromatherapies are now used for relaxation. It should be strongly noted that some of exotic plant extracts in these formulas have been associated with a wide range of skin allergies.

Valerian. Valerian is an herb that has sedative qualities and may reduce stress and associated physical effects. This herb is listed on the FDA's list of generally safe products. Of note, however, its effects could be dangerously increased if it is used with standard sedatives. Other interactions and long-term side effects are unknown. Side effects include vivid dreams. It should be noted that high doses of valerian can cause blurred vision, excitability, and changes in heart rhythm.

Warnings on Alternative and So-Called Natural Remedies

Alternative or natural remedies are not regulated and their quality is not publicly controlled. In addition, any substance that can affect the body's chemistry can, like any drug, produce side effects that may be harmful. Even if studies report positive benefits from herbal remedies, the compounds used in such studies are, in most cases, not what are being marketed to the public.

There have been a number of reported cases of serious and even lethal side effects from herbal products. In addition, some so-called natural remedies were found to contain standard prescription medication. Of specific concern are studies suggesting that up to 30% of herbal patent remedies imported from China having been laced with potent pharmaceuticals such as phenacetin and steroids. Most reported problems occur in herbal remedies imported from Asia, with one study reporting a significant percentage of such remedies containing toxic metals.

Special Warning on Kava. Kava has been commonly used to reduce anxiety and stress. It is now highly associated with liver injury and even failure in a few cases. Experts now strongly warn against its use.

People seeking relief from stress should be wary of those that promise a cure or urge the purchase of expensive but useless and sometimes potentially dangerous treatments.


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