Stress and Being Stressed Out 02.26
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Transcript of Stress and Being Stressed Out 02.26
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Symptoms are intermittent
T
hrobbing pain ³everywhere´ ± Worse in the morning, better mid day, bad
again right before bed time
± Nothing helps
Tried ibuprofen, Tylenol, caffeine, excedrinmigraine, hot packs, cold packs
± Keeps her up at night
Feels fatigued during the day
Headache
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Intermittent periods of stomach pain
± Cramping, stabbing, throbbing in mid abdomen
Similar pattern to headaches
± Worse in the morning and night
Not related to PO intake
No change in bowel movements, no
symptoms of constipation
GI Upset
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Difficulty sleeping ± mostly trouble falling asleep ± ³I think too much right before bed´
Poor appetite ± ³The pain keeps me from eating´
Hot and cold flashes ± Happen mostly at school
± Wearing layers of clothes to cope
No fevers, no change in diet, no change in weight
R OS otherwise negative ± Denies symptoms of low mood, difficulties with
concentration, restlessness, generalized worry, etc..
Other symptoms
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Past Medical History: None, otherwise healthy
Developmental History: Met all milestones on time
Substance Use: ³I¶ve never tried any of it´ Current Medications: ³Mom gave me melatonin for
sleep´
± ³It¶s not working´
Family History: No family history of thyroiddisease, GI problems, or migraines. No history of anxiety, or depression.
History
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Social History:
± Middle child of 2 brothers and 2 sisters, parents
are married. ± Currently in 10th grade. Does ³awesome´ in
school ± except for three weeks ago when she
entered a national essay competition in her
English Class ± now school ³sucks.´ ± Dad lost his job two weeks ago and mom is
³super stressed about the money stuff´
± Not sexually active but thinking about it
Social History
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VSS
GENERAL: Thin adolescent female dressed is school uniform. No apparent physical
distress.
SKIN: No ecchymosis, rashes or abrasions.
HEENT: Normocephalic and atraumatic. Moist mucous membranes.
NECK: Supple, no lymphadenopathy, no thyromegaly.
LUNGS: Clear to auscultation bilaterally.
HEART: R egular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended. Positive bowel sounds.
BACK: No CVA tenderness. GENITOUR INARY A ND R ECTAL: Declined, not indicated at this time.
EXTR EMITIES: +2 radialis pulse bilaterally, +2 posterior tibialis pulses bilaterally, no
tibial edema, no cyanosis noted.
NEUR OLOGIC: CrN II-XII intact, +2 deep tendon reflexes. A ble to perform heel to
shin, finger to nose intact. Sensation intact to light touch proximally and distally.
Strength symmetrical throughout. Negative R omberg noted normal with gait.
Physical Exam
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DIFFER ENTIAL???
15 year old with two week
history of headaches andabdominal pain
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Stress and
Being
Stressed Out
R achel State, MD/MPH
Triple Board
PGY
-3(IDCC 2/27/2012)
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What isS
tress?
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The Good,
The
Bad, &
The Ugly
Good
± Motivation
± Better Performance
Bad
± Tension
± Anxiety ± Out of Control
± Overwhelming
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The Good,
The
Bad, &
The Ugly
Ugly
± Headaches
± Muscle pains
± Sleep disturbances
± GI discomfort
± Chest pain
± Food issues
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Frequent headachesGritting, grinding teeth
Stuttering or stammering
Tremors, trembling of lips, hands
Neck ache, back pain, muscle spasmsLight headedness, faintness, dizziness
Ringing, buzzing or "popping sounds
Frequent blushing, sweating
Cold or sweaty hands, feet
Dry mouth, problems swallowing
Frequent colds, infections, herpes
Rashes, itching, hives, "goose bumps"
Unexplained "allergy" attacks
Heartburn, stomach pain, nausea
Excess belching, flatulence
Constipation, diarrhea
Difficulty breathingSudden attacks of panic
Chest pain, palpitationsFrequent urination
Poor sexual desire or performance
Excess anxiety, worry, guilt, nervousness
Increased anger, frustration, hostility
Depression, frequent mood swings
Increased or decreased appetite
Racing thoughts
Insomnia, nightmares, disturbing dreams
Difficulty concentrating
Trouble learning new information
Forgetfulness, disorganization, confusionDifficulty in making decisions
Feeling overloaded or overwhelmed
Frequent crying spell or suicidal thoughts
Feelings of loneliness or worthlessnessLittle interest in appearance, punctuality
Nervous habits, fidgeting, feet tapping
Increased frustration, irritability, edginess
Overreaction to petty annoyances
Increased number of minor accidentsObsessive or compulsive behaviorReduced work efficiency or productivity
Lies or excuses to cover up poor work
Rapid or mumbled speech
Excessive defensiveness orsuspiciousness
Problems in communication, sharing
Social withdrawal and isolation
Constant tiredness, weakness, fatigueFrequent use of over-the-counter drugs
Weight gain or loss without diet
Increased smoking, alcohol or drug use
Excessive gambling or impulse buying
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Why?
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Fight-or-
Flight
Sympathetic branch of the autonomicnervous system
± Epinephrine ± Norepinephrine
± Aldosterone
± Cortisol
± Thyroid Hormone
± Vasopressin
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Fight-or-
Flight
± Increase cardiac output
± Increase in respiratorydrive
± Increase in bloodglucose levels
± Increase in bloodvolume
± Decrease in clottingtime
± Increase blood pressure
± Inhibit inflammation
± Increase restingmetabolic rate
± Muscle contraction
± Decrease in saliva
± Increase in stomachacid
± Acceleration or
deceleration of GI peristalsis
± Inhibit immunefunction
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Not Just Us
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Stats in our
Youth
Top 10 overall health concerns for U.S.
Children
± Stress moved from 8th in 2009 to 5th in 2010
1 in 5 children surveyed reported they
worry ³a great deal or a lot´
86% of kids are significantly affected by
stressed out parents
C.S. Mott Children¶s Hospital National Poll on Children¶s Health R eport
http://
www.apa.org/news
/ press
/releases
/2010
/11
/stress-in-america.aspx
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Who¶sS
tressedA bout What
?
Source of Stress Youth (8-17) Moms Dads
Money 76% 88% 68%
Work 70% 62% 73%
R elationships 55% 8% 50%
Economy 65% 70% 60%
Health Problems
affecting my
family
47% 47% 42%
Personal Health
Concerns
52% 51% 45%
Personal Safety 30% 24% 18%
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Parent-ChildD
iscrepancies Answered they were under a great deal of
stress: 20% vs. 3%
Feel parental stress causes stress in kids:
89% vs. 31%
Believe family finances are source of stress:
30% vs. 18%
Marked experiencing headaches and trouble
sleeping as significant symptoms of stress:
43% & 48% vs. 13%
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Youth
Trouble falling asleep: 48%
Headache 43%
Stomach Upset: 41%
Eating too much or too little: 38%
Lack of motivation: 34%
Anger /getting into fights: 22% Bad grades: 7%
Drinking alcohol/smoking: 4%
http://www.apa.org/news/ press/releases/stress2010/national-report.pdf
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Adults
Irritability/Anger 45%
Fatigue: 44%
Lack of interest or motivation: 39% Headache: 38%
Feeling nervous or anxious: 36%
Stomach upset: 29%
Muscular tension: 23%
Teeth grinding: 17%
Tightness in chest: 16%
http://www.apa.org/news/ press/releases/stress2010/national-report.pdf
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R andom
Stats
1 in 4 workers have taken a mental health dayoff from work to cope with stress
40 ± 75% of all physician office visits are for stress related ailments and complaints
43% of all adults suffer from adverse healtheffects from stress
Over 90% of disease is caused or complicated by stress
Up to 60% of employee absences are due to psychological problems ± stress listed as #1
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HowD
o WeD
eal WithS
tress?
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How Kids Cope Listen to music: 49%
Exercise or walk: 48%
S pend time with
family/friends: 46%
R ead: 45%
TV/movies: 38% Pray 37%
Video Games/Surf the
web: 35%
Nap 34%
Eat: 26%
Church/religious
activities: 22%
Drink alcohol: 16%
Smoke 13% Nothing: 6%
Seek help from Dr:
4%
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Some Healthy Options
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Stress Management
Techniques
Mediation
± Mental focus
± Mindfulness Visualization
± Programmed
± R eceptive
Autogenic Training ± Self hypnosis
± Heavy, warm, quiet, calm, and relaxed
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Stress Management
Techniques
Body Scan
± Start with toes
± Note sensations ± Work up noting every muscle group
± R epeat and note changes
Progressive Muscle
R elaxation ± Intentionally contract and relax each muscle
group
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EasyS
tuff Counting Down
± Just relax in reverse order of importance to you
± Each muscle group with a number
Breathing Awareness
± Chest vs. Belly Breathing
Alternate Nostril Breathing ± In one out the other
± Exhale twice as long
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MyF
avorite The Lemon in The Fridge
± Meditation
± Visualization
± Body Scan
± Breathing
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Basics
Schedule a convenient time and place
Be as comfortable as possible
Try not to try
Keep a relaxation log
A
void falling asleep Come back slowly
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Psychopharmacology SSR Is ± response rate 40%-70%
± Fluoxitine (Prozac)
Start 10mg, effective dose 20-40mg, max 80mg
± S
ertraline (Zoloft) Start 25mg, effective dose 50-200mg, max 200mg
± Citalopram (Celexa)
Start 20mg, effective dose 30-40mg, max 60mg
± Escitalopram (Lexapro)
Start 5mg, effective dose 10-20mg, max 20mg
± Paroxitine (Paxil) Start 10mg, effective dose 20-40mg, max 60mg
Expect response in 4-6 weeks
Medications should be continued for at least 6-12 months once patient becomes asymptomatic.
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³We do not see things as they are; we seethings as we are´ ± Talmud
³Man is not disturbed by events, but by theview he takes on them´ ± Epictetus
³What lies behind us and what lies before usare tiny matters compared to what lies
within us´ ± Oliver Wendell Holmes, MD
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Thanks!!