Pain Management Stress and Anxiety

Patient Information Leaflet produced by the Physiotherapy Service Specialist Services Unit (Cambridgeshire)

Providing a lifetime of care

Cambridgeshire Community Services NHS Trust: providing services across Cambridgeshire, Peterborough, Luton and Suffolk

Stress What is Stress? We need to consider those things that cause the worry or anxiety = the stressor (stressors dont always have to be negative) And we also need to consider the stress response (how your body reacts to the worry) You can probably all think of things that would cause you to worry for example: Life events (such as a marriage, a death) Daily hassles (having to wait for a bus when you are already late). Emergency situations (narrowly avoiding a car accident) How does the body respond to these kinds of situations? By fight or flight (literally by preparing to face the challenge or running away)

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What would your body do in a situation where you sense you are being followed? Your breathing might change faster, shallower Your heart rate would increase You might feel your heart pounding like palpitations You might feel your muscles tense up You might become sweaty You might need the loo Or you might feel sick or dizzy These responses can be a good thing in a situation when you need to run away from something dangerous, and they are likely to come on very fast. The body reacts to these emergencies by producing a number of chemicals and once the stress has passed, these may take a while to return to normal levels. Some people find the physical responses of the body to the emergency quite frightening or unnerving because they do not know what is happening in their body. Luckily for us, these kinds of emergency situations do not occur very often. It is more likely that you will experience daily hassles, partly because we now all live in a busy modern world. However the body cant always tell the difference between these two kinds of stressor and may react just as strongly to the daily hassle as to the real emergency and produce the same chemicals in response.

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Effects of Stress It is important to think about how stress can affect pain, activities, thoughts, and feelings. And also to think about how these are all related. Stress can affect each aspect and so, as they are all related, stress on one will have an effect on the other(s). Being in chronic pain can also lead to extra stress and so it may be that with the build up of chemicals over time, and the over-reaction of the body to daily hassles that we can become quite tense without noticing it. Muscle tension might then make your pain worse. Stress is not always a bad thing, we need some stress in our lives can help motivate us. Too much stress is more difficult to cope with. If you have pain and stress the two can work together to create a vicious circle of pain and stress: Pain =>stress Increased stress => more pain More pain => more stress

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Managing Stress What are some of the best ways of preventing the build up of stress? Firstly try to recognise how you feel when you are stressed and which situations are likely to make you feel stressed. Try finding some techniques to help you de-stress when you feel tense and anxious. Using a breathing technique called diaphragmatic breathing can help. This is really important as it can help prevent you becoming stressed in the first place.

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Anxiety What is anxiety? Anxiety is a reaction to stress. Many people respond to physical or emotional pressures by becoming anxious, but the experience of anxiety varies from person to person. It can span a range from worry and agitation to panic or even terror.

Moderate anxiety is normal too much anxiety causes problems Its important to remember that everyone feels anxiety and that it is in fact useful. Just like stress, a little anxiety can help you perform better at tasks. However, it can become a problem when the anxiety reaction is too strong, occurs too often, lasts too long, or occurs in response to the wrong situations. Again like stress, too much anxiety can produce a physical reaction in our bodies. It can also cause psychological symptoms and behavioural symptoms.

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Bodily symptoms: Difficulties in swallowing Difficulties in breathing Increased breathing Increased heart rate Sweating Increased blood pressure Muscular tension

Cant sleep Headaches Nervous shaking Aches and pains Constipation Butterflies in the stomach Dizziness

Psychological symptoms: Poor concentration Irritability Difficulty making decision Difficult thinking clearly

Low self confidence Fear and dread Poor memory Depression Tiredness

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Behavioural symptoms Patterns of avoidance can arise in people who are anxious. For example they may avoid going out of the house it their anxiety is related to outside experiences. Or they may avoid socialising if their anxiety is related to meeting people. Sometimes the activities are not essential to normal life (ie flying) and so cause relatively few problems. On other occasions the anxiety-causing situation can be overcome with help, if necessary. How does anxiety develop? Particular fears may develop in childhood and are of course common: dogs, thunder, etc. These tend to disappear as we get older but occasionally they dont. Some fears are caused by unpleasant injuries or shocks. Sometimes its difficult to pinpoint the origin of a certain anxiety and there doesnt seem to be an obvious starting point and these fears develop very gradually. Some people may have a general anxiety, may say that they have always been anxious and feel anxious in all situations. Why does anxiety stay? There are two main things that may keep anxiety going: 1. Anxiety may remain a problem because you avoid the situations you fear. For example, someone who is afraid of flying will not fly. Anxiety may remain a problem because of negative thoughts and irrational beliefs about the consequences of the activity. Page No 8

2.

Avoidance Why do we avoid the situations we fear? If we avoid doing the stressful activity or leave a stressful situation immediately our anxiety levels drop and a connection is made. Dont go out => less fear. This is partly because there is a general feeling that when faced with a frightening situation our fear levels will just go on getting higher and higher until we cant cope any longer and something terrible happens, like we pass out, are sick or have a heart attack. In fact this doesnt happen. The longer we remain in an anxiety-producing situation, the more likely it is that anxiety levels will decrease. But if you never stay in the situation long enough to find that out, you will never learn from the experience. Ways of thinking about activities positive and negative ways There are different ways of thinking about our fears and interpreting our bodily responses. For example some may worry about the dentist but know that any pain will be temporary, or that a job interview may be stressful but that if this interview is unsuccessful then other opportunities will come their way.

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These are realistic positive responses to fear of certain situations. Similarly we can interpret our bodily responses in a positive way too. Such as: This feeling of butterflies in my tummy is horrible now, but I know its because Im worrying and I know Im going to faint or collapse. Over-anxious people may think about stressful situations in a different way, such as: It will be really awful having my tooth drilled, I just dont think I can handle it. Or If I dont get this job, my career will be ruined. And we can also view our bodily responses negatively too: I feel so bad, Im sure Im going to die How does the feeling of anxiety develop? Some people who suffer from anxiety say that they get sudden panic attacks. In fact these dont usually hit out of the blue but develop in a number of stages.

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Stage 1 This is where we come across the situation we fear and feel a slight surge of anxiety in bodily reactions. We may also have some panic thoughts Stage 2 This is where we can see the fearful situation and are also aware of our bodys reaction to the situation. We think oh no there goes my heart again. We are becoming anxious about being anxious. Stage 3 We see our anxiety growing bigger and bigger and seeing this makes the whole thing worse. We are in a panic spiral. The more panic we feel, the less chance we have of controlling it.

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Managing a panic attack - counter the vicious circle Just as we learnt that stress and pain can build on each other in a vicious circle, so too breathing and panic can combine to increase the problem. During a panic attack you are probably going to be breathing very fast and deeply. This will reduce the amount of carbon dioxide in your lungs which in turn will create a lot of unpleasant bodily symptoms. These are also likely to make you more afraid. Fear => over breathing Over breathing => bodily symptoms Bodily symptoms =>fear

Stopping this can be done. If you hold a paper bag tightly over your nose so no air can get to your lungs from outside the bag and breath in and out a number of times, you will find the symptoms decrease. Taking in less air from outside surprisingly leads to a feeling of being less breathless. With a decrease in the physical symptoms so comes a decrease in apprehension.

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A second way of stopping this if you dont have a paper bag handy, is to slow down your breathing in small steps. Attempt to breathe in smoothly and slowly and to let your breath out just as slowly. As you slow your breathing you are bound to increase the depth of each breath somewhat. What you are aiming for is smooth, slow, regular and fairly shallow breathing. If you have managed to slow down for a few seconds, but feel out of breath, and a strong urge to take a quick gulp, dont. Resist it by swallowing a couple of times, that should get rid of the urge.

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To sum up, breathe in and out as slowly and evenly as you can and avoid any big increase in depth as you do so. To help yourself slow down you could count to yourself while breathing. You might start by saying: in 1 thousand , out 2 thousand , in 1 thousand, out 2 thousand As you begin to feel better you can increase the length of the breaths: in 1 thousand 2 thousand , out 3 thousand 4 thousand in 1 thousand 2 thousand , out 3 thousand 4 thousand

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For further information about this service contact: For Huntingdon and Cambridge City and South areas If you are unsure about any of the advice in this leaflet or if you require further advice from a Chartered Physiotherapist, please contact your local self referral service on: Huntingdon - 8.15am - 12.15pm

01480 434980
Cambridge City and South Cambridgeshire - 1pm - 5pm

01223 446999
For East Cambs and Fenland area Self referral is not currently available, please contact your local Physiotherapy Department if you are unsure about any of the advice: Physiotherapy Department, Princess of Wales Hospital, Lynn Road, Ely, Cambs, CB6 1DN - Tel: 01353 652046 Physiotherapy Department, Doddington Hospital, Benwick Road, Doddington, Cambs, PE15 0UG - Tel: 01354 644213 Physiotherapy Department, North Cambs Hospital, The Park, Wisbech, Cambs, PE13 3AB - Tel: 01945 488062 For Peterborough area Self referral is not currently available, please contact your local MSK Physiotherapy Department if you are unsure about any of the advice: City Health Clinic, Wellington Street, Peterborough, PE1 5DU Tel: 01733 466671
Cambridgeshire Community Services NHS Trust Tel: 01480 355184 / 308216 Email: ccscommunications@ccs.nhs.uk Website: www.cambscommunityservices.nhs.uk Code: AS/PD/LFT/0280 - V1.4 (Octt 2012) Date of Production: November 2010 Date of Review: November 2013

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If you have any concerns about this service or suggestions for improvements, contact our Patient Advice and Liaison Service on Freephone 0800 013 2511 or email: ccs-tr.pals@nhs.net For free, confidential health advice and information 24 hours a day, 365 days a year contact NHS Direct on 0845 46 47 or via www.nhsdirect.nhs.uk If you need this information in a different format such as in large print or on audio tape, or in a different language please contact Cambridgeshire Community Services NHS Trust Communications Team on 01480 308216 or via email at: ccscommunications@ccs.nhs.uk Polish: Jeeli potrzebujesz tych informacji w innym formacie, jak na przykad w duej czcionce, w formacie audio lub w innym jzyku, prosimy o kontakt z Cambridgeshire Community Services NHS Trust (Publiczny Zesp Opieki Zdrowotnej i rodowiskowej) pod numerem telefonu: 01480 308216 lub email na adres: ccscommunications@ccs.nhs.uk Portuguese: Se precisar desta informao em formato diferente, tal como impresso em letra grande, cassete udio ou noutra lngua, por favor contacte o Cambridgeshire Community Services NHS Trust (Trust NHS dos Servios Comunitrios de Cambridgeshire), atravs do telefone 01480 308216, ou envie um e-mail para: ccscommunications@ccs.nhs.uk Russian: , , , 01480 308216 no ccscommunications@ccs.nhs.uk Cantonese: Cambridgeshire Community Services NHS Trust01480 308216 ccscommunications@ccs.nhs.uk Bengali

Turkish: Eer bu bilgininin kendi dilinizde evirisini (ya da daha byk harflerle basksn veya kasete kaytl halini) isterseniz, ltfen Cambridge Blgesi Kamu Hizmetleri Ulusal Salk Hizmeti Birimini (Cambridgeshire Community Services NHS Trust) 01480 308216 nolu telefon numarasndan arayn veya ccscommunications@ccs.nhs.uk adresine e-mail gnderin.