Leonardi A.

Goenawan
Impaired pumping efficiency ~ myocardial ischemia
1
Physician who had had the highest scores on a test of hostility
while still in medical school were seven times as likely to have
died by the age of fifty as were those with low hostility scores
2
Those who had been rated as easily roused to anger were
three times more likely to die of cardiac arrest than those who
were more even-tempered
3
Being angry more than doubled the risk of cardiac arrest in
people who already had heart disease; the heightened risk
lased for about two hours after the anger was aroused
4
1. Gail Ironson et al: Effects of anger on left ventricular ejection fraction in coronary artery disease, The
American Journal of Cardiology, 70 1992.
2. Redford Williams: Hostility & heart disease, The trusting heart, New York Times Books, 1989
3. Linda H.: Emotional arousal as a predictor of long-term mortality and morbidity in Post MI men,
Circulation, vol 82, no.4, Supplement III, Oct 1990.
4. Murray A.M.: Triggering of myocardial infarction onset by episodes of anger, Circulation, vol.82,
no.2, 1994
Anger
more fact about anger....
Anger is a normal human emotion, which is a problem
when it is too intense, occurs too frequently, lasts too
long, is harmful to ones health, leads to person-
directed aggression or damages interpersonal
relationships.
Anxiety helps us prepare to deal with some danger (a
presumed utility in evolution).
In modern life anxiety is more often OUT of proportion
and OUT of place distress comes in the face of
situations that we must live with or that are CONJURED
by the mind, NOT REAL dangers we need to confront.
Anxiety the distress evoked by lifes pressure.
Perhaps the emotion with the greatest weight of
scientific evidence connecting it to the onset of sickness
and course of recovery.

Anxiety
Compromising immune function to the point that it can
speed the metastasis of cancer
Increasing vulnerability to viral infections
Exacerbating plaque formation leading to atherosclerosis and
blood clotting leading to myocardial infarction
Accelerating the onset of Type I diabetes and the course of
Type II diabetes
Worsening or triggering an asthma attack
Leading to ulceration of the gastrointestinal tract
Triggering symptoms in ulcerative colitis & in inflammatory
bowel disease
The brain itself is susceptible to the long-term effects of
sustained stress, including damage to the hippocampus.

more bad news about Angst
1. Bruce McEwen & Eliot Stellar: Stress and metastasis, Stress and the Individual mechanism leading to
disease, Archives of Internal Medicine 153 (Sept 1993)
2. M Robertson & J Ritz: Biology and Clinical Relevance of Human Natural Killer Cells, Blood 76 (1990)
Definition
A state of mental exhaustion that affects
human service professionals, like educators,
job nurses and physicians, due to chronic emotional
and interpersonal job related stressors.
1


Encompasses three aspects: exhaustion, depersonalization,
and lack of personal accomplishment.
2

1. Freundenberger H. Staff burnout. J Soc Issues 1974;30:15965.
2. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol
2001;52:397422.
about self.....
Exhaustion
Exhaustion corresponds to feelings of being emotionally
overwhelmed and exhausted by ones work and is
generally referred to as emotional exhaustion
Physicians are required to deal DAILY with the powerful
emotions of human existence: pain, death, life, sexuality,
anger, abuse
Its parameters often somatic (GI symptoms, rapid
breath, headache, etc), emotional (sadness, negativism,
decrease creativity, increase cynism) & interpersonal
manifestations (quickness to anger, defensiveness, edgy
and ready to blame others, family problems and a
negative worldview)

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol
2001;52:397422.
about self.....
Depersonalization
Refers to an impassive and impersonal response
toward recipients of ones service, care,
treatment, or instruction
Depersonalization of patients and distancing
develop in patient/staff relations
Manifests as Apathy and Cynicism
Increase Ineffectiveness
Theory behind Genocide Participants

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol
2001;52:397422.
about self.....
Loss of Personal Accomplishment
Loss of feeling of competence and successful
achievement in ones work with people
Most ominous symptom.

Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol
2001;52:397422.
Decreased job performance and commitment
Lower career satisfaction, which can lead to worse
quality of care when health professionals are affected.
Potentially very serious for health workers, as burnout
can lead to stress-related health problems, low morale,
physical exhaustion, insomnia, increased use of
alcohol and drugs, and increased family problems.



1. Leiter MP, Harvie P, Frizzell C. The correspondence of patient
satisfaction and nurse burnout. Soc Sci Med 1998;47:16117
2. Goldberg R, Boss RW, Chan L, Goldberg J, Mallon WK, Moradzadeh D,
et al. Burnout and its correlates in emergency physicians: four years
experience with a wellness booth. Acad Emerg Med 1996;3:115664.
3. Gundersen L. Physician burnout. Ann Intern Med 2001;135: 1458.
Burnout differs from depression because
it involves only a persons relationship to
his or her work, whereas depression
globally affects a persons life

About one third of Swiss primary care physicians
presented a moderate or a high degree of burnout,
which was mainly associated with extrinsic work-
related stressors.
1
Burnout is frequent among physicians, with rates
ranging from 25% to 76%, depending on the working
conditions and medical specialty.
2-6


1. Goehring, C., Gallacchi, MB. Knzi, B., Bovier, P.: Swiss Med Wkly, 2005;135:101108
2. Ramirez AJ, et al.: Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet
1996;347:7248
3. Grassi L, Magnani K.: Psychiatric morbidity and burnout in the medical profession: an Italian study of general
practitioners and hospital physicians. Psychother Psychosom 2000;69:32934.
4. Shanafelt TD, et al.: Burnout and self-reported patient care in an internal medicine residency program. Ann Intern
Med 2002;136:35867
5. Kirwan M, et al.: Investigation of burnout in a sample of British general practitioners. Br J Gen Pract 1995;45:25960.
6. Visser MR, Smets EM, Oort FJ, de Haes HC. Stress, satisfaction and burnout among Dutch medical specialists. CMAJ
2003;168:2715
A survey of British consultants in gastroenterology,
surgery, radiology and oncology showed a frequency
of burnout varying from 27% (surgeons)
to 35% (oncologists) for emotional exhaustion,
from 19% (surgeons) to 28% (gastroenterologists)
for depersonalization, and from 32% (surgeons) to
49% (radiologists) for low personal accomplishment

Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM.
Mental health of hospital consultants: the effects of stress and
satisfaction at work. Lancet 1996;347:7248.
Decrease / Discontinue Caffeine
Caffeine is a strong stimulant that actually generates a
stress reaction in the body
More relaxed, less jittery or nervous, sleep better, have
more energy (a paradox, since you are removing a
stimulant), less heartburn and fewer muscle aches
Migraine-type withdrawal headaches
Caffeine is NOT a highly addictive substance
Regular Exercise
The stress reaction is IN us, not "out there." It provides us
with the strength and energy to either fight or run away
from danger and is therefore self-protective.
The only problem: fighting and running away are rarely
appropriate responses to stressful situations in the modern
world. The result is that our bodies go into a state of high
energy but there is usually no place for that energy to go;
therefore, our bodies can stay in a state of arousal for hours
at a time.
Exercise is the most logical way to dissipate this excess
energy.
Exercise three times per week for a minimum of 30 minutes
each time.

Relaxation / Meditation
We have also inherited the ability to put our bodies
into a state of deep relaxation
Where the stress reaction is automatic, however, the
relaxation response needs to be brought forth by
intention
Whereas exercise dissipates stress energy, relaxation
techniques neutralize it, producing a calming effect.
20 minutes once or twice per day confers significant
benefit.
Use mind to change physiology
Inborn set of physiological
changes that offset flight or
fight response
The physiological responses are
reductions in HR, BP, RR, &
muscle tension
Used to counteract harmful
effects of stress.
Practice diaphragmatic
breathing (i.e., slowly & deeply)

1. Pick a focus word, phrase,
image, or prayer; or focus on
breathing.
2. Sit quietly in comfortable
position.
3. Close eyes & relax muscles
4. Breathe slowly & naturally
as you do, repeat focus word
or phase as you exhale.
5. When other thoughts come
to mind, just go back to
repetition of word or
breathing.
6. Do this 5-10 minutes qd or
bid
Sleep
Vicious Cycle: Chronically stressed patients almost all
suffer from fatigue (in some cases resulting from stress-
induced insomnia), and people who are tired do not cope
well with stressful situations.
When distressed patients get more sleep, they feel better
and are more resilient and adaptable in dealing with day-
to-day events.
Usual sleep requirement is 5 to 10 hours per night; the
average being 6 to 8.
The three criteria of success are waking refreshed, good
daytime energy and waking naturally before the alarm goes
off in the morning.
Catnap (five to 20 minutes) can be rejuvenating.

Time-outs & Leisure
The two major issues are pacing and work/leisure
balance.
Monitoring your stress and energy level, and then
pacing yourself accordingly.
We all require time to meet our own needs (self-care,
self-nurturing, etc.) and when that is neglected,
trouble usually follows.
Self directed activities can include exercise or
recreation, relaxation, socializing, entertainment and
hobbies.
Hedonism vs healthy amount of self-indulge
Realistic Expectations
When expectations are realistic, life feels more
predictable and therefore more manageable.
An increased feeling of control because you can plan
and prepare yourself (physically and psychologically).


Expect less from people who cannot give you what you
want. It makes it easier - not great, just less upsetting
Reframing
One of the most powerful and creative stress reducers
A technique used to change the way you look at things in order
to feel better about them
The key to reframing is to recognize that there are many ways to
interpret the same situation
Step outside of yourself and look at other possible
interpretations
Reframing does not change the external reality but simply helps
people view things differently (and less stressfully)
You are not trying to disrespect their point of view but only to
suggest there are other, less stressful ways of looking at the same
thing

"There is more than one meaning to the same reality."
Belief System
We have literally thousands of premises and
assumptions about all kinds of things that we hold to
be the truth.
We have beliefs about how things are, how people
should behave and about ourselves.
The beliefs are expressions of people's philosophy or
value system, but all lead to increased effort and
decreased relaxation - a formula for stress.
Opinion OR truth?
Ventilation/Support System
Talking cure
A problem shared is a problem halved
The presence of a trusted and empathic listener has
been therapeutic
Be there, listen attentively and show our concern and
caring
Validation, encouragement or advice

Humor
Humor is a wonderful stress reducer, an antidote to
upsets.
Humor is an individual thing
Be careful and respectful in what we say