Stress Management

A Harvard Medical School Special Health Report
Stress Management
Approaches for preventing and reducing stress
In this report:
Mini-relaxations for
quick stress relief
How stress affects
your brain, heart,
and lungs
The positive side
of stress
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Y our portable guide
to stress relief
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Stress ManagEment
SPECIAL HEALTH REPORT
Medical Editors
Herbert Benson, M.D.
Director Emeritus, Benson-Henry Institute for Mind
Body Medicine at Massachusetts General Hospital
Mind/Body Medical Institute Associate Professor
of Medicine, Harvard Medical School
Contents
Understanding the stress response. . . . . . . . . . . . . . . . . . . 2
What is stress?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
The positive side of stress . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Stress and its toll on your body. . . . . . . . . . . . . . . . . . . . . . . . . 4
Aggie Casey, M.S., R.N.
Stress in your life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Director, Cardiac Wellness Programs,

Benson-Henry Institute for Mind Body Medicine at
Massachusetts General Hospital
Associate in Medicine, Harvard Medical School
The major life event stress scale. . . . . . . . . . . . . . . . . . . . . . . . 7

Recognizing the early signals . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Unhealthy responses to stress . . . . . . . . . . . . . . . . . . . . . . . . . 9
Editor
Annmarie Dadoly
How to prevent and manage stress . . . . . . . . . . . . . . . . . 10
Writers
Francesca Coltrera, Stephanie Slon
Editor, Special Health Reports
Kathleen Cahill Allison
Illustrators
Scott Leighton, Marcia Williams
Art Director
Heather Derocher
Learning the relaxation response. . . . . . . . . . . . . . . . . . . . . . .

Breath focus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Body scan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Guided imagery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Proper nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Social support. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Nurturing yourself. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10
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Production Editors
Mary Allen, Melissa Rico
SPECIAL BONUS SECTION:

Your portable guide to stress relief. . . . . . . . . . . . . . . . . . 21
Published by Harvard Medical School

Anthony L. Komaroff, M.D., Editor in Chief
Edward Coburn, Publishing Director
Journals: Easing stress the write way. . . . . . . . . . . . . . . . . . . . 25

Cognitive restructuring: You are what you think. . . . . . . . . . . . . 27
The role of positive psychology. . . . . . . . . . . . . . . . . . . . . . . . 29
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The different faces of stress. . . . . . . . . . . . . . . . . . . . . . . 31

Sex and stress. . . . . . .
Age and stress. . . . . . .
Caregiving and stress. .
Work and stress. . . . . .
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How stress affects the body . . . . . . . . . . . . . . . . . . . . . . . 35

Stress and cardiovascular disease . . . . . . . . . . . . . . . . . . . . .
Stress and cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stress and high blood pressure. . . . . . . . . . . . . . . . . . . . . . . .
Stress and the immune system. . . . . . . . . . . . . . . . . . . . . . . .
Stress and asthma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Stress and gastrointestinal disorders . . . . . . . . . . . . . . . . . . .
35
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Developing your personal plan for stress relief. . . . . . . . . 40

Glossary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Resources. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
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Dear Reader,
Glance at the 10 leading causes of death in America, and you wont find the word stress anywhere. Yet many well-respected studies link stress to heart disease and strokethe No. 1 and
No. 3 killers, respectively, in the United States. There is evidence that stress may influence cancer and chronic lower respiratory diseaseswhich are also among the top five leading killers.
Stress has implications for many other ailments. Depression and anxiety can be caused or exacerbated by stress. Stress also triggers flare-ups of asthma, rheumatoid arthritis, and gastrointestinal problems, such as irritable bowel syndrome. And illness is just the tip of the iceberg.
Stress affects you emotionally as well, marring the joy you draw from life and loved ones.
What is stress? For one thing, its not all bad. Your perception of a real or imagined threat can
spark the stress response, a physiological cascade that prepares the body to fight or flee. That swift
reflex was encoded in you for survival and can save you from injury or worse. Its a rush of hormones that spurs you to jump out of the path of a speeding car, flee from a menacing wild animal, or quickly douse a small fire. Stress has another positive side as well. Researchers have found
that as stress or anxiety increases, so do performance and efficiencyat least initially. At a certain
point, though, rising stress becomes detrimental, and performance and efficiency decline.
Trouble usually brews when your stress response is evoked repeatedly, causing unnecessary
wear and tear on your body that can lead to poor health. In a world bursting with situations
that can cause stresstraffic jams, layoffs, illness, and money woesits not surprising that
people experience stress frequently. Certainly, no one can completely avoid stressful situations. Yet its entirely possible to learn to better manage these situations.
Its our hope that this report can help you do just that. Reading it will help you identify your
stress warning signs and learn how to better manage stressful situations. In these pages, youll
find a variety of tools you can use to accomplish that task. Your job is to decide which tools fit
you best and to start using them. (Of course, before you use any of the techniques described
in this report to treat a health condition, you should consult with your doctor.)
As the saying goes, Rome wasnt built in a day. It took time to raise the scaffolding that supports the negative cycles of stress in your life, and learning to dismantle it will also take
time. Yet your efforts can reward you richly with better health, greater peace of mind, and a
smoother, more joyful course through life.
Sincerely,

Medical Editor
Aggie Casey, M.S., R.N.

Medical Editor
Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
Understanding the stress response
ust what is stress? Does it have positive attributes?

How have decades of research shaped current theories on stress? This section answers these questions
and touches briefly on how stress affects the body. The
list titled My stress warning signs (page 8) will help
you identify how you feel when faced with stressful
situations in your own life.
What is stress?
You may define stress as bumper-to-bumper traffic, a

deadline bearing down fast, a worrisome illness, or a
contentious argument with your spouse. A friend may
define it as a relationship spiraling downward, the need
to care for an ailing parent, or a pile of unpaid bills.
If you were a medical expert, though, you would
label these scenarios stressorsthat is, examples of
stressful events and circumstances. Stress itself can
be defined more broadly as an automatic physical
response to any stimulus that requires you to adjust to
change. Whether its a sudden car crash, a loud argument, or the ache of rheumatoid arthritis, each real
or perceived threat to your body triggers a cascade of
stress hormones that produce well-orchestrated physiological changes.
All of us know these sensations intimately. Your
heart pounds. Muscles tense. Breathing quickens, and
beads of sweat appear. But exactly how and why these
reactions occur and what effects they might have over
time are questions that have intrigued researchers for
many years.
Harvard physiologist Walter B. Cannon was a
pioneer in exploring the biochemistry of stress. His
research nearly a century ago convinced him that
fright was not all in the mind, but also stemmed from
the adrenal glands, which sit atop the kidneys. During experiments with barking dogs and caged cats,
Cannon was able to isolate a hormone secreted by
the adrenal glands of the frightened cats. When he
2
Stress Management
injected that hormone into a second, perfectly calm

cat, it touched off a physical reaction of fear. The cats
heartbeat and blood pressure shot up, while blood
flow to the muscles increased. Cannon dubbed this
occurrence the fright, fight, or flight response. Currently, though, its known as fight or flight or the
stress response.
The stress response

The initial hormone Cannon isolated was epinephrine. Its also called adrenaline, after the glands that
manufacture it. Next, Cannon found a second stressresponse hormone called norepinephrine, or noradrenaline. Other researchers discovered cortisol,
which belongs to a second class of stress hormones
(known as glucocorticoids) that play key roles in the
stress response.
The stress response starts with a signal from the
part of your brain called the hypothalamus. Perched
above the brain stem, the hypothalamus is a network
of nerves wired to the rest of your body through the
autonomic nervous system. The autonomic nervous
system rules such involuntary body functions as
breathing, blood pressure, heartbeat, and the dilation
or constriction of key blood vessels and small airways
in the lungs called bronchioles. Its two tributaries are
the sympathetic nervous system, which revs up the
body in response to perceived dangers, and the parasympathetic nervous system, which calms the body
after the danger has passed.
When the hypothalamus processes certain informationperhaps the sight of your boss bearing down
with an ominous expression, or the sound of screeching car tires behind youit sends a chemical messenger called corticotropin-releasing factor (CRF) down
a pathway to the nearby pituitary gland (see Figure
1). This stimulates cells in the pituitary to send their
own chemical messenger, adrenocorticotropic hormone (ACTH), to the adrenal glands, which spill corw w w.h ealt h .ha r va r d.e du
tisol into the bloodstream. Surges of adrenaline and

noradrenaline are also released by the adrenal glands
on instructions from the brain and simultaneously
throughout the body by the sympathetic nervous system. (The powerful triumvirate of the hypothalamus,
pituitary gland, and adrenal glands is dubbed the HPA
axis. It governs a multitude of hormonal activities
in the body and provides a feedback loop that helps
switch off the stress response when levels of certain
hormones are too high.)
Stress hormones race through your bloodstream
to different parts of your body, preparing you to fight
or flee. Your breath quickens as your body takes in
extra oxygen. Energy-boosting glucose and fats are
released from storage sites into your bloodstream.
Sharpened senses, such as sight and hearing, make
you more alert.
Your heart beats fasterup to two to three times
as quickly as normaland your blood pressure rises.
Certain blood vessels constrict, which helps direct
blood flow to your muscles and brain and away from
your skin and other organs.
Blood cells called platelets become stickier, so
clots can form more easily to minimize bleeding
from potential injuries. Immune system activity picks
up. Your muscleseven tiny, hair-raising muscles
beneath your skintighten, preparing you to spring
into action.
Body systems not needed for the immediate emergency are suppressed. The stomach and intestines
cease operations. Sexual arousal lessens. Repair and
growth of body tissues slows.
Cannon believed the stress response was temporary. Minutes after the rush triggered by adrenaline,
he thought, the body would wind down to its normal
balance, a physical state known as homeostasis. That
meant your lungs would slow their rate of breathing.
Your blood pressure would drop as your heartbeat
slowed and blood flowed in normal patterns again.
Your intestines would start their work again, providing new fuel to replace the energy burned in the emergency. Bones would resume repairs or start growing
again, and sex might appear more inviting.
With the challenge that sparked the stress response
behind you and the parasympathetic nervous system
ww w. h ealt h . h ar v ar d . e du
exerting its calming influence, the day-to-day business

of your body would resume. Later research showed,
however, that Cannon was not completely correct (see
Stress and its toll on your body, page 4).
The positive side of stress
As many people have noted, the stress response can be

enormously helpful. Surging adrenaline enables people to perform Herculean feats. Who can forget the
firemen laden with lifesaving equipment who charged
up flights of smoke-filled stairs in the World Trade
Figure 1 The HPA axis and the stress response

Hypothalamus
Pituitary gland
Senses sharpen
ACTH released
Breath quickens
and lungs take
in more oxygen
Blood pressure rises

Heart beats
faster
Muscles tighten
Glucose and fats

are released into
bloodstream
Adrenal
glands
release
cortisol,
adrenaline,
and nor
adrenaline
The hypothalamus, pituitary gland, and adrenal glands make up

the HPA axis, which plays a pivotal role in triggering the stress
response. By releasing certain chemicals, such as adrenocortico
tropic hormone (ACTH) and cortisol, the HPA axis rouses the
body for action when its faced with a stressor. As the illustration
reveals, the effect of this release of hormones is widespread.
Senses become sharper, muscles tighten, the heart beats faster,
blood pressure rises, and breathing quickens. All of this prepares
you to fight or flee in the face of danger.
Stress Management
Center after the terrorist attacks of Sept. 11, 2001? Or

the ordinary citizens who carried injured and disabled
people out of the towers?
Fight-or-flight responses are appropriate and
essential in such overwhelming situations. When
appropriately invoked, the stress response helps us rise
to many challenges. These challenges may be external forces, such as a fire or an earthquake, or internal threats, such as your circulatory system teetering
on the brink of a deadly collapse. The fight-or-flight
response can prove beneficial under far less dangerous
circumstances, too.
Physiologist Hans Selye, whose work helped shape
modern stress theory, advanced the idea that physical
and psychosocial stressors trigger the same physiological response. Selye explored the line between short-term
stress that stimulates people to summon the resources
to hurdle obstacles (good stress) and ongoing or
overabundant stress, which wears down the ability to
adapt and cope (bad stress, or distress). Two Harvard
researchers, Robert M. Yerkes and John D. Dodson, likewise demonstrated that a jolt of stress isnt necessarily
bad. They noted that as stress or anxiety levels rose, so
did performance and efficiencyup to a point (see Figure 2). At this turning point, further stress and anxiety
led to significant declines in performance and ability.
Where that turning point falls seems to differ
from person to person. For while the stress response is
hard-wired into humans and other animals, the events
and perceptions that set it off vary widely. What you
perceive as a threatening situation, your neighbor may
easily brush aside or even relish.
Scientists have tackled the question of why some
Figure 2 Yerkes-Dodson law
performance
or efficiency
stress or anxiety
As stress increases, performance initially rises and then declines.
Stress Management
people appear less vulnerable to stress or even seem to

thrive on regular doses of it. Some research has identified characteristics common to stress-hardy folks.
Exercise and social support proved essential. So did
control, challenge, and commitment. Stress-hardy people seem to feel a sense of control or the ability to influence events, embrace the challenge in situations others
might find stressful, and describe themselves as committed to something meaningful. According to one
study, people with these characteristics report fewer
illnesses and are less likely to be absent from work.
Stress and its toll on your body
Intuitively, the stress response makes sense. It enables

us to rise to occasions and events that reward heightened awareness and abilities. You see a bus rushing
toward you, and the surge of adrenaline helps you
sprint out of its path far faster than you normally
move. The stress hormones that spilled into your
bloodstream at the sight of the bus found the perfect
physical outlet.
But experience tells us obvious dangers are not the
only scenarios that elicit that response. Any situation
you perceive as threatening or which requires you to
adjust to a change may do the same. Thats where the
trouble starts.
Your body does a poor job of distinguishing
between life-threatening events and day-to-day stressful situations. Anger or anxiety triggered by less
momentous sources of stress, such as financial fears or
traffic jams, doesnt find a quick physical release and
tends to build up as the day rolls on. Adding to the
turmoil is anticipation of potential problems, such as
what you might experience in waiting for the results of
a medical test. The physical and psychological symptoms of stressa clenched jaw, shakiness, anxious
feelingscompound this, creating a negative, selfperpetuating cycle.
When your body repeatedly experiences the stress
response or when arousal following a terrible trauma
is never fully switched off (see Post-traumatic stress
disorder, page 5), worrisome health problems can
occur. A prime example of this is high blood pressure,
or hypertension, which is a major risk factor for heart
w w w.h ealt h .ha r va r d.e du
disease. Another is suppression of the immune system,

which increases susceptibility to colds and other common illnesses (see Stress linked to health problems,
at right, and How stress affects the body, page 35).
Its impossible to sidestep all sources of stress,
nor would you want to. Our lives are full of physical
and psychological challenges, which add zest to life
and sometimes deliver satisfying rewards. But while
you cant easily erase certain sources of stress, you can
learn to perceive and respond to them differently. The
section How to prevent and manage stress on page
10 describes many tools to help you accomplish this.
Post-traumatic stress disorder (PTSD)

Traumatic experiences often scar the psyche. Many of
the people who fled or witnessed the destruction of
the World Trade Center during the Sept. 11 attacks,
as well as rescue workers who flocked to the site, suffered symptoms of post-traumatic stress disorder
(PTSD). So too have military personnel who have
been in combat, most recently in Iraq and Afghanistan. According to the National Center for Posttraumatic Stress Disorder, 12% to 20% of veterans of the
Iraq war, 6% to 11% of veterans of the Afghanistan
conflict, and as many as 30% of Vietnam veterans
have experienced PTSD.
Other traumatic eventssuch as rape, physical
assault, accidents, natural disasters, living in a war
zone or otherwise violent locale, and losing a loved
one suddenlymay also trigger PTSD. The risk of
developing PTSD is higher among people with a family history of depression.
These are its key symptoms:
recurrent flashbacks, dreams, or intrusive thoughts
about a traumatic event
withdrawal from people and certain situations
avoidance of reminders of the event or difficulty
recalling it
difficulty sleeping
being overly vigilant or easily startled.
Not everyone who survives a traumatic event
develops PTSD. Even if your immediate response to
a disaster is extreme, this is not a sign of an emotional disorder or mental illness. Reaching out to
Stress linked to health problems

Stress may contribute to or exacerbate various health
problems, including these:
allergic skin reactions
anxiety
arthritis
constipation
cough
depression
diabetes
dizziness
headaches
heart problems, such as angina, heart attack, and
cardiac arrhythmia
heartburn
hypertension
infectious diseases, such as colds or herpes
infertility
insomnia
irritable bowel syndrome
menopausal symptoms, such as hot flashes
morning sickness, the nausea and vomiting of
pregnancy
nervousness
pain of any sort, including backaches, headaches,
abdominal pain, muscle pain, joint aches, postoperative

pain, and chronic pain caused by many conditions
postoperative swelling
premenstrual syndrome
side effects of AIDS
side effects of cancer and cancer treatments
slow wound healing
trouble sleeping and resulting fatigue
ulcers.
To the extent that stress causes these ailments, the

relaxation response (a state of profound rest) and other
stress-relief methods can be healing (see How to prevent
and manage stress, page 10). More in-depth information
about some of the medical effects of stress appears in
How stress affects the body on page 35.
Adapted primarily from The Wellness Book, Herbert Benson, M.D., and
Eileen M. Stuart, R.N., M.S. (New York: Fireside, 1993).
Stress Management
others and resuming normal life may provide solace.

Relaxation therapies, physical activity, and expressing emotions while concentrating on the future may
also prove useful.
However, you should seek help from a licensed
mental health professional if symptoms affect you for
more than a few weeks. Keep in mind, too, that sometimes symptoms dont occur until six months or more
after the triggering event.
Anxiety and depression

The buildup of stress often feeds or causes anxiety
and depression, too. Adopting the strategies outlined
in this report may help prevent these problems. Practicing stress-management techniques may also bring
some relief from anxiety and symptoms of depression;
however, its important to seek advice from a licensed
health professional. He or she can evaluate you and
may recommend a combination of medications and
counseling, as well as a mind/body program or other
stress-management approaches.
Seek a professional opinion if your anxiety is
severe enough to interfere with your daily life. Symptoms may include any of the following:
Stress Management
extreme worry or fear much of the time, or repeated

panicky feelings
irrational feelings of fear, dread, or danger
frequent physical symptomssuch as agitation,
shakiness and trembling, nausea, hot and cold
flashes, dizziness, shortness of breath, or frequent
urinationin the absence of a rational threat
recurrent distressing thoughts and uncontrollable
repetitive behaviors intended to reduce the anxiety
triggered by those thoughts.
Likewise, its important to seek a professional opinion if you have the following symptoms of depression:
prolonged feelings of sadness or irritability
loss of interest in activities you once enjoyed
sleeping or eating markedly more or less than usual
feelings of guilt, worthlessness, or hopelessness
feeling anxious and unable to sit still
trouble concentrating and making decisions.
Recurrent thoughts of death or suicide are symptoms of depression that call for immediate professional attention.
Stress in your life
n the course of a lifetime, odds are good that youll

survive some very stressful events. Youll also face
a gamut of far smaller day-to-day stressors. The list
that appears later in this section will help you recognize the stress warning signs in your life. Once youre
aware of how stress makes you feel and act, you can
use the many different tools described here to help
quell its effects.
The major life event stress scale
Several decades ago, two psychiatrists at the University of

Washington devised a scale for researchers that weighed
the stress of major life events by asking 394 men and
women to rank specific situations. The subjects were told
that marriage equaled 50 units out of a possible 100, and
they were asked to rate a list of other life events with that
in mind. Their responses were then averaged.
Major life event stress scale (out of a possible 100)

Event
Score
Event
Score
Spouses death
100
Son or daughter leaving home
29
Divorce
73
Trouble with in-laws
29
Marriage separation
65
Outstanding personal achievement
28
Jail term
63
Spouse starts or stops working
26
Death of close relative
63
Start or stop school
26
Injury or illness
53
Change in living conditions
25
Marriage
50
Change in personal habits
24
Fired from job
47
Difficulty with boss
23
Marriage reconciliation
45
Shift in job hours or conditions
20
Retirement
45
Change in residence
20
Change in health of family member
44
Changing schools
20
Pregnancy
40
Change in recreation
19
Sexual difficulties
39
Change in church activities
19
New family member
39
Change in social activities
18
Business readjustment
39
Moderate debt
17
Change in finances
38
Shift in sleep habits
16
Death of close friend
37
Change in number of family get-togethers
15
Shift to different type of work
36
Shift in eating habits
15
Shift in number of arguments with spouse
35
Vacation
13
Moderate to high mortgage payments
31
Christmas
12
Foreclosure of mortgage or loan
30
Minor legal violations
11
Shift in work responsibilities
29
Adapted from The Relaxation Response, Herbert Benson, M.D., with Miriam Z. Klipper, updated and expanded edition (New York: Avon Books, 2000).
Stress Management
In subsequent studies, Thomas Holmes and Richard Rahe, the scales creators, noted that the death of
a spousewhich ranks highestappeared to have
a serious impact on health. Surviving spouses were
10 times as likely to die within the subsequent year
than others in their age group. Likewise, spouses who
divorced were 12 times as likely to get sick in the following year than were married people.
Many researchers have used the scale in studying how stress affects people. However, it has limitations. The studys age may limit its relevance today.
In addition, it covers only major events, which repre-
My stress warning signs

Being able to recognize when youre feeling stressed can help you quickly counteract the stress response.
A good first step is to look over the list below and circle all the symptoms you recognize.
Physical symptoms
Emotional symptoms
Tight neck and shoulders
Crying
Back pain
Irritability
Sleep difficulties
Edginess
Tiredness or fatigue
Anger
Racing heartbeat or palpitations
Feeling powerless to change things
Shakiness or tremors
Nervousness
Sweating
Feeling anxious
Ringing in ears
Quick temper
Dizziness or fainting
Lack of meaning in life and pursuits
Choking sensation
Boredom
Difficulty swallowing
Loneliness
Stomachache
Unhappiness with no clear cause
Indigestion
Depression
Diarrhea or constipation
Cognitive symptoms
Frequent, urgent need to urinate
Continual worry
Loss of interest in sex
Poor concentration
Restlessness
Trouble remembering things
Behavioral symptoms
Loss of sense of humor
Grinding of teeth
Indecisiveness
Inability to complete tasks
Lack of creativity
Overly critical attitude
Trouble thinking clearly
Bossiness
Other symptoms
Fidgeting
_____________________________________________
Overuse of alcohol
_____________________________________________
Emotional eating or overeating
_____________________________________________
Fist clenching
_____________________________________________
Changes in the amount of alcohol or food you consume
_____________________________________________
Taking up smoking or smoking more than usual
_____________________________________________
Increased desire to be with or withdraw from others

Rumination (frequent talking or brooding about stressful
situations)
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Adapted primarily from The Wellness Book, Herbert Benson, M.D., and Eileen M.
Stuart, R.N., M.S. (New York: Fireside, 1993).
sent a small fraction of daily stressors. Simple everyday stressorswaiting in long lines, sitting in traffic,
or coping with the demands of a jobcan accumulate
and endanger your physical and emotional health.
While primarily a tool for researchers, the scale
can be helpful for those outside the field, too. You
may find it useful to know that others have categorized an event that you may be facingsuch as a
change in your jobas particularly stressful. Its
intriguing that many of the events on the scale arent
obviously negative. An outstanding personal achievement, a new baby, or a marriage may seem like cause
for celebration. But many changes can be construed
as uplifting or upsettingor perhaps a bit of both.
Truly, the perception of stress is specific to the person experiencing it.
The scale can also serve as a reminder. If youre
coping with one or more of the stressors listed in the
major life event stress scale, you may want to spend
extra time practicing stress-management techniques
and other self-help strategies.
Recognizing the early signals
Most likely, you intuitively know how you react to

stressful situations. Certainly big events and obvious distress are easy to spot. But smaller ripples may
slip by your radar. Noting exactly how youre affected
by stress will make you more aware of your personal
stress warning signs early so you can derail unnecessary stress responses (see My stress warning signs,
at left).
Unhealthy responses to stress
You probably have your own ways of dealing with stressful times. Some may be healthy, such as calling a friend,
cooking a comforting dinner, or curling up in bed earlier than usual. Others may not be as benign. All too
often, people self-medicate or turn to other unhealthy
behaviors in an attempt to relieve pressure they feel.
They may do so in a variety of ways. For example:
watching endless hours of TV
withdrawing from friends or partners or, conversely,
jumping into a frenzied social life to avoid facing
problems
overeating or weight gain
undereating or weight loss
sleeping too much
drinking too much alcohol
lashing out at others in emotionally or physically
violent outbursts
taking up smoking or smoking more than usual
taking prescription or over-the-counter drugs that
promise some form of relief, such as sleeping pills,
muscle relaxants, or anti-anxiety pills
taking illegal or unsafe drugs.
Becoming aware of how you typically handle
stress can help you make healthy choices. If you normally reach for a sugary snack, for example, you might
instead call a friend. Choosing to connect rather than
consume can relieve your stress. Studies suggest that
emphasizing social ties can provide definite health
benefitswith no calories!
Stress Management
How to prevent and manage stress
n the late 1970s, working in the same room at Harvard Medical School where Cannon had labored years
before, a cardiologist named Herbert Benson launched
landmark research into the damaging effects of stress
and the bodys potential for self-healing. In the years
since, he and many other researchers have investigated
the stress response and its antidotesthe relaxation
response and other stress-relieving strategies.
Dr. Benson is the medical editor of this report
and the president of the Benson-Henry Institute for
Mind Body Medicine at Massachusetts General Hospital in Boston, which advises using a combination of
approaches for stress management. Among them:
learning various techniques that evoke the relaxation
response, such as breath focus and body scanning
nurturing yourself by setting aside time for socialization, relaxation, exercise, connecting with others,
and pursuing activities that add joy to your life
using cognitive restructuring, a method of helping
you reframe negative thoughts in order to cope more
effectively with a situation.
Such self-care is an essential ingredient for good
health. The example of cardiovascular disease illustrates how it can make a difference. Currently, millions
Relaxing the brain

A small study of five subjects used functional magnetic resonance imaging (fMRI) to map the parts of the brain that are
active during meditation sessions that induce the relaxation
response. Although global brain activity declined, signals
increased in areas of the brain involved in attention as well
as arousal and control of the autonomic nervous system. This
suggests that meditation induces deep relaxation, yet sparks
intense neural activity because of the vigilance required to
keep the mind from wandering. By shining light on observable biological changes triggered by the relaxation response,
this study helps bolster the concept that it is a distinct state
and may also build support for its use in modern health care.
10
Stress Management
of Americans take medication to lower blood pressure

and unhealthy cholesterol levels, two risk factors for
heart disease. Surgical procedures, such as angioplasty
and coronary artery bypass, can reopen blocked vessels or divert the flow of blood to healthier vessels.
These two approachesmedication and medical proceduresare invaluable. Yet when used alone, they
form only two legs of a sturdy three-legged stool that
represents the best of modern health care. The third
leg is self-care approaches of proven worth.
Research shows that regularly invoking the relaxation response leads to lasting declines in high blood
pressure. Stress-management techniques that shortcircuit the stress response, such as cognitive restructuring, can also reduce blood pressure. Good nutrition
and regular exercise can improve levels of cholesterol,
as well as blood pressure. And social support also has
a strong protective effect on health. Over time, the
combination of these self-care approaches may ward
off serious consequences and reduce or possibly even
eliminate the need for certain medications.
Learning the relaxation response
The relaxation responsewhich is the opposite of the

stress responsecan be elicited at will to create a state
of profound peace and rest. The relaxation response is
a physiologic shift that puts the brakes on the runaway
biological changes that first put us into overdrive. By
regularly practicing techniques that evoke the relaxation response, you can help your body decrease the
cumulative effects of stress.
A number of physiological changes occur during the relaxation response. When a person practices
relaxation response techniques, for example, heartbeat
and breathing slow down. The body uses less oxygen,
and blood flows more easily throughout the body.
Blood lactate levels, which some researchers believe
are linked with anxiety attacks, decline markedly.
You can elicit the relaxation response in many different ways, including these:
breath focus (see page 12)
meditation (see Meditation on the go, page 22, and
Mindfulness meditation: The art of staying in the
present, page 15)
visualization or guided imagery (see page 14)
body scanning (see page 13)
yoga, tai chi, or qi gong (see Choosing exercise with
relaxation in mind, page 18)
repetitive prayer (see page 25).
These are not the only techniques that can elicit the
relaxation response. You may find that others are quite
effective. Whats crucial is that the method you choose
interrupts everyday thoughts by letting you focus on
a word, phrase, prayer, or repetitive muscular activity. Once learned, these techniques can be practiced
regularly almost anywhere. No special equipment or
expert trainer is required, although many people find
mind/body programs and meditation or yoga classes

helpful as they learn a new technique (see Resources,
page 43).
Creating a routine
Rather than choosing just one technique to elicit the
relaxation response, you can benefit from sampling
many. It will help you decide which methods work
well for you. And if your favorite fails to engage you
sometimes, you will have an alternative. In fact, many
people get the best results from combining several
techniques.
You may find it helpful to follow these tips when
developing your routine:
Find a quiet, peaceful place to sit or lie down.
Focus. Choose a simple focus: your breath, a sound,
or a word or phrase that you repeat aloud or silently.
Learn to let go and relax. Accept any thoughts, feelings, or sensations that arise.
Table 1 Which technique is right for you?

By regularly practicing techniques that elicit the relaxation response, you create a well of calm to dip into as the need arises. As this chart details,
these techniques can be especially beneficial under certain circumstances, but may not be suitable under others.
Method
What is it?
Especially beneficial
May not be suitable
Breath
focus
Focusing on slow, deep breathing and

gently disengaging the mind from dis
tracting thoughts and sensations
If you have an eating disorder or tend

to hold in your stomach; may help you
focus on your body in healthier ways
If you have health problems that make

breathing difficult, such as respiratory ail
ments, congestive heart failure, or panic
attacks
Breathing deeply while staying in the

If racing thoughts make other forms of
Mindmoment by deliberately focusing on
meditation difficult
fulness
meditation thoughts and sensations that arise during
If you find it too hard to commit the

needed time
Body scan
Focusing on one part of the body or

group of muscles at a time and mentally
releasing any physical tension you feel
there
For increasing your awareness of the

mind/body connection
If you have had a recent surgery that

affects body image
Yoga, tai
chi, and
qi gong
Three ancient arts that combine rhythmic

breathing with a series of postures or
flowing movements
At
times when your mind is racing

you find it especially hard to
settle down and focus
If you wish to enhance flexibility and
balance
If you are not normally active or have

health problems or a painful or disabling
condition; if so, speak with your doctor
before starting any program of exercise
Repetitive
prayer
Using a short prayer or phrase from a

prayer to help enhance breath focus
If religion or spirituality are meaningful

to you
If you are not religious
Guided
imagery
Using pleasing mental images to help you When you want to reinforce a positive
relax and focus
vision of yourself or a goal you wish to
reach
the meditation session
Whenever
If you have intrusive thoughts that make

imagery difficult
If you have difficulty with visualizations
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11
Figure 3 What happens as you breathe

Inhalation
Lungs
Oxygen
intake
Breath focus
Diaphragm
Diaphragm pulls downward,

helping lungs expand with oxygen
Exhalation
Carbon
dioxide
Diaphragm returns upward,

forcing lungs to expel carbon dioxide
Learning to breathe properly is the first step in practicing breath

focus, a stress-management technique. As you breathe in, your
diaphragm drops, giving your lungs the room they need to expand.
If you are breathing properly, you should feel your lungs fill com
pletely and your chest and belly rise. As you exhale, your diaphragm
pushes up against your lungs, which helps to expel the carbon
dioxide. If youre breathing deeply, your belly will fall as you exhale.
Practice regularlyaim for once or twice a day.

Sticking with a particular time of day can enhance
the sense of ritual, which will enable you to practice
more easily. Many people choose to elicit the relaxation response in the morning before breakfast since
it can be hard to schedule time later in the day. Evi12
dence suggests the more regularly you practice these

techniques, the better the outcome.
A good goal is between 10 and 20 minutes daily.
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Breath focus is a simple yet powerful technique that

can elicit the relaxation response for people of different backgrounds. Occasionally, however, health problems may make using this technique uncomfortable
(see Table 1). The first step to practicing breath focus
is to learn to breathe properly.
The importance of your breath

Proper breathing goes by many names. You may have
heard it called diaphragmatic breathing, abdominal breathing, or belly breathing. When you breathe
deeply, the air coming in through your nose fully fills
your lungs, and you will notice that your lower belly
rises. The ability to breathe so deeply and powerfully is
not limited to a select few. This skill is inborn but often
lies dormant. Reawakening it allows you to tap one of
your bodys strongest self-healing mechanisms.
Why does breathing deeply seem unnatural to
many of us? One reason may be that our culture often
rewards us for stifling strong emotions. Girls and
women are expected to rein in anger. Boys and men
are exhorted not to cry. What happens when you hold
back tears, stifle anger during a charged confrontation, tiptoe through a fearful situation, or try to keep
pain at bay? Unconsciously, you hold your breath or
breathe irregularly.
Body image affects breathing, too. A washboard
stomach considered so attractive in our culture encourages men and women to constrict their stomach muscles. This adds to tension and anxiety, and gradually
makes shallow chest breathing feel normal.
The act of breathing engages the diaphragm, a
strong sheet of muscle that divides the chest from the
abdomen. As you breathe in, the diaphragm drops
downward, pulling your lungs with it and pressing
against abdominal organs to make room for your
lungs to expand as they fill with air. As you breathe
out, the diaphragm presses back upward against your
lungs, helping to expel carbon dioxide.
Shallow breathing hobbles the diaphragms range

of motion. The lowest portion of the lungswhich is
where many small blood vessels instrumental in carrying oxygen to cells residenever gets a full share of
oxygenated air. That can make you feel short of breath
and anxious.
Deep abdominal breathing encourages full oxygen
exchangethat is, the beneficial trade of incoming
oxygen for outgoing carbon dioxide. Not surprisingly,
this type of breathing slows the heartbeat and can
lower or stabilize blood pressure.
Practicing breath focus

Diaphragmatic breathing is the foundation of breath
focus, which is quite simple to do.
First steps. Find a comfortable, quiet place to sit
or lie down. Start by observing your breath. First take a
normal breath. Now try taking a slow, deep breath. The
air coming in through your nose should move downward into your lower belly. Let your abdomen expand
fully. Now breathe out through your mouth (or your
nose, if that feels more natural). Alternate normal and
deep breaths several times. Pay attention to how you feel
when you inhale and exhale normally and when you
breathe deeply. Shallow breathing often feels tense and
constricted, while deep breathing produces relaxation.
Now practice diaphragmatic breathing for several
minutes. Put one hand on your abdomen, just below
your belly button. Feel your hand rise about an inch
each time you inhale and fall about an inch each time
you exhale. Your chest will rise slightly, too, in concert
with your abdomen. Remember to relax your belly so
that each inhalation expands it fully.
Breath focus in practice. Once youve taken the
steps above, you can move on to regular practice of
breath focus. As you sit comfortably with your eyes
closed, blend your breathing with helpful imagery and
a focus word or phrase that will help you relax. Imagine that the air you breathe in washes peace and calm
into your body. As you breathe out, imagine that the
air leaving your body carries tension and anxiety away
with it. As you inhale, try saying this phrase to yourself: Breathing in peace and calm. And as you exhale,
say: Breathing out tension and anxiety. When you
first start, 10 minutes of breath focus is a reasonable
goal. Gradually add time until your sessions are about

15 to 20 minutes long.
Body scan
A body scan is a relaxation technique that incorporates breath focus and visualization (see Guided
imagery, page 14). This technique helps you become
more attuned to your body and aware of the connection between your mind and body.
Almost everyone carries unnecessary tension in
his or her muscles. But where each of us feels it varies.
One woman might have a tight neck and shoulders,
while her husband feels an iron band digging into
his forehead. A body scan can help you locateand
releasethe tension in your body.
Performing a body scan is quite simple. Concentrate on one part of your body at a time. As you do,
picture that muscle in your mind. Imagine it open,
warm, and relaxed. Feel any tension melt away.
As a guide, use these steps, which are adapted
from Dr. Herbert Benson and Aggie Caseys book
Mind Your Heart:
Sit or lie down. Begin with breath focus. Breathe
deeply, allowing your stomach to rise as you inhale
and fall as you exhale. Breathe this way for two minutes before you start.
C oncentrate on your right big toe. Imagine the
atoms in your toe and focus on the space between
each atom. Imagine your toe feeling open, warm,
and relaxed.
Now shift your focus to each of the other toes on
your right foot, visualizing them one by one. Again,
notice the sensations of your toes and envision them
as open, warm, and relaxed.
Slowly shift your focus to your foot, moving mentally from the ball of your foot to the arch, then the
top of the foot.
Now work your way up your leg, turning your attention to your ankle, calf, knee, thigh, and hip. Take
your time, slowly working through each area. For
each body part, envision the atoms and the space
between those atoms. Picture each muscle feeling
open, warm, and relaxed.
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13
Allow your right leg to relax, sinking into the support of the floor.
Now repeat these steps, focusing on your left foot
and leg.
Next, become aware of your back. Does it feel tight
or tense? Pay attention to each vertebra and the
space that surrounds it. Let each vertebra feel light
and spacious. Slowly work your way up your back,
relaxing each muscle there.
Gradually, move on to your abdomen and chest. Picture your organs and the space between them. Allow
your belly to feel light and open.
Become aware of your right thumb, and then your
remaining fingers. Envision each finger one by one,
then slowly work your way through your hand and
arm: relax your palm, wrist, forearm, elbow, upper
arm, and shoulder.
Feel your right arm relax and feel warm, spacious,
and light.
Do the same thing with your left hand and arm.
Think about your neck and jaw. Yawn. Allow each
part of your face to relax, working through your jaw,
eyes, and forehead. Shift your attention to the top
and back of your head.
Let your whole body sink into your chair or bed.
Does it feel light and relaxed? Focus on your breath.
Imagine yourself breathing in calm and peace. As
you breathe out, imagine any remaining tension
being expelled from your body.
If any part of your body is still tense, focus your
breathing in that area, releasing tension from that
spot as you exhale.
Sit or lie quietly for a few minutes, noting how light
and spacious your body feels. Then open your eyes
slowly. Take a moment to stretch, if youd like.
Guided imagery
Guided imagery, or visualization, that mentally conjures soothing scenes can be a powerful way of evoking
the relaxation response. The images you choose
whether scenes, places, or experiencesenhance
the sensation of inner calm. They break the chain of
14
Stress Management
everyday thought. While imagery is often touted as

beneficial for people with cancer or other illnesses, not
enough studies support some of the health-enhancing
claims. It has, however, been proved to lessen pain and
side effects of various drugs, including chemotherapy.
Lush descriptions of sandy beaches, bubbling
streams, and fields of flowers are often verbalized by a
therapist or recorded on a CD to help people visualize
calming scenes. Just be sure that the image is soothing
to you, because the exercise wont be effective otherwise. For example, a field of flowers could have negative associations if you suffer from hay fever.
If you arent using a CD, conjure up your own safe
or special haven and imagine yourself there. What do
you smellpine needles, rain steaming off hot pavement, vanilla in a kitchen? What do you hear? Are
clouds or birds passing by? Drink in the surrounding colors. Concentrate on sensory pleasures: a cool
breeze on your cheek, gravel crunching underfoot, or
the scent of flowering trees. Make a voice recording
describing all of this if you think that would help you
find this spot again.
Before you start your guided imagery session, find
a quiet place to sit. Arrange your body comfortably.
Clear your mind while taking deep, even breaths for
several minutes, and then conjure up the images you
find relaxing. Accept intrusive thoughts passively by
observing them. Then return to the web woven by
your senses. Practice for 10 to 20 minutes.
Proper nutrition
The computer-age aphorism garbage in, garbage out

applies to far more than software development. The
food choices you make can feed your stress or ease
it by truly nourishing your body. What you eat plays
a big role in your risk of developing many illnesses,
including hypertension, heart disease, diabetes, and
cancer, which in turn affect your overall stress level.
Obesity due to overeating is linked with many ailments, too. Its also a source of stress for millions of
Americans who are continually reminded of their failure to achieve the slim look idolized in this culture.
Undernourishment can be a problem, too, especially among older people. According to research
Mindfulness meditation: The art of staying in the present

In our busy world, multitasking is a way of life. We fold the
laundry while keeping one eye on the kids and another on
the television. We chat on our cell phones while commuting
to work. We pay the bills, munch on a snack, and listen to a
spouse complain about a work project, all at the same time.
But in the rush to accomplish necessary tasks, we often lose
our connection with the present moment. We sprint through
daily activities without being truly attentive to what were
doing and how were feeling.
In contrast, mindfulness, which has its roots
in Buddhist practices, teaches us to live each
moment as it unfolds. It is the practice of focusing attention on what is happening in the
present and accepting it without judgment.
And thatmany physicians and therapists
believecan be a powerful therapeutic tool.
Mindfulness is often learned through meditation, a method of regulating your attention
by focusing on your breathing, a phrase, or
an image. Over the last few decades, scientists have discovered the benefits of using
mindfulness meditation techniques to help
relieve stress, treat heart disease, and alleviate conditions such as high blood pressure,
chronic pain, sleep problems, and gastrointestinal difficulties.
In recent years, therapistsparticularly cognitive behavioral therapistshave turned to mindfulness techniques to
treat mood problems. Studies have found that mindfulness
meditation can help prevent relapse in people who have
had several episodes of depression. There is evidence that
meditation has distinct effects on the brain. In one study,
researchers measured brain electrical activity before, immediately after, and four months after a two-month course
in mindfulness meditation. They found persistent increased
activity on the left side of the prefrontal cortex, which is
associated with joyful and serene emotions.
Mindfulness offers other benefits. One of the goals is to
enhance your appreciation of simple everyday experiences.
By learning to focus on the here and now, many people
who practice mindfulness find that they are less likely to get
caught up in worries about the future or regrets over the past.
Mindfulness meditation teaches you to focus on distracting thoughts and sensations that occur. Some experts in
the fieldsuch as Jon Kabat-Zinn, author of Full Catastrophe Living and founder and former director of the Stress
Reduction Clinic at the University of Massachusetts Medical
Centerbelieve that facing what arises and opening yourself up to it is the first step toward personal transformation
and growth.
Practicing mindfulness meditation

Heres how to get started with mindfulness meditation. Sit
on a straight-backed chair or cross-legged on the floor. Focus
on an aspect of your breathing, such as the sensations of
air flowing into your nostrils and out of your mouth, or your
belly rising and falling as you inhale and exhale. Once youve
narrowed your concentration in this way, begin to widen
your focus. Become aware of sounds, sensations, and ideas.
Embrace and consider each without judgment. If your mind starts to race, return your
focus to your breathing. Then expand your
awareness again. Kabat-Zinn recommends
committing to 45 minutes of meditation at
least six days a week without expectations,
but if time is a factor you can try a 20-minute
session daily.
A less formal approach to mindfulness can
also encourage you to stay in the present
and truly participate in your life. You can
choose any task or moment to practice mindfulness. Whether you are eating, showering,
walking, touching a partner, or playing with a
child or grandchild, attending to these three
points will help:
1. Start with breath focus and return to it periodically, staying aware of each inhalation and exhalation.
2. Proceed with the task or pleasure at hand slowly and with
full deliberation.
3. Engage your senses fully so that you savor every sensation.
Peeling and eating an orange offers an excellent example.
For a few moments, just concentrate on your breath moving
in and out of your nostrils. Look at the orange, turning it over
in your hands. Run your fingertips over its bumpy texture and
absorb its vibrant color and light citrus scent. As you peel
it, engage your senses fully. Note the slight spray as your
fingers dig into and peel back the hardened skin and soft
white pith. How does the orange smell and feel now? Are
you salivating? When you put a slice of it into your mouth
and break through the thin membrane into its juicy center,
what sensations do you feel?
Try not to hurry through one mouthful of orange to get to
the next. Slow down and stay in the moment. Before you
swallow each portion of the orange, be aware of the rising
desire to do so. Then note how it feels when you swallow.
Throughout the experience, remain fully aware. How much
are you eating? How do you feel physically and psychologically before, during, and after eating?
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15
done for the Baltimore Longitudinal Study of Aging,

most older men and women in America have nutritional deficits in calcium, zinc, iron, magnesium, folic
acid, and vitamins B, B, and D. These nutrients
affect your energy, bones, heart, mental acuity, and
mood. Such nutritional deficits have implications for
stress, too.
Food symbolizes far more than sustenance for
many people. Some people eat to relieve anxiety or
to fill an emotional void. Conversely, eating can be
fraught with anxiety for those with eating disorders.
Tips for achieving nutritional balance

Supplying your body with good food in the right amounts
goes a long way toward helping maintain your energy level.
At breakfast: Combine fruits with whole grains and lean
proteins. Good options include a glass of skim milk and a
serving of oatmeal topped with half a cup of fresh blueberries, or a couple of pieces of whole-grain toast with a
piece of fresh fruit and skim milk. Or choose low-fat plain
yogurt with berries and a serving of whole-grain cereal.
For lunch and dinner: Use your plate as a visual guide.
Fill half of it with raw or cooked vegetables. Whole grains
should account for one-quarter, and lean protein such as
chicken, turkey, fish, beans, lentils, or tofu should make up
the other quarter.
When snacking: Dole out an appropriate-size serving and eat that, instead of snacking directly out of the
box. Also, avoid surrounding yourself with temptation.
Instead of stocking the fridge with cartons of ice cream,
fill it with fresh fruits, veggies, and healthful treats. Then,
at the times when youre really craving ice cream, go out
for a scoop.
In general:
Eat from smaller plates; large plates encourage taking
bigger helpings.
Avoid seconds; if youre still hungry at the end of the
meal, choose a piece of fruit instead.

Start your meal with a hot beverage such as tea, soup, or
broth. Hot drinks are more filling than cold ones and can
help you avoid overeating.
Before snacking, take a deep breath and ask yourself if
you really are hungry or whether anxiety, boredom, or

loneliness is driving your desire to eat. If you are feeling
stressed, find another means to relax yourself, like going
for a walk or calling a friend. Also, try drinking a glass of
water to see if that satisfies you.
16
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Making changes
After weighing data gathered from thousands of men
and women enrolled in well-designed, long-term studies, Harvard nutrition experts developed the Healthy
Eating Pyramid (see Figure 4). The recommendations
in the pyramid are explained in greater detail in the
book Eat, Drink, and Be Healthy: The Harvard Medical
School Guide to Healthy Eating, by Dr. Walter Willett,
chairman of the department of nutrition at the Harvard School of Public Health and professor of medicine at Harvard Medical School.
The diet suggested here may bear little resemblance
to what you normally eat. Rather than create more
stress about how well or poorly you eat, consider a few
simple changes to strengthen your current diet. Could
you increase your daily servings of vegetables and
fruit? Could you expand your color palette, choosing
a range of deep-hued vegetables and fruits, which tend
to have more antioxidants and important nutrients?
Could you replace some unhealthy fats (such as those
found in meat, cheese, and most commercial baked
goods) with healthier sources (such as olive or canola
oil and fats found in nuts and cold-water fish like
salmon)? Could you choose whole grains like brown
rice, barley, whole-wheat bread and pasta, quinoa, and
whole-wheat couscous more often than refined grains
like white rice or white flour? These simple steps can
have a real impact on your health.
Eat mindfully
Food offers comfort and pleasure as well as nourishment. Gulping down fast food while changing lanes
on the freeway, however, offers none of these benefits.
Were a culture in a rush, and that influences how we
eat. Fast-food meals have replaced family mealtimes,
and the practice of eating while driving has become
such a cultural phenomenon that the term dashboard
dining has been coined to describe it. But the problem with eating fast and furiously is that you may
end up eating more than you intendnot to mention
the indigestion that is almost sure to follow. Taking
the time to eat mindfully can renew your enjoyment
of food. It will also help you regulate your food consumption, since it takes 20 minutes from the time you
start eating for the fullness signal in the brain to kick
in. That means that when you rush through a meal,

you may well be finished eating before you even begin
feeling satisfied.
Instead, try to take the time to savor each bite. To
practice mindful eating, start by setting a place for
yourself and sit down. Close your eyes for several seconds, and inhale and exhale deeply to help yourself
focus. Bring your full attention to the moment. Look at
your food and breathe in its aromas before you taste it.
Chew slowly so you can delight in textures and flavors.
Try not to rush through one mouthful to get to the
next. Bringing all your senses into play can sharpen
your taste for fresher, healthier foods and help break
the cycle of stress-related eating.
Think of how you feel before you begin to eat,
while youre eating, and afterward. Are you feeling
physical signs of hunger, or is it simply time for dinner? Are you eating to quell stress? As you become
more aware of your feelings, you may find other stresscontrol techniques just as satisfying as eating.
Exercise
Nearly every form of exercise offers a host of healthenhancing benefits if performed regularly at moderate
intensity. Exercise improves cholesterol levels, lowers
blood pressure, keeps bones strong and healthy, and
enhances the immune system. It also boosts metabolism and mood, and helps you maintain your vitality
and independence in later years. Research suggests
that even so-called lifestyle activities, such as gardening or playing active games with children, offer many
of these benefits.
You can use exercise to stifle the buildup of stress
in several ways. If you exercise shortly after the stress
response is engagedlets say by sprinting away from
an oncoming busyou burn off stress hormones just
as nature intended. Just about any form of motion helps
relieve pent-up muscle tension. And certain activities,
such as yoga, tai chi, or qi gong (see Choosing exercise with relaxation in mind, page 18), and repetitive
exercises, such as walking, running, or rowing, elicit the
relaxation response, too. Regularly engaging in these
kinds of activities can help you ward off everyday stress.
To boost the stress-relief rewards, make an effort
Figure 4 The Healthy Eating Pyramid
Daily
multivitamin
for most
Adapted from Eat, Drink, and Be Healthy: The Harvard Medical School Guide to Healthy
Eating by Walter Willett, M.D. (Simon & Schuster, 2005).
to shift your attention to become aware of yourself

what and how youre feelingand your surroundings
during exercise. This should leave you feeling calmer
and more centered. This approach can also be incorporated into resistance training. As you raise and
lower the weights, coordinate your breathing with
your movements, and focus your attention on the sensations in your body as you perform each exercise.
A few words of care are in order:
If you arent normally active, or if you have health problems or a painful or disabling condition, speak with
your doctor before beginning any exercise program.
When you do exercise, listen to your body. Perform
only movements that feel comfortable to you. As
you grow stronger or more limber, gradually expand
your range.
Try to integrate deep, calm breathing into your routine. You may find it easiest to first familiarize yourself with the movements of the exercises you select
and then combine them with deep breathing.
If you wish to try yoga, tai chi, or qi gong, join a
class with an experienced instructor who can help
you learn the movements correctly and adapt the
program to your needs.
Stress Management
17
Choosing exercise with relaxation in mind

Some exercises, such as the following, are especially
effective at promoting relaxation. Try working some
or all of these activities into your routine.
Yoga. Based on Indian philosophy, yoga is an
excellent way to develop body awareness and elicit the
relaxation response. The many different types of yoga
share certain basic elements: pranayamas (rhythmic
breathing), meditation, and asanas (stretching postures). Like tai chi and qi gong, yoga increases flexibility and coordination, releases muscle tension, and
enhances tranquility.
A 2005 study of lifestyle and health habits revealed
another potential benefit for yoga practitioners. Middle-aged adults of average weight who practiced yoga
for four or more years gained 3 fewer pounds over a
10-year period than those who did not do yoga. Overweight individuals who regularly practiced yoga over
the same period actually lost an average of 5 pounds.
Since yoga is generally not vigorous enough for this
Putting stress relief in someone elses

hands: The benefits of massage
A massage at the hands of a skilled practitioner can be
rejuvenating. Research shows massage has a physiological
impact, too. A 2005 review of research studies involving
massage therapy showed that massage consistently lowered levels of cortisol while increasing activity of pleasurerelated brain chemicals in patients with a broad range of
physical and psychological conditions. Massage also lowers
blood pressure and heart rate and may enhance certain
measures of immune function.
A 2005 study showed that women with breast cancer who
participated in massage therapy three times a week for five
weeks showed more immune system activity and reported
less depression, anxiety, and fatigue than the women who
didnt receive massages regularly. Some studies have found
that massage is also beneficial in boosting the immune
systems of people with HIV.
Whether its for therapeutic reasons or purely for pleas
ure, massage offers the comforts of a warm touch and
release from muscle tension. Experienced practitioners
can be found through professional organizations, such
as the American Massage Therapy Association (www.
amtamassage.org or toll-free at 877-905-2700) and the
National Certification Board for Therapeutic Massage and
Bodywork (www.ncbtmb.com or toll-free at 800-296-0664).
18
Stress Management
effect to be attributed to extra calorie expenditure, the

study authors offered two other possible explanations.
One hypothesis is that yoga affects weight control on
a cellular level, because it lowers concentrations of
the stress hormone cortisol in the body. High levels
of cortisol are implicated in the thickening waistline
that often accompanies middle age. Another theory is
that the mindfulness cultivated by the practice of yoga
helps create a heightened awareness of ones bodya
state of mind that translates into healthier eating and
exercise habits.
Tai chi. This series of slow, fluid, circular motions
originated as a martial art. Tai chi especially benefits older people. By enhancing balance and muscle
strength and improving aerobic capacity, it helps prevent falls that can lead to fractures and girds against
gradual decline in physical function. One randomized
trial published in the Journal of the American Geriatrics Society concluded that tai chi nearly halved the
risk of falling in men and women ages 70 or older. Its
low-intensity movements produce declines in blood
pressure similar to those achieved with moderateintensity aerobics, according to another randomized
study of sedentary adults ages 60 or older. Some doctors recommend tai chi for people with osteoarthritis
as a way to reduce joint swelling and improve range
of motion.
Qi gong. This ancient Chinese art melds breathing, meditation, gentle exercise, and flowing movements. Qi, or chi, is the Chinese word for life energy
believed to course through the body. Qi gong aims to
unblock and properly balance the flow of qi. When
practiced regularly, it can lower your blood pressure,
pulse, and demand for oxygen. These effects are all
components of the relaxation response. Qi gong may
also enhance balance and flexibility.
Rhythmic, repetitive activities. Rhythmic exercises,
such as walking, jogging, swimming, or bicycling, can
be calming and relaxing. Once you get under way,
become aware of how your breathing complements
the activity. Breathe rhythmically, repeating the focus
word, phrase, or prayer youve chosen. Remember to
adopt a passive attitude. When disruptive thoughts
intrude, gently turn your mind away from them and
focus on moving and breathing.
A mindful walk. Taking a mindful walk is a good
example of exercising with relaxation in mind. As you

move and breathe rhythmically, be aware of the sensations of your body. How does it feel as your breath
flows in through your nostrils and out through your
mouth? Gradually expand your awareness to the sights
and smells around you. Notice the freshly mown grass,
flowers, trees, fallen leaves, dappled sun, or gray clouds.
How does the outside air feel against your body? How
does the surface beneath your feet feel and sound?
What thoughts are moving through your head? A slow,
mindful walk helps center and relax you. Alternatively,
a brisker pace that pushes your limits can be calming
and energizing in equal parts. In this case, place more
emphasis on the sensations of your body, such as your
quickened breathing and heartbeat and the way your
muscles respond as you tax them.
Social support
Just as a ship is protected by the rubber bumpers that

separate it from a hard wooden dock, so, too, do people benefit when social buffers soften the inevitable
bumps and bruises of life. Studies show that social
tiesat least those that represent positive relationshipssignificantly protect health and well-being.
In Sweden, researchers following more than 17,000
men and women for six years found that the group
that reported the most isolation and loneliness had
almost four times the risk of an early death as those
with good social networks. California researchers
who tracked roughly 7,000 Alameda County residents
for nine years found that a lack of strong community
and social bonds multiplied the likelihood of dying by
nearly two to three times.
Confidants, friends, acquaintances, co-workers,
relatives, and spouses or companions weave a lifeenhancing social net. Their support may involve outright assistance or may be largely emotional. Studies
show that people who have greater social support fare
better on measures of immune function when faced
with stressors as diverse as caregiving, surgery, exams,
and job strain. For example, women with breast cancer who felt they had high-quality emotional support
from an intimate relationship, social support from a
doctor, and nourishment from other connections had

more natural killer cellscapable of destroying virusladen cells and certain tumor cellsthan those who
lacked these advantages.
Not surprisingly, the quality of relationships
counts. Research suggests that negative onessuch
as an embattled marriage or a draining caretaking
arrangementcan be more harmful than helpful.
Strengthening your social bonds

Given the pleasures and benefits of social ties, why not
grasp opportunities to expand your social circle and
deepen the ties youve already made? Here are some
ways to do just that:
If you normally wait for others to reach out, pick up
the phone and propose a date.
Explore some of the many volunteer opportunities
available, from wielding tools to spruce up affordable housing to mentoring a child or businessperson.
Check with VolunteerMatch (www.volunteermatch.
org) or Senior Corps (www.seniorcorps.org), or call
your local chapter of the United Way for opportunities that fit your talents and interests.
Harness the warmer side of technology. E-mail and
telephones extend your reach around the world.
Libraries and senior centers may offer free online time
and may even help you set up a free e-mail account.
Find like-minded people through intriguing classes
and organizations.
If its hard to get to religious services, ask fellow congregants to escort you. If a significant illness keeps
you away, find out if your spiritual leader makes
home visits.
Social support is a two-way street. Offer assistance to
friends, family, and neighbors, and accept it when its
offered to you.
Share a confidence. Doing so can turn a friendly relationship into an even deeper one.
Consider adopting a pet. Research shows that pets
can have beneficial effects on your physical and emotional health.
If depression, low self-esteem, or social phobias
affect your ability to make connections, seek help.
Stress Management
19
Start by talking with your doctor. Many people have

been aided by therapy, medications, or both.
Nurturing yourself
Learning to nurture yourself is another key task in
managing stress. While you may know a great deal
about nurturing others, satisfying your own needs
may not be second nature.
Its common wisdom, for example, that women
spend a larger percentage of their waking hours nurturing others than men do. Whether or not women
work outside the home, studies suggest that they spend
more time than men do tending house and loved
ones. If youre a woman, odds are good that you provide the emotional glue that holds relationships and
families together. You buy the birthday cards, pick up
the phone to offer help when someone is sick, and do
much of the work or coordination of services involved
in caring for elderly parents, children, grandchildren,
and spouses in need of assistance. Our culture expects
you to be self-sacrificing. Your needs may take last
place; putting yourself first is cast as selfishness.
For men, our society places great emphasis on getting ahead. That can encourage a single-minded focus
on career to the detriment of other activities. In this
way, men are discouraged from indulging their nurturing side.
Just as women are pressed from the get-go to give
to others, men are pushed toward the receiving end.
That creates imbalances and potential sources of distress for both sexes. If youre a woman, you may not
feel comfortable taking time to refresh yourself. If
youre a man, you may not have much practice creating your own nurturing rituals and, like your female
counterpart, you may feel uneasy doing so. Clearly,
both women and men can benefit from learning to
focus on themselves in healthy, rejuvenating ways.
Learning to care for yourself

The art of nurturing yourself is not a single technique. Rather, its an overarching concept for your
life, says Harvard psychologist Alice D. Domar in her
book Self-Nurture. The spark you gain from nurturing your imagination, career, relationships, sex life,
20
Stress Management
or spiritual side amplifies the healing effects of other

stress-relief techniques. The many, varied options for
self-nurture include:
journal writing
cognitive restructuring
relaxation exercises
affirmations and prayer
social support
creative, productive, and leisure activities.
Imagine these techniques and self-nurturing
acts as dry seeds for a garden. Lush growth rewards
those who do more than scratch the earth, toss in a
few seeds, and step back to see what comes up. Dig
deep. Water frequently. Remove choking weeds from
the plot when necessary. Combining the richness of
your past experiences, a willingness to expand your
current boundaries, and a desire to fill your life with
courage, love, and joy can make a great deal of difference in what you reap.
Creativity, productivity, and leisure

The nerve-jangling pressure of lengthy daily to do
lists can leach away energy. The thought of adding
more items to the list may fill you with more dismay
than delight, even if the addition is relaxation, creativity, or time with a loved one. Yet when you refresh
yourself in ways that are meaningful to you, you add
to your stock of energy and joy.
What does creativity mean to you? Writing a
short story? Sculpting clay? Designing a retreat? Pulling
out a paint box? Dancing around the room? Building a
deck? Cooking up a feast? Landscaping a garden?
If you have a dream youve never explored, find
small and big ways to follow through. Sing in the
shower, take lessons from a pro, or try out a song in
front of friends. If you have no idea where to turn, sign
up for a class you think you might enjoy. Give yourself
the opportunity to try a variety of options. Dont give
up if the first one fails to captivate you or if the results
of your effort dont meet your expectations. Discover
what creative work you love, and do it.
Productive work forges links between you and the
world and invests life with meaning. It matters little
continued on page 25
S pe c ial S e c t io n
Your portable guide

to stress relief
T
1
he best-written book on stress control is no help to you if you cant find time to read it. If
you have only a short while to spare, dip into the stress-busting suggestions described in this
section. Whether you have one minute or half an hour, youll find ways to ease your day.
Take the sting out of 10 common stressors
S ometimes just thinking about embarking on a program of stress control can be stressful. Rather than
freeze in your tracks, start small and
bask in the glow of your successes.
Give yourself a week to focus on
practical solutions that could help
you cope with just one stumbling
block or source of stress in your life.
Pick a problem, and see if these suggestions work for you.
1. Frequently late? Apply time-man-
agement principles. Consider

your priorities (be sure to include
time for yourself) and delegate or
discard unnecessary tasks. Map
out your day, segment by segment, setting aside time for different tasks, such as writing or
phone calls. If you are overly
optimistic about travel time, consistently give yourself an extra 15
ww w. h ealt h . h ar v ar d . e d u
minutes or more to get to your

destinations. If lateness stems
from dragging your heels, consider the underlying issue. Are
you anxious about what will happen after you get to work or to
a social event, for example? Or
maybe youre trying to jam too
many tasks into too little time.
2. Often angry or irritated? Consider
the weight of cognitive distortions. Are you magnifying a

problem, leaping to conclusions,
or applying emotional reasoning? Take the time to stop,
breathe, reflect, and choose (see
pages 24 and 28).
3. Unsure of your ability to do something? Dont try to go it alone. If
the problem is work, talk to a coworker or supportive boss. Ask

a knowledgeable friend or call
the local library or an organization that can supply the information you need. Write down
other ways that you might get
the answers or skills you need.
Turn to tapes, books, or classes,
for example, if you need a little
tutoring. This works equally well
when youre learning relaxation
response techniques, too.
4. Overextended? Clear the deck of at
least one time-consuming household task. Hire a housecleaning service, shop for groceries
through the Internet, convene a
family meeting to consider who
can take on certain jobs, or barter with or pay teens for work
around the house and yard. Consider what is truly essential and
important to you and what might
take a backseat right now.
S tre ss M an ag emen t
21
Special Section
| Your portable guide to stress relief
5. Not enough time for stress relief?
Try mini-relaxations. Or make a

commitment to yourself to pare
down your schedule for just one
week so you can practice the
relaxation response every day.
Slowing down to pay attention
to just one task or pleasure at
hand is an excellent method of
stress relief.
6. Feeling unbearably tense? Try
massage, a hot bath, mini-relaxations, a body scan, or a mindful

walk. Practically any exercisea
brisk walk, a quick run, a sprint
up and down the stairswill
help, too. Done regularly, exercise wards off tension, as do
relaxation response techniques.
7. F requently
feel
pessimistic?
Remind yourself of the value of

learned optimism: a more joyful life and, quite possibly, better
health. Practice deflating cognitive distortions. Rent funny
movies and read amusing books.
Create a mental list of reasons
you have to feel grateful. If the
list seems too short, consider
beefing up your social network

and adding creative, productive,
and leisure pursuits to your life.
8. Upset by conflicts with others?
State your needs or distress

directly, avoiding you always
or you never zingers. Say, I
feel ________when you _____ .
I would really appreciate it
if you could ______. I need
some help setting priorities.
What needs to be done first and
what should I tackle later? If
conflicts are a significant source
of distress for you, consider
taking a class on assertiveness
training.
9. Worn-out or burned-out? Focus
on self-nurturing techniques.
Carve out time to practice the
relaxation response or at least
indulge in mini-relaxations.
Care for your body by eating
good, healthy food and for your
heart by seeking out others. Give
thought to creative, productive,
and leisure activities. Consider
your priorities in life: Is it worth
feeling this way, or is another
path open to you? If you want

help, consider what kind would
be best. Do you want the job
taken off your hands? Do you
want to do it at a later date? Do
you need someone with particular expertise to assist you?
10. Feeling lonely? Connect with
others. Even little connectionsa brief conversation

in line at the grocery store, an
exchange about local goingson with a neighbor, a question
for a colleaguecan help melt
the ice within you. It may embolden you, too, to seek more
opportunities to connect. Be a
volunteer. Attend religious or
community functions. Suggest
coffee with an acquaintance.
Call a friend or relative you
miss. Take an interesting class.
If a social phobia, low self-esteem, or depression is dampening your desire to reach out,
seek help. The world is a kinder, more wondrous place when
you share its pleasures and
burdens.
Meditation on the go
Meditation can evoke the relaxation response, and appears to have health benefits as well (see page 15). Its also simple to
perform. Heres how to get started:
Choose a mental device to help you focus. Silently repeat
a word, sound, prayer, or phrase (such as one, peace,

Om, or breathing in calm). You may close your eyes if
you like or focus your gaze on an object.
Adopt a passive attitude. Disregard distracting thoughts or
concerns about how well youre doing. Any time your attention drifts, simply say, Oh, well to yourself and return to
silently repeating your focus word or phrase.
22
Stress Ma n ag em e nt
Now slowly relax your muscles, moving your attention
gradually from your face to your feet. Breathe easily and

naturally while using your focal device for 10 to 20 minutes.
After you finish, sit quietly for a minute or so with your eyes
closed. Then open your eyes, and wait another minute before
standing up.
Try to practice this meditation daily for 10 to 20 minutes,
preferably at a specific time each day.
Your portable guide to stress relief | Special Section
Try a mini-relaxation
Mini-relaxations can help allay fear

and reduce pain while you sit in
the dentists chair. Theyre equally
helpful in thwarting stress before
an important meeting, while stuck
in traffic, or when faced with people or situations that annoy you.
Here are a few quick relaxation
techniques to try.
When youve got 1 minute

Place your hand just beneath your
navel so you can feel the gentle rise
and fall of your belly as you breathe.
Breathe in slowly. Pause for a count
of three. Breathe out. Pause for a
count of three. Continue to breathe
deeply for one minute, pausing for
a count of three after each inhalation and exhalation.
Or alternatively, while sitting comfortably, take a few slow
deep breaths and quietly repeat to
yourself I am as you breathe in
and at peace as you breathe out.
Repeat slowly two or three times.
Then feel your entire body relax
into the support of the chair.
When youve got 2 minutes
Count down slowly from 10 to
zero. With each number, take one
complete breath, inhaling and
exhaling. For example, breathe
in deeply saying 10 to yourself.
Breathe out slowly. On your next
breath, say nine, and so on. If you
feel lightheaded, count down more
slowly to space your breaths further apart. When you reach zero,
you should feel more relaxed. If

not, go through the exercise again.
tiny circles around the base of

your skull. Slowly massage the
rest of your scalp with your fingertips. Then tap your fingers
against your scalp, moving from
the front to the back and then
over the sides.

While sitting down, take a break
from whatever youre doing and
check your body for tension. Relax
your facial muscles and allow your
jaw to fall open slightly. Let your
shoulders drop. Let your arms fall
to your sides. Allow your hands
to loosen so that there are spaces
between your fingers. Uncross
your legs or ankles. Feel your
thighs sink into your chair, letting
your legs fall comfortably apart.
Feel your shins and calves become
heavier and your feet grow roots
into the floor. Now breathe in
slowly and breathe out slowly.
Now massage your face. Make

a series of tiny circles with your
thumbs or fingertips. Pay particular attention to your temples,
forehead, and jaw muscles. Use
your middle fingers to massage
the bridge of your nose and work
outward over your eyebrows to
your temples.

Try self-massage. A combination of
strokes works well to relieve muscle
tension. Try gentle chops with the
edge of your hands or tapping with
fingers or cupped palms. Put fingertip pressure on muscle knots. Knead
across muscles, and try long, light,
gliding strokes. You can apply these
strokes to any part of the body that
falls easily within your reach. For a
short session like this, try focusing
on your neck and head.
Start by kneading the muscles
at the back of your neck and
shoulders. Make a loose fist and
drum swiftly up and down the
sides and back of your neck.
Next, use your thumbs to work

Try imagery. Start by sitting comfortably in a quiet room. Breathe
deeply for a few minutes. Now picture yourself in a place that conjures up good memories. What
do you smellthe heavy scent of
roses on a hot day, crisp fall air, the
wholesome smell of baking bread?
What do you hear? Drink in the
colors and shapes that surround
you. Focus on sensory pleasures:
the swoosh of a gentle wind; soft,
cool grass tickling your feet; the
salty smell and rhythmic beat of
the ocean. Passively observe intrusive thoughts, and then gently disengage from them to return to the
world youve created.
Finally, close your eyes. Cup your

hands loosely over your face and
inhale and exhale easily for a
short while.
S tre ss M a nag emen t
23
Special Section
| Your portable guide to stress relief
Keep a gratitude journal
Deflate cognitive distortions
Reflecting on the positive experiences, feelings, and relationships

in your life can bring you greater
joy. A gratitude journal is a good
way to acknowledge the things
that brighten your life and help
you turn your focus away from
negative thoughts and feelings.
Keep a journal by your bed
so that at the end of each day,
you can spend five to 10 minutes writing about something that

you were grateful for in your day.
Savor pleasant sights, sounds, and
experiencesa sunset, the birds
chirping outside your window,
a hug from your child, or a call
from a friend. Celebrate accomplishments large and small
learning to master a new hobby,
When you recognize negative thoughts cropping up,

take the following steps.
Stop: Consciously call a mental time-out.
Breathe: Take a few deep breaths to help release bur-
geoning tension.
Reflect: Ask some hard questions. Is this thought or
belief true? Did I jump to a conclusion? What evidence do I actually have? Am I letting negative
thoughts balloon? Is there another way to view the
situation? What would be the worst that could happen? Does it help me to think this way?
Choose: Decide how to deal with the source of your
stress. If distortion is the root of the problem, can you

recognize this and let go? Think about the goose in the
bottle (see page 29). Is the problem or constraint a real
one or is it one of your minds making? If the problem is
real, are there practical steps you can take to cope with
it? Practicing a mini-relaxation may also help.
24
Stress Ma n ag em e nt
doing well on a project at work,

or getting the kids off to school
on time.
Conjure up the scene in your
mind and try to write about it in
detail. Then, spend a few minutes
soaking in the experience again.
You can also use this journal to
reflect on things from the past that
you are grateful for.
Make a worry box
Everyone gets distracted by worries and concerns, but sometimes these worries can spill over, seeping into the fabric
of your day. Having a place to contain your worriesquite
literallymay help you set them aside so that you can focus
on the more pleasurable or meaningful parts of your life.
Begin by finding or making a worry box. Any box will do.
This is a great exercise for children, but youngsters may find
it even more appealing if they can decorate the box as they
like and keep it in a special place.
At the end of the day, take a few minutes to write down
two or three of your concerns on slips of paper and place
them inside the box. Or if the box is handy, you can write
down worries as each crops up and drop your worries into
the box throughout the day.
The worry box allows you to mentally let go of your worries. Once your worries are deposited in the box, try to turn
your attention to other matters.
What you do with your slips of paper is up to you. Some
people choose to throw out the notes without reading them
again while others benefit from looking through them periodically before tossing them away. In that case, you may be
surprised to find that most of your worrying was fruitless; the
scenarios you imagined never came to pass.
continued from page 20
whether these tasks are performed via a paid or volunteer job or while digging in the garden. They offer
pleasure and sometimes the chance to be creative.
If youre retired or find that the work that pays
your bills offers few opportunities for satisfaction,
indulge your productive side elsewhere. The simplest
task, such as slicing vegetables for dinner or scrubbing a floor, may be less tedious and more joyful if you
approach it mindfully. Jobs that involve other people
can spark connections that nurture you in other ways.
Work that benefits others often offers special satisfactions. Such volunteer opportunities abound for people
of every age and level of ability. Check with local volunteer organizations for tasks that fit your talents and
available time.
The job many of us find hardest is setting aside
time for pursuits defined as leisure. Reading a novel,
playing a game of tennis, soaking in a hot bath, or
spending a half-hour meditating may seem like selfish activities. Productive and even creative pursuits
are more likely to meet with accepting nods. Yet playfulness invites joy back into your life. And relaxation
enhances flow, a state described by psychologist Mihaly Csikszentmihalyi in which creative juices are freed
and their full expression is directed to all pursuits.
So, stretch out on a hammock for a nap. Enjoy a
massage. Carve out 20 minutes during your busy day
for breath focus or a body scan. Soak in the sounds
of music you find calming or invigorating or simply
pleasurable. Taking this time for yourself helps ward
off exhaustion and burnout, allowing you to focus
more attentively and less resentfully on the tasks of
your day. Consider it a gift to yourself that also pays
dividends to others.
Journals: Easing stress

the write way
If youre like most people, youve learned to bottle

up unacceptable emotions, such as anger, fear,
frustration, and grief. Sometimes, of course, the
cap slips off. Then these emotions spill forth at
high intensity, although not necessarily in the right
direction. One safe way to decant any emotions
even the most hurtful, terrifying, or sad feelingsis
journal writing. A blank sheet of paper and a pen

can offer enormous release and, possibly, insight
into hidden conflicts.
Writing about traumatic events can have physical benefits, too, according to psychologist James W.
Pennebaker, who began studying this issue in the late
1970s. A series of studies required one group of people to write down their deepest thoughts and feelings about the most traumatic event they recalled. A
control group wrote only about trivial events. Both
groups wrote for 15 minutes a day for four days. In
one study, the group that expressed deep emotions
Power of prayer
Several large studies suggest that people with an active
religious life tend to stay healthier, live longer, and be
happier. For example, a review article in the Journal of the
American Geriatrics Society cited an international study
of nearly 170,000 men and women from 14 countries
that found religious affiliation and attendance at services
significantly increased the likelihood of happiness and
satisfaction. Twelve years of data from 2,800 older adults
enrolled in the Yale Health and Aging Study, reported in
The Journals of Gerontology, showed members of religious
congregations had a slower onset of physical disability.
Other studies on how religion affects health have noted
less hostility and anxiety, lower blood pressure, and better
quality of life among people with strong beliefs.
But the power of prayer is not easy to document. A 2002
study in Annals of Behavioral Medicine sifted through
research claiming religion and spirituality have positive
effects on cardiovascular disease and hypertension. The
investigators disputed these results, citing numerous
flawed or irrelevant supporting studies.
Still, prayer offers solace and comfort to many people. Religious communities can be part of a larger social network
that keeps a person afloat with emotional support and
outright assistance (see Social support, page 19). By reinforcing positive emotions, religious belief might stimulate
healthy physiological responses through complex nervous
system pathways, much as a constant flood of negative
thoughts may set the opposite reaction in motion. And, of
course, certain religions encourage better health habits,
such as avoiding alcohol and tobacco.
If prayer is meaningful to you, it can enhance the relaxa
tion response and perhaps your health as well. You may
want to use your favorite prayer or a phrase from it to help
you focus.
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25
reported feeling better and also had significantly

fewer doctors visits and symptoms of illness for
nearly half a year afterward. After a similar experiment, the group that revealed deep emotions had
livelier immune system defenders called T cells for
the next six weeks. Other research has found that
people with asthma and arthritis benefit from journal writing, too.
Why does writing about emotional issues make
a difference in physical and emotional health? Pennebaker theorizes that confiding bottled-up feelings
relieves stress that otherwise would ratchet up blood
pressure, heart rate, and muscle tension.
Clinicians at the Benson-Henry Institute for
Mind Body Medicine have found that the following journal exercise helps relieve ongoing sources of
stress. A single attempt is not enough, though. When
you first sit down to write about a problem, you may
feel more anxious. The wound, once exposed, may
initially hurt more than it did while hidden. But
continuing to write about the same problem over
Affirmations
Affirmations are statements that express love, acceptance
and, often, a joyous vision for your self and your life. A
stream of positive thoughts can drown out more negative
ones. Try incorporating simple affirmations, such as
I breathe in healing or I breathe out tension, into
relaxation techniques. Or paste them to your mirror or
another prominent place where you can read them several
times a day. The more often you repeat an affirmation, the
more likely you are to believe it and act on it.
Whether you write your own affirmation or borrow one
from a helpful bumper sticker (One day at a time), the
words should resonate for you. When creating an affirmation, choose a stressful aspect of your life and decide what
a positive outcome would be or how you wish you felt
about the situation. Try to craft statements in first person
and present tense, such as these:
I can do this.
I am doing my best.
I am calm.
I deserve respect.
Week by week, I am growing healthier and stronger.
I can relax my body.
I am a loving, caring person.
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Stress Management
the course of several days often enables you to work

through difficult emotions and reach resolution or
acceptance.
Writing it out
Heres some advice before you begin:
Deeply troubling events and situations, such as
domestic violence, rape, or direct exposure to acts
of terrorism or war, are best explored with an experienced therapist. For other situations, you can proceed on your own and seek professional help only if
you feel you need assistance.
If youre physically healthy, choose the most stressful event or problem you currently face. Its usually
one that you frequently dwell upon. Or, if you think
your current problems stem from past circumstance,
write about upsetting events in your past.
Truly let go. Write down what you feel and why you
feel that way.
Write for yourself, not others. Dont worry about grammar or sentence structure. If you run out of things to
say in the time allotted, feel free to repeat yourself.
Do this exercise for 15 to 20 minutes a day for three
to four days, or as long as a week if you feel writing
continues to be helpful.
Bringing more joy to your life
You neednt only write about sources of stress. Another
approach is to keep a gratitude journal (see page 24)
or to use a journal to identify ways to bring more joy
and meaning to your life. For this exercise, set aside
10 minutes a day to write in your journal about any
positive event thats taken place in your life. Perhaps it
was having a baby, getting a coveted job, touring the
French countryside, or getting an advanced degree.
Focus on how you felt at the time and on your feelings now. After youre done writing, take a few minutes to reflect on your emotions. Did you feel proud
of a hard-won accomplishment? Exhilarated by a new
experience? Awash in love and acceptance because of
a connection with a loved one? Now look for ways to
experience those feelings again. Can you find opportunities in the present that might bring you those
same feelings?
Cognitive restructuring:
You are what you think
Stop for a moment and try to remember the thoughts

that were running through your head as you got
dressed for work this morning. What were you saying to yourself? What were you thinking? Then think
about how you felt.
Perhaps a simple thought, such as the train is
late, quickly drifted out of control. Suddenly, you
were thinking: Ill be late to work. I wont make it to
my meeting on time. My boss will be angry with me.
My job is in jeopardy.
Sometimes even seemingly happy thoughts hurtle
down the same track. Wonderful, the lab report says
my biopsy results are negative! can quickly turn to I
wonder how good that lab is? Maybe the results were
positive, and the lab didnt pick it up. Cancer thats
undetected gets worse. By the time the error is found,
it could be too late.
These scenarios are examples of automatic thinking.
They can engage the stress response almost as easily as a
growling Doberman bounding in your direction.
So, too, can the barrage of negative thoughts that
many people play through their minds on an endless
loop, or flip on automatically when faced with certain
people or situations. Familiar examples include: I
look awful, I cant do this, Im stupid, Im such a
screw-up, and Im a loser. The voice may be yours or
that of someone else from your life, such as an overly
critical parent. Even in the absence of obviously stressful situations, this inner critic can make you miserable
and stressed.
Cognitive therapy is built on the premise that
thoughts and perceptions shape moods and emotions.
A stream of highly negative thoughts may contribute
to depression and anxiety. These negative thoughts
are often riddled with irrational distortions and exaggerations. They can be examined and deflated, though,
once you learn the skills of cognitive restructuring, a
cognitive therapy technique that helps people change
the way they think.
Recognizing your distortions

Ten common cognitive distortions appear below. They
are based on theories of cognitive therapy expounded
by Dr. Aaron T. Beck, which were further refined and

brought to popular attention by Dr. David D. Burns.
Do any of these distortions resonate with you? Use
this list to help make you aware of ingrained negative
thought patterns and try to substitute more realistic,
positive thoughts.
All or nothing. Everything is black or white; nothing is gray. If you dont perform flawlessly, you consider yourself a complete failure.
Overgeneralization. One negative event, such as a
slight from your spouse or an encounter with a dishonest merchant, is perceived to be part of an endless
pattern of dismaying circumstances and defeat. For
example, you might think, Hes always cold or You
cant trust anyone.
Mental filter. One negative episode, such as a rude
comment made to you during an otherwise enjoyable
evening, shades everything like a drop of food coloring in a glass of water. Its as though you are filtering
out all the light and only see darkness.
Disqualifying the positive. Positive input, such as
an affectionate gesture or outright praise, just doesnt
count. You deflect all compliments with self-deprecation. You might say, Its no big deal.
Jumping to conclusions. You draw negative conclusions without checking to see if they have any foundation in fact. You may be mind-reading: My friend
seems upset; she must be mad at me. Or you may be
fortune-telling: I just know the results of my medical
test wont be good.
Magnification or minimization. You exaggerate
potential problems or mistakes until they take on the
proportions of a catastrophe. Or you minimize anything that might make you feel good, such as appreciation for a kind act you did or the recognition that
other people have flaws, too.
Emotional reasoning. You assume your negative
emotions reflect the way things are. For example,
I feel inferior. Therefore, I must not be as good as
others.
Should statements. You adhere to a rigid set of
beliefs and internal rules about what you should be
doing and feel guilty when you dont stay the course.
Labeling. Rather than describe a mistake or challenge in your life, you label yourself negatively: Im
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27
a screw-up. When another persons behavior bothers

you, you pin a global label on him or her: Shes so
controlling.
Personalization. You blame yourself for triggering
a negative event that occurred for complex reasons or
for something that was largely out of your control. If I
had taken care of myself properly, I never would have
gotten cancer.
Other clues can also help you identify distorted
thinking. Sentences that include the words must,
should, ought, always, and never are often
harsher than necessary and reflect rigid thinking that
could stand to be softened.
Stop, breathe, reflect, choose

If youre like most people, some of the distortions
listed above are familiar to you. The next step is to
challenge any overly simplistic, negative thoughts that
cause you unnecessary distress. Its easiest, of course,
when the thoughts are patently untrue: I never do
anything right, for example. Its harder when theres
an element of truth mixed in with simplistic falsehoods: At my age, I know Ill never reach my goals.
If you always longed to be a famous opera singer but
you lacked the time and talent to bring your dream
to fruition, that statement may apply. For one goal.
Most likely, though, you could list other goals that
you did reach. And if you scaled down your dream
by realizing that you enjoy singing, whether or not
the audience of the Metropolitan Opera pays rapt
attention, you could even set course for a new goal
and actually meet it.
This four-step process taught at the BensonHenry Institute for Mind Body Medicine is one way
to help derail stress that stems from distortions and
negative thoughts:
Stop. Consciously call a mental time-out. The
next time you feel stressed, simply say Stop. This
stops the negative stress cycle in its tracks.
Breathe. Take a few deep breaths to reduce physical tension and help you relax.
Reflect. Ask yourself the following questions:
Is this thought or belief true? Did I jump to a conclusion? What evidence do I actually have? Am I letting negative thoughts balloon? Is there another way
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Stress Management
to view the situation? What would be the worst that

could happen? Does it help me to think this way?
Choose. Decide how to deal with the source of
your stress. If a distortion is the root of the problem,
challenge your thinking and adjust your view of reality. Ask yourself the following questions: How else can
I think about this? What else can I do to cope more
effectively? Remember, most things we worry about
never come to fruition.
Restructuring negative thoughts and distortions
takes practice. You neednt ignore reality or put on an
artificially happy face. Often its possible to shift your
focus toward the positive, rather than dwelling on
the negative. At other times, you can acknowledge a
painful truth without losing sight of the larger, more
positive picture.
For example, I should be practicing relaxation
response techniques every day can be rephrased as I
want to practice relaxation response techniques every
day, or I feel calmer and happier when I practice
relaxation response techniques regularly. Rather than
Optimists are more likely to put a positive

spin on stressors, look for ways to make the
best of a bad situation, and use problemsolving strategies to tackle difficulties.
berating yourself for falling short, encourage yourself
to keep finding time.
When an illness flares up and leaves you feeling hopeless, it may help to acknowledge this without allowing it to engulf you. Change Ill never get
any better to I feel sick and in pain today. I know
that I can try a combination of medications and techniques to help relieve my discomfort. Next week, Ill
probably feel better and be able to follow my normal
schedule.
Often, you can benefit from a friends perspective
on a problem or issue that seems insurmountable. He
or she may recognize a major flaw in your thinking
that has escaped your notice. Or it may help to distract
yourself from the problem rather than continuing to
worry about it. Try a mini-relaxation or calm yourself
through imagery.
If distortions are particularly thorny or deeply

ingrained, seek help from a licensed mental health
professional who has experience with cognitive
restructuring, or attend a mind/body program.
stop and picture the goose. Ask yourself: Is this just

a goose in a bottle? And consider how else you can
think about the situation.
Schedule your worries

You may also find it helpful to structure your worry
either by setting aside a time to worry (see below) or
creating a place to hold your worries (see Make a
worry box, page 24). These techniques can help you
keep negative thoughts and fears from weaving their
way throughout your days.
At times when your mind is racing, you feel overwhelmed and anxious, and you cant seem to focus, call
a time-out for yourself. Set a timer for 15 minutes and
write down everything that youre worried about. But
when the buzzer sounds, put your worries away and
allow yourself to be fully present. Try to accept your concerns and fears without judgment. Practicing mindfulness meditation (see page 15) may help with this task.
If you are going through a tumultuous or difficult
timeperhaps you are in the midst of a divorce or you
are facing a financial setbackand worry is persistent,
you may find it helpful to set aside a specific time each
day to record your worries.
The role of positive psychology
Consider the goose in a bottle

When you find yourself jumping to conclusions or
dwelling on negative thoughts, the goose in the bottle
exercise may help challenge your thinking. The exercise has its roots in a well-known Zen koan that asks us
to consider how to free a goose from a glass bottle.
In this story, an official asks a Zen master to consider this problem: a man places a gosling in a bottle,
feeding it through the neck of the bottle until it is fully
grown and there is no room in the bottle anymore.
How can the man get the goose out without harming it or breaking the bottle? The master imagines the
scene and then shouts, See! The goose is out.
The mind created this problem; the goose was
imagined in the bottle and can just as easily be imagined out of it. The story is a reminder that worry is the
misuse of imagination.
The next time you are playing out worst-case scenarios or allowing negative thoughts to snowball,
Positive psychology is an emerging field recognized

by the American Psychological Association, and many
experts who design stress-management programs harness its principles. It focuses on determining and promoting the factors that permit people to thrive. Rather
than search for the roots of unhappiness, research
coming out of this field investigates the ingredients of
a good life and weighs the effects of traits like optimism, humor, and even eccentricity.
Optimists, for example, tend to do better than pessimists when coping with stressful situations. They are
more likely to put a positive spin on stressors, look for
ways to make the best of a bad situation, and use problem-solving strategies to tackle difficulties.
Some studies indicate that optimists often fare
better physically, too. A long-term study of more than
830 people found that those classified as pessimists
had a 19% higher risk of mortality over the course of
30 years than those who were optimists. In addition,
a 10-year study of 1,300 men suggested that a sense
of optimism may protect older men against heart
disease. Supporting that is a 2007 study of approximately 2,900 healthy adults that found that those who
reported upbeat moods had lower levels of cortisol,
one of the stress hormones that may contribute to
high blood pressure and decreased immune function.
In addition, women with positive outlooks had lower
levels of two inflammatory markers, C-reactive protein and interleukin-6; high levels of these substances
may contribute to type 2 diabetes and atherosclerosis,
the buildup of fatty deposits in arteries that can cause
heart attacks and strokes.
If youre not a natural optimist, this information
could merely fuel your pessimism. Dont let it. Take a
deep breath and relax. Evidence suggests that avoiding pessimism is more important than boosting optimism. Its true that there are people with naturally
sunny natures, but its equally true that the way you
handle yourself emotionally owes a great deal to nurStress Management
29
Boost your happiness

Looking for ways to feel happier and fight off depression?
A recent study found that these exercises delivered positive
results, particularly when they are done regularly.
A gratitude visit. Identify someone who has been
particularly kind to you whom you havent thanked
properlyperhaps a parent, friend, teacher, coach, teammate, or employer. Try to choose someone you can meet
with in person. In the next week, write a letter of gratitude
to that person and then hand-deliver it. Make your letter
as specific as possible, spelling out what the person did
for you, how often you remember those efforts, and what
effect they had on you. When you meet, read your letter
aloud to the recipient. Afterward, think about the following
questions: How did you feel as you wrote your letter? How
did the other person react to your letter, and how were you
affected by the reaction? Is there someone else you would
like to express your gratitude to in a similar way?
Three good things in life. For the next week, each night
reflect on your day and find three things that went really
well. Spend 10 minutes writing about them in a journal,
including information on why they went well. Its important
to record these in a journal, rather than simply noting them
ture. With practice, your current outlook and behaviors can change for the better.
You may already have tried some techniques used
in positive psychology. They include cognitive restructuring and journal writing, as well as emphasizing the
importance of intimate bonds. Other techniques help
people tap into a sense of gratitude and thankfulness
or simply a sense of humor. All of these therapeutic
approaches focus on amplifying the positive.
A study that assessed the effects of several different happiness exercises found a few that were particularly effective in increasing happiness and decreasing
depressive symptoms. The researcherswho included
Martin Seligman, the director of the University of
Pennsylvania Positive Psychology Center and a leader
in the positive psychology fieldasked 577 adults to
perform one of five happiness exercises or a placebo
(writing down their early memories every night for
one week). The participants completed two surveys
a happiness index and a depression scalebefore and
after performing the exercises.
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Stress Management
in your head. The things dont need to be momentous. They

could be as simple as reading a bedtime story to your toddler or having your spouse pick up ice cream for dessert.
Then, next to each positive event, answer this question:
Why did this good thing happen? For example, someone
might write that her husband picked up ice cream because my husband is really thoughtful sometimes.
Using signature strengths in a new way. The study
participants were asked to fill out a character survey that
identified their top five strengths. At the time this report
went to press, the survey was available online at http://
www.authentichappiness.sas.upenn.edu. You can take the
survey to identify your character strengths. Or, if this isnt
possible, reflect on your own character and try to find five
qualities that are your strong suits. You may want to ask
a supportive friend or family member to help you identify
these character strengths. After doing this, choose one of
your strengths, and every day for the next week try to use
it in a different way.
Adapted and printed with permission from Martin E.P. Seligman, Ph.D., Direc
tor of the University of Pennsylvania Positive Psychology Center and author of
Authentic Happiness (New York: Free Press, 2002) and Learned Optimism (New
York: Vintage Books, 2006).
Two of these exercises Using signature strengths

in a new way and Three good thingshad lasting
effects, increasing happiness and decreasing depressive
symptoms for as long as six months. The researchers
had asked the participants to perform these exercises
for one week, but in follow-up interviews they found
that those who continued the exercises on their own got
better, longer-lasting results. Another exercise, Gratitude visit, delivered the best initial resultsboosting
happiness scores and lowering depressive symptoms
considerablybut the effects disappeared by the threemonth mark. For information on how to perform these
exercises, see Boost your happiness, above.
In addition, there have been many intriguing studies on humor. Researchers have found that laughter
boosts immune system activity and lowers the amount
of circulating stress hormones, such as adrenaline and
cortisol. No wonder many mind/body practitioners
prescribe laughter. They often urge patients to rent
funny movies, read amusing books, and embrace the
absurd in daily life.
The different faces of stress
erceptions of what constitutes a stressful situation

and reactions to stress vary from person to person. Yet all of us are influenced by a number of broad
issues. Are you male or female? How old are you? Are
you working? Or do you wish you were? Are you caring for an elderly or sick relative? This section explores
the different faces of stress.
Sex and stress
The physiology of the stress response is similar for

everyone. But some researchers believe that there are
distinct differences in the way women and men experience and respond to stress.
Community surveys taken in many countries find
women consistently report greater distress than men
do. A study of roughly 1,100 American adults that
appeared in the Journal of Personality and Social Psychology found that women were more likely than men
to experience ongoing stress and feel that their lives
were out of their control.
Why the disparity? Some researchers believe that
the social responsibilities typically handled by women
including child care, care of older relatives, and houseworkexpose them to more abundant opportunities
for distress. These responsibilities constitute the second shift for women who work outside the home.
This additional burden can lay the groundwork for
long-term health problems, as was demonstrated in a
large study of nurses. The women in the study charged
with caring for a disabled or chronically ill spouse for
nine or more hours a week were at increased risk of
having a heart attack or other manifestation of coronary artery disease over a four-year period. Men, on
the other hand, more often report financial stress than
women do, which makes sense since men are traditionally expected to be breadwinners.
Another study asked 166 married couples to keep
a daily diary tracking 21 common stressors, such as
arguments and overloads at home and work, for six

weeks. Wives proved 5% more likely than husbands
to report days marked by any distress and 19%
more likely to experience high-distress days. The
women did not typically carry feelings of high distress from one day to the next, but did report facing a
greater overall number of stressful situations. Certain
demands affected men or women more. Men reacted
more strongly to an argument with a child, financial
woes, or work overload, for example, while women
were more distressed by arguments with a spouse,
transportation difficulties, or family demands.
Some interesting preliminary research suggests
women and men tend to cope with stressful situations differently, too. A team of UCLA psychologists
published a study in Psychological Review suggesting
that women are less likely to fight or flee when faced
with stressors. Instead, they are likely to tend-andbefriend. Tending is nurturing behavior designed
to protect and relieve distress. Befriending, which
may support tending, refers to seeking and maintaining social connections.
The researchers believe sex hormones and the
pituitary hormone oxytocin are partly responsible for
such differences and suggest the behavior may have
held evolutionary advantages for women. Oxytocin
dampens anxiety and induces relaxation. Its effects
are enhanced by female sex hormones and diminished
by male sex hormones. When under stress, both men
and women release adrenaline and cortisol; men also
release testosterone, which tends to increase hostility and aggression. The impulse to fight or flee in the
face of danger could have disastrous consequences for
women, who tend to be smaller than men and may be
pregnant or caring for small children. It is intriguing
to speculate on whether tend-and-befriend could
have positive consequences for women. After all,
social connections are key to reducing the damaging
effects of stress (see Social support, page 19).
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31
Age and stress
Does age have any effect on stress? Certainly some

major life events, such as the death of a spouse, illness, and accidents, are more likely to touch you
with time. Ailments more common among older
people, such as heart disease, arthritis, and cancer,
are significant sources of pain and disability. Side
effects from medications and other treatments can
be unpleasant daily realities. Sleep disturbances are
also common in later life. Any or all of these can be
a source of stress.
A dwindling interest in exercisetied, perhaps,
to osteoporosis or compromised vision, hearing, and
balance as you grow oldercan make you more of a
shut-in than you would like to be. This can set off a
cycle of declining physical abilities and increasing
frailty. Is that stressful? Just ask anyone who worries
Tips for taming stress for older adults

Attend a mind/body program. Some are specifically
designed for seniors. Others may focus on chronic

pain or specific ailments, such as heart disease (see
Resources, page 43).
Ask your doctor whether you might benefit from certain
types of exercise, such as tai chi, which enhances balance and aerobic capacity, or strength training, which
has been shown to build bone density and muscle
strength in elderly people. Many other kinds of physical
activity improve your health, lift your mood, and reduce
stress, too.
If insomnia is a considerable source of stress, cognitive
behavioral therapy may help. This form of therapy aims

to correct ingrained patterns of self-defeating behavior
and negative thoughts. In a randomized, controlled study
of 78 older adults published in the Journal of the American Medical Association in 1999, cognitive behavioral
therapy was significantly more effective than sleep medication for improving insomnia over sustained periods.
Ask your doctor to recommend a therapist or counselor
who could help.
If disability is a source of stress, talk with your doctor, a
geriatrician, an occupational therapist, or a staff member at your local council on aging about changes in your
home that might help you live more independently.
Consider whether you might benefit from cognitive
restructuring techniques or a course in assertiveness

training that would help you state your wishes and
handle conflicts.
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Stress Management
that a walk outside might end in broken bones or finds

it difficult to do simple tasks around the house. People
do adapt to changing abilities, its true, but the road to
that point may not be smooth.
Cultural training may make a difference, too. Older
people were raised at a time when emotional displays
were frowned upon. Many older women never learned
how to state needs directly and handle uncomfortable
conflicts before they become a source of stress; nor did
they have abundant opportunities to work outside of
the home, which offers creative, productive outlets to
some women. On the other hand, many do take comfort from religion, which may have an effect on health
and longevity.
Some preliminary evidence suggests that disturbances in the HPA axis, which controls the stress
response (see page 2), compound certain health problems that are common among older people, such as
cardiovascular disease and stroke. Aging and longterm stress both appear to trigger these disturbances
in some people. Constant exposure to certain stress
hormones, such as cortisol, can harm nerve cells in
the hippocampus, potentially affecting learning and
memory processing.
Fortunately, not all of these consequences are written in stone. Once you identify key sources of stress in
your life, odds are good that you can overcome them.
Its possible to prevent or at least combat physical
decline and some age-related ailments through exercise, good nutrition, appropriate medications, and
stress-control techniques. Also try the Tips for taming stress for older adults, at left.
Caregiving and stress
Caring for others fulfills a basic social contract in ways

that can draw generations and individuals closer to
one another. Certainly, caring for an elderly parent or
ailing spouse is a worthy, often satisfying pursuit. But
it isnt easy. If youre a caregiver, you may often wrestle with stress as well as exhaustion, anger, guilt, grief,
and other difficult emotions.
More often than not, caregivers are women. The
task is especially hard on women in the so-called
sandwich generation, who are simultaneously caring
for children and older parents, quite possibly while

working outside the home, too.
While you attend to the needs of others, your own
sense of well-being may head south. Studies of men
and women responsible for the long-term care of relatives show higher rates of illness, suppressed immune
response, slower healing, and even increased mortality among caregivers. Additionally, research pub-
Tips for taming caregiver stress

The relaxation response (see page 10) and self-nurturing
techniques (see Nurturing yourself, page 20) are vital.

Practicing them often will enable you to feel calmer, happier, and better able to help others. If its too hard to find
the time, consider getting extra help with some household tasks.
Protect your own health. Research suggests that a care-
givers immune function is often suppressed by the stress

of caring for others. Boost your resistance by eating well,
getting enough rest and exercise, and pursuing activities
that bring you pleasure.
A blend of assertiveness and cognitive restructuring
skills can help you share the work, instead of taking on

everything yourself. Spell out to other family members
what needs to be done and what sort of help would
be best. If no one offers help, ask for it. When someone
offers, accept it. Write out a list of smaller tasks people
can do, such as calling regularly, cooking an occasional
dinner, and running errands, and dole these out. Or simply ask people to check off what they can do.
Take advantage of regular respite care from profession-
als, family, and friends to give yourself much-needed

breaks.
Join a support group to talk out frustrations with other
people in your situation and to get helpful ideas. Some

caregiver support groups are available online (such as a
nationwide chat group run by AARP), while others are
run by local hospitals, senior centers, and community
groups.
Periodically, consider what you can offer and what
assistance you need. If its getting too hard for you to

fulfill certain needs, ask family members for help or
consider other options, such as hiring paid caregivers
to take on these tasks. Consult a geriatric care manager or a social worker for help; your local council on
aging or visiting nurse association should be able to
help you find one. If necessary, consider another living
arrangement that would help you meet your needs and
those of your loved one.
lished in 2003 revealed that ongoing stress endured

by older adults caring for spouses with Alzheimers
disease had a negative impact on the caregivers own
mental functioning.
In order to give care, you need stress relief, support, and time for yourself and your family. The Tips
for taming caregiver stress at left may help.
Work and stress
Americans spend more time working than they did in

previous decades. Cell phones, telecommuting, e-mail,
and fax machines have breached the wall between
work and leisure time. Frequent threats of layoffs
and the flight of industries to markets where labor is
cheaper fuel worker worries. The jobs of older workers may be jeopardized by younger aspirants who are
well-versed in new technologies or simply less costly
to a corporation. A generally shaky economy and the
rise in food and gas prices also feed anxiety.
Given this picture, is work-related stress increasing? Its hard to be certain. Some researchers have
pointed out that the scales designed to measure stress
at work may be too narrow to fit people in a wide range
of occupations and arent always applicable to current
work practices. In addition, beneficial changes, such
as the elimination of some dirty, tedious jobs and a
growth in opportunities available in challenging new
fields, generally get little attention. So do the positive
psychological effects of work.
Perhaps a better question, then, is how does your
job affect you? Does it engage and energize you or
leave you sapped? Does it satisfy you? Do you get the
support you need to do your job? How much control do you have over your work? A study of almost
21,300 female registered nurses found those reporting
minimal control over their jobs, little social support
at work, and high job demands were more likely to be
in poor health when data collection started. They also
suffered greater functional declines during the next
four years. In this study, published in BMJ in 2000, job
control depended on the workers ability to acquire
and apply new skills on the job and to have decisionmaking authority. Women in jobs with the highest
control and lowest demands stayed healthiest.
Stress Management
33
Tips for taming work-related stress

Try a mini-relaxation (see page 23) for fast relief.
Halt cognitive distortions before they get too strong a
toehold. Remember to stop, breathe, reflect, and choose
(see Cognitive restructuring: You are what you think,
page 27).
Take a 10-minute break for a body scan (see page 13) on
days when tension builds up.
Practice self-nurturing techniques at work as well as outside of it (see Nurturing yourself, page 20). Buy flowers
for your desk, have lunch with your favorite co-workers,
or strap on your in-line skates for a lunchtime spin.
A more recent study linked job stress and heart

disease. Researchers conducting the 2008 study, which
involved 10,000 London-based male and female civil
servants, found that chronic work stress was associated with coronary artery disease, especially among
people under age 50.
No matter how you rate your job, you can find
ways to defuse the stress response whenever work
34
Stress Management
triggers it. Start by trying the Tips for taming workrelated stress at left.
Not working can be as stressful as working.
Answering the often-asked question What do you
do? can be troubling to people who are unemployed
or retired. Even those who work as homemakers may
feel anxious about it. Too often, the jobs held by people define their places in society. Labels such as stayat-home mom, retired, and laid off conjure up
stereotypes. Then there are the financial pressures of
not working or working in a nonpaying job.
You can counter these stressors in many ways.
Addressing cognitive distortions (see Cognitive
restructuring: You are what you think, page 27) can
help you manage realistic and unrealistic fears. Practicing relaxation and self-nurturing techniques will lower
your stress levels. And bookstores are filled with career
advice ranging from identifying the work you love to
acing job interviews. Be aware, too, that there is a life
beyond work where satisfaction and opportunity exist
(see Creativity, productivity, and leisure, page 20).
How stress affects the body
great deal of research suggests exposure to longterm stress can harm your body. Chronic stress
influences high blood pressure and heart disease. It
may also suppress the immune system and have implications for asthma, gastrointestinal disorders, cancer, and ulcers. Additionally, emerging research now
supports the popular notion that high levels of stress
somehow speed up the aging process.
A 2004 study that followed mothers of chronically
ill children showed that the stress of caregiving actually
caused these women to age faster on a cellular level than
did the mothers of healthy children who constituted the
control group. When cells divide, the protective caps on
the ends of the chromosomes, called telomeres, shorten
slightly with each replication. The telomere length of
the stressed caregiving mothers indicated that their
cells had aged an additional nine to 17 years over the
normal aging pace of the low-stress group.
What explains the physical toll of stress? Reasons
stress could be harmful include direct effectssuch as
through long-term suppression of the immune system,
causing stickier-than-normal platelets, slowing wound
healing, or constricting major blood vesselsand indirect effects on behavior. People respond to stress in many
ways, not all of them healthy. Overeating, smoking,

drinking too much, not exercising enough, and engaging in other risky behavior can certainly take a toll.
What does this body of research mean to you? It
suggests that you can avoid or ease the negative effects
of stress through regular use of the methods outlined
in How to prevent and manage stress on page 10.
While stress-relief techniques can help, some conditions require other treatment. Your doctor can recommend the treatment plan thats best for you.
Stress and cardiovascular disease
Cardiovascular disease encompasses a range of ailments

that affect the heart or impinge upon the thousands of
miles of blood vessels that nurture cells throughout the
body. Three obvious examples are atherosclerosis (the
accumulation of fatty deposits on artery walls), heart
attacks, and strokes. The landmark Framingham Heart
Study noted that certain factors raise the risk of cardiovascular disease. Some, such as race, age, sex, and
genetics, are beyond your control. But others lie within
your sphere of influence. Traditionally, the controllable risk factors have included smoking, inactivity, obe-
Figure 5 Inside a narrowed artery

Blood vessel wall
LDL cholesterol
Stress may damage your arteries. Scientists theorize that

stress hormones increase cholesterol levels. People with
high levels of low-density lipoprotein (LDL) cholesterol
are more likely to develop atherosclerosis, which is the
buildup of fatty deposits on artery walls. As the mixture
of fats, calcium deposits, and cell debris accumulates on
artery walls, the channel that the blood flows through
becomes progressively narrower. Eventually, blood flow
is obstructed. The blockage can cause angina, a heart
attack, or stroke.
Atherosclerosis
Stress Management
35
sity, high blood pressure, high blood cholesterol, and

diabetes. Psychological stress appears to be a potent risk
factor as well. One three-year study asked 2,700 American adults to complete an online survey of physical and
mental health following the Sept. 11 terrorist attacks.
People who had high levels of stress immediately after
the attacks were nearly twice as likely to develop high
blood pressure and more than three times as likely to
develop heart problems during the following two years
compared with those who had low stress levels.
In addition, research indicates that a number of
psychological and social factorsincluding depression, anxiety, anger and hostility, a lack of social support, work stress, marital stress, low socioeconomic
status, and caregiver strainplay significant roles in
the development of cardiovascular disease. Acting
alone, each of these factors heightens the chances of
developing heart disease. When combined, their power
increases exponentially. On a more positive note, the
reverse is also truetreating depression, controlling
anger and hostility, and improving social support can
lower your odds of developing cardiovascular disease.
How might stress contribute to cardiovascular dis-
ease? Several avenues are under study. The release of

stress hormones, such as adrenaline, into the bloodstream appears to increase the amount of cholesterol
made by the body. Repeated arousal of the sympathetic
nervous system can trigger changes that increase the
risk of heart disease. For example, when the sympathetic nervous system is aroused, blood pressure rises
and platelets become stickier (see The stress response,
page 2). Stickier platelets make blood clots more likely,
while ongoing high blood pressure damages the heart,
blood vessels, and other organs, and greatly increases
your chances of developing heart disease.
Dysregulation of the immune system and inflammation have also been implicated. Chronic inflammation plays key roles in the process leading to
cholesterol-clogged arteries and heart attacks. Inflammation is an intricate dance involving different types
of white blood cells, the antibodies they make, and a
dizzying array of chemical messengers known as cyto
kines. Its aim is to defend the body against bacteria,
viruses, and other foreign invaders, to remove debris,
and to help repair damaged tissue. Inside arteries,
however, inflammation helps kick off atherosclerosis
Exploring the links between relaxation techniques and protective chemicals in the body
Can relaxation response techniques boost the production
of certain substances that protect the body from illness and
help stifle pain? Research suggests that they can.
In 2005, a team of Harvard Medical School researchers led
by Dr. Jeffrey A. Dusek found that the relaxation response
is associated with production of nitric oxide, a substance
that offers a variety of health benefits. In this study, oxygen
consumption and nitric oxide exhalation were measured in
participants at the start of the trial, then again after eight
weeks of training in the relaxation response. While there
was no correlation between the two measurements at the
beginning of the program, by the end, oxygen consumption
had decreased in proportion to an increase in nitric oxide
production in the people who used the relaxation response.
A similar change wasnt observed in a control group.
What are the benefits of nitric oxide? In a complex study
published in 2001 in Brain Research Reviews, a research team
led by George B. Stefano investigated its multifaceted role.
This molecule is present in human tissues and is best known
for dilating blood vessels. But it performs other vital functions
as well. It acts as a signaling molecule shuttling communica-
36
Stress Management
tions between key body systems, dampens the activity of

certain immune cells, and inhibits blood clotting. It also has
antibacterial and antiviral properties. In fact, it stimulates
activation of an enzyme that leads to the release of enkelytin,
an antibacterial peptide, and enkephalins, compounds that
enhance mood, reduce pain perception, and stimulate some
immune system cells. To the researchers, this suggested that
having sufficient levels of nitric oxide offers potential protection against microbes, health problems such as hypertension,
and overzealous activity in the immune and vascular systems.
Stefano and his team also pondered intriguing connections
between the relaxation response and the placebo effect, a
phenomenon that turns a persons positive expectations or
deeply held beliefs into an effective tool against illness. They
posited that both the relaxation response and the placebo
effect work through a complex connection of mind/body
networks that prompts the release of nitric oxide, enkelytin,
and enkephalins and harnesses their beneficial effects. The
placebo effect, which can have beneficial health effects, is
automatic, or perhaps the result of conditioning. The relaxa
tion response, on the other hand, can be learned.
Figure 6 A cycle of damage

Nephron
4 Nephrons filtering
capacity is impaired
LDL cholesterol
1 Increased pressure
on vessel wall
3 Released hormone
increases blood pressure
Atherosclerosis
2 Reduced
blood supply
to kidney
Renin released
and keeps the process smoldering. Atherosclerosis can

narrow blood vessels dangerously, causing chest pain,
a heart attack, or a stroke (see Figure 5). Inflammation
even influences the formation of artery-blocking clots,
the ultimate cause of heart attacks and many strokes.
In addition, stress has an indirect influence, with
negative emotions shaping behaviors that affect cardiovascular risk. People who are stressed are more likely to
smoke and less likely to engage in physical activity.
Research also shows that sudden spasms in coronary arteries can be brought on by mental stressat least
when people with existing heart disease are asked to do
complex equations during laboratory experiments. A
sudden spasm can block blood flow to part of the heart,
causing temporary chest pain or even a heart attack.
An ambitious research project published in The Lancet in 2004, which involved over 24,000 participants from
52 countries, demonstrated the role of stress in heightening heart attack risk. Roughly 11,000 patients who had
just had a first heart attack were asked, as they left the
hospital, about various forms of stress they had experienced in the preceding 12 months. The questions probed
reactions to job and home stress, financial problems, and
major life events. Members of a control group, who were
Kidney
Stress can contribute to high blood

pressure, which can set the stage
for atherosclerosis and sometimes
kidney damage. High blood pressure
can cause tiny cracks in the lining of
arteries. These cracks provide a breed
ing ground for fatty deposits. As the
deposits accumulate along artery walls,
blood flow is hampered. If the arter
ies that feed blood to the kidneys are
affected, the body reacts by producing
renin, a hormone that causes small
arteries known as arterioles to narrow
further. This kicks off a cycle of even
higher blood pressure and further kid
ney damage. Over time, the diminished
blood flow can damage or destroy the
nephrons, the tiny filtering units inside
your kidneys. When this happens, the
kidney cannot filter wastes properly.
matched to the patients for age and sex but had no history
of heart disease, underwent similar assessments. Despite
variations in the prevalence of stress across countries and
ethnic groups, increased stress levels conferred a greater
risk of heart attack than did hypertension, abdominal
obesity, diabetes, and several other risk factors.
Stress and cancer
Can stress cause cancer? Currently, there isnt any evidence to suggest that stress can do so by itself. But
whether long-term stress may play a role by tampering
with immune defenses is a question that bears closer
scrutiny. One theory about how cancer develops suggests that cancerous changes in cells occur frequently for
a variety of reasons, but the immune system recognizes
the cells as aberrant and destroys them. Only when the
immune system becomes ineffective are the cancer cells
able to multiply. Chronic stress can hamper the immune
system, and this might affect the bodys ability to head off
the uncontrolled proliferation of cancerous cells.
What is clear, however, is that stress management
can have a role in cancer recovery. A 2005 study of
women undergoing breast cancer treatment concluded
Stress Management
37
Stress and ulcers

Just a few decades ago, ulcer patients were routinely
advised to eat bland foods and cut sources of stress from
their lives. Then scientists identified the bacterium Helicobacter pylori as a key instigator in the development of peptic ulcers, and antibiotics became the weapon of choice to
combat them. Now the pendulum is swinging back some of
the way. A 13-year study of more than 4,000 people found
that those who believed their lives were stressful were
nearly twice as likely to get ulcers.
Experts believe that stress may hamper the bodys ability to repair the wall of the gut. Many studies have found
that stress affects wound healing, which could clearly
have implications for ulcers, even those created by bacteria. One experiment with medical students, for example,
found that small incisions made in the forearm three days
before a major exam took 40% longer to heal on average
than when they were given during summer vacation. Stress
might affect ulcers in other ways, too. It may trigger more
gastric secretions, which increase inflammation and lessen
the bodys ability to buffer gastric acids.
that a high stress level preceding the cancer diagnosis

resulted in a lower physical and emotional quality of
life immediately after treatment and even a year later.
In another study, women with Stage I or II breast cancer underwent a 10-week program of stress management
and relaxation training. Similarly diagnosed women in a
control group were not offered the training. At the end
of the study period, researchers measured the levels of
the stress hormone cortisol in each group. Women in the
group that received the training had lower cortisol levels.
Interestingly, their lower cortisol levels were connected
not to lower stress levels, but to a greater awareness of the
positive effects of their illness, such as better family relationships and an increased sense of purpose in life.
Stress and high blood pressure
The pumping action of your heart keeps blood circulating throughout your body. That blood carries nutrients
and oxygen to billions of cells and carts off carbon dioxide and other metabolic debris to the organs responsible
for their disposal. The force that moves the blood along
can be measured as blood pressure. Blood pressure fluctuates throughout the day, spiking when you exercise or
get upset and dipping when you rest quietly or sleep.
38
Stress Management
As mentioned earlier in this report, the release of

stress hormones causes your heart to beat faster and
your blood pressure to rise. Often, this rise is temporary, and your heartbeat slows and your blood pressure drops once a threat has passed. But if the stress
response is triggered repeatedly, blood pressure may
remain consistently high.
High blood pressure, or hypertension, is dangerous
for several reasons. It forces the heart to pump harder
to circulate blood. Eventually, the muscles of the heart
respond by thickening. But this doesnt necessarily translate into added strength. In fact, often the hearts blood
supply doesnt increase to the same degree, and, over
time, the heart weakens. This can lead to heart failure.
High blood pressure also damages artery walls
in a way that promotes atherosclerosis. By narrowing
arteries and interfering with blood flow, atherosclerosis can lead to a host of health problems, including
angina (chest pain), heart attack, stroke, and kidney
damage (see Figure 6). In fact, the higher your blood
pressure, the greater your risk for heart attack, heart
failure, stroke, and kidney disease.
Stress and the immune system
Studies suggest that the immune system is affected by

both short-term sources of stress, such as academic
exams or a fender-bender, and long-term sources,
such as job strain or ongoing conflict with a spouse.
However, while a great deal of research has been done
on this topic, until the science of human immunity
is more fully understood, the effect of stress on the
bodys ability to resist disease remains uncertain.
With that said, short-term stress creates a temporary
increase in certain measures of immune system activity. For example, its been shown to boost the transfer
of infection-fighting cells called lymphocytes from the
bloodstream to the skin, which some researchers think
could help block infection and enhance healing. Longterm stress, however, appears to have different effects
on certain immune cells. For example, natural killer
cells, which attack virus-laden cells and certain tumor
cells, may be suppressed by chronic stress. Viruses may
also exploit vulnerability created by stress.
Once affected by stress, how swiftly does the
immune system rebound? That depends on the original source of stress and the individual. But worrisome
changes in immune function have remained apparent
for weeks and months following earthquakes and hurricanes. One study of current and former caregivers
of spouses with Alzheimers disease found that natural killer cells were significantly subdued among the
caregivers compared with a control group. On average, this dampening of the immune system continued
for three years after the role as caregiver ended.
Stress and asthma
The bronchioles are small airways inside the lungs. Oxygen passing through them reaches air sacs called alveoli
and is released into the bloodstream. Carbon dioxide
from the blood collects in the alveoli and passes back
through the bronchioles to be expelled by the lungs as
you breathe out. The autonomic nervous system constricts and dilates the bronchioles. Strong arousal can
provoke bronchiole constriction, which makes it more
difficult to move air in and out of the lungs. As a result,
stress and strong emotions such as fear or anger commonly trigger asthma attacks (bouts of breathlessness
and wheezing) in some people who have asthma (see
Figure 7). Of course, physical stressors, such as cold
weather and exercise, can do the same.
The extent of the role stress plays in the development of asthma is still being debated. Intense family
stress early in life has been proposed as one of several key risk factors. However, genetic predisposition,
exposure to certain allergens, viral infections, and
raised levels of certain allergy markers in the blood are
also considered important.
Stress and gastrointestinal

disorders
According to an influential report published in Gut

in 1999, a combination of psychological and physical factors can trigger gastrointestinal pain and other
bowel symptoms. Severe life stress, it also noted, often
precedes the onset of functional bowel disorders for
patients in gastrointestinal clinics. Laboratory experiments show the digestive system responds to emoww w. h ealt h . h ar v ar d . e du
Figure 7 Provoking an asthma attack

Bronchioles
tighten
Stress can cause the small airways inside the lungs known as
bronchioles to tighten. This constriction interferes with the flow of
air into and out of your lungs. In people who are prone to asthma,
this can trigger wheezing, breathlessness, and other symptoms of
an asthma attack.
tional arousal and mental stress. Gastric acid secretion

can increase, which may lead to heartburn and inflammation of the esophagus. Stress may play a role in the
development of ulcers, too (see Stress and ulcers, at
left). Stress can also cause abnormal contractions in
the small intestine and colon and affect the pace at
which food travels through the gastrointestinal tract.
Interestingly, the parasympathetic nervous system,
which brings the body back to normal after the stress
response occurs, is responsible for the change in colon
contractions and the increase in gastric acid. Equally
intriguing, the effect of stress on the gastrointestinal
tract seems to differ from person to person. Irritable
bowel syndrome (IBS), which is associated with stress,
offers one example of such variation. IBS is characterized by abnormal contractions of the large and small
intestines and abdominal discomfort with no apparent
organic cause. Two English gastroenterologists found
that when IBS patients were under stress, food moved
more slowly through the small intestine in those patients
who usually suffered from constipation. The opposite
held true for those who typically had diarrhea.
A wide variety of triggers may cause IBS to flare
up. Among them are a high-fat diet, certain hormones
that affect the gastrointestinal tract, and everyday
stressors, such as arguments or work pressures. Some
research suggests that the early loss of one or both parents through death or divorce results in higher-thanaverage rates of IBS and peptic ulcer disease.
Stress Management
39
Developing your personal plan

for stress relief
aving a personalized stress-relief plan can help

you manage stressful situations better and even
prevent stress from building in the first place. As you
begin to create your personalized plan, go back for a
moment to My stress warning signs (page 8), which
helps you identify how stress affects you personally.
Whenever you notice these symptoms, take a moment
to do the following:
S top and breathe. Can you identify a specific stressful event?
Reflect. What were your automatic thoughts? Write

these down. Were there any distortions?
Choose. Ask yourself: Is there another way to think
about this situation? Can you use an affirmation?
What steps can you take to reduce your stress level?
N
otice how you feel now and write it down. Congratulate yourself for coping with the situation better.
Remember to take one step at a time. The more
you practice, the easier the process gets.
My plan for stress management

Key tasks
This week I will try
Days and times set aside What I noticed
Evoke the relaxation response through

techniques such as deep breathing
and a body scan (see How to prevent and manage stress, page 10).
Nurture yourself by setting aside time

for relaxation, eating well, exercising,
connecting with others, and pursuing activities that add joy to your life
(see Nurturing yourself, page 20).
Change the pattern of how you

appraise and respond to sources
of stress through cognitive restructuring (see page 27). Stop,
breathe, reflect, and choose.
40
Stress Management
While the steps above can help you manage stress,

youll also want to apply the techniques youve learned
in this report on a regular basis to keep stress at bay.
Youll get the best results if you elicit the relaxation
response every day for 10 to 20 minutes.
The chart on page 40 can help you start to do this
by working these and other key components of an
effective stress-management program into your daily
routine. Practicing these techniques regularly may put
you on the path toward a more peaceful, joyous, and
healthy life.
Aim to try a variety of techniques, so that you can
find the ones that work best for you. Let the first column of the chart refresh your memory of the primary
techniques that help disarm the stress response. Then
decide what youre willing to try and when you can

do it. Even small changespenciling in a few minirelaxations to break up daily tasks, reconnecting with
a friend over lunch, or taking a mindful walkare
important steps toward your goal. By writing down
what you noticed after taking these steps, you can
encourage yourself to keep at it. Try your plan for one
or two weeks before you make any changes.
What if you dont stick to the schedule youve
drawn up? Try not to feel discouraged. Consider
what got in the way and whether you set out to do
too much. Ask yourself what strategies could help
you circumvent these obstacles next week. Finally,
embrace what felt good and find the opportunity to
repeat it.
Stress Management
41
Glossary
adrenaline and noradrenaline: Also called epinephrine and
norepinephrine, these key stress hormones cause a cascade of
physiological responses in the body, such as faster heartbeat
and respiration, a rise in blood pressure, and the release of
energy-boosting fats and glucose.
autonomic nervous system: The part of the nervous system
that rules such involuntary body functions as breathing, blood
pressure, heartbeat, and the dilation or constriction of arteries
and small airways in the lungs. Includes the sympathetic and
parasympathetic nervous systems.
breath focus: A form of meditation that elicits the relaxation
response; breath focus relies on deep, even breathing, a passive attitude, and a focus word or focal point.
cortisol: One of a class of stress hormones, called glucocorticoids, released by the adrenal glands during the stress
response.
focus words: Words or phrases that enhance your sense of
peace, relaxation, and connection while you practice deep
breathing and other techniques that elicit the relaxation
response.
HPA (hypothalamic-pituitary-adrenal) axis: A system that
governs many hormonal activities in the body, including the
stress response.
hypothalamus: A network of nerves, located above the brain
stem, that helps control the sympathetic and parasympathetic
nervous systems and, through the pituitary gland, the endocrine system. Sparks the stress response by releasing the first
of several chemical messengers that put the body on alert.
mindfulness: A set of techniques that encourage you to slow
your pace and live fully in the moment.
42
Stress Management
mindfulness meditation: An ancient Buddhist practice that

induces the relaxation response by focusing you on the distracting thoughts and sensations that may occur during meditation; also called insight meditation.
parasympathetic nervous system: One of two offshoots of
the autonomic nervous system; it calms body systems excited
by the release of stress hormones.
positive psychology: An emerging field recognized by the
American Psychological Association that focuses on identifying and promoting factors that allow people to thrive.
post-traumatic stress disorder (PTSD): A prolonged reaction to trauma characterized by recurrent flashbacks, dreams,
or intrusive thoughts about the traumatic event; withdrawal
from people and certain situations; being easily startled; and
having difficulty sleeping.
relaxation response: A term coined by Dr. Herbert Benson to
describe the physical effects of meditation and certain other
techniques that are opposite to those of the stress response.
Effects include marked drops in oxygen consumption, carbon
dioxide expiration, heartbeat, and respiration, as well as stabilization or lowering of blood pressure.
stress response: Physiological changes, such as quickened breathing and heartbeat and increased blood pressure,
brought on by stress hormones released in response to a
real or perceived threat to your safety or ability to cope. Also
called the fight-or-flight response.
stressors: Stressful events or circumstances that may be real
or perceived threats to your equilibrium and well-being.
sympathetic nervous system: An offshoot of the autonomic
nervous system; it cranks up the body when stress hormones
are released in response to perceived or real dangers.
Resources
Organizations
Benson-Henry Institute for Mind Body
Medicine at Massachusetts General
Hospital
151 Merrimac Street, 4th Floor
Boston, MA 02114
617-643-6090
www.bhimgh.org
National Center for Complementary

and Alternative Medicine (NCCAM)
NCCAM Clearinghouse
P.O. Box 7923
Gaithersburg, MD 20898
888-644-6226 (toll-free)
www.nccam.nih.gov
Home base to Dr. Herbert Benson (one

of the medical editors of this report) and
his colleagues, who have investigated the
stress response and taught the relaxation
response and other stress-management
approaches for many years. The institute
offers programs for people with various
concerns and stress-related medical conditions, such as heart disease, chronic pain,
cancer, or infertility. It also offers exercise,
nutrition, wellness, and prevention programs, as well as school-based programs
for children and young adults.
Part of the National Institutes of Health,

this government agency offers a wealth of
publications on a variety of health problems. It also sponsors valuable research on
alternative and complementary medicine.
Center for Mindfulness in Medicine,

Health Care, and Society
55 Lake Ave. N.
Worcester, MA 01655
508-856-2656
www.umassmed.edu/cfm
Founded by Jon Kabat-Zinn, author of Full
Catastrophe Living, the center offers information and programs on stress reduction.
Its clinical treatment program is affiliated
with the University of Massachusetts Medical School.
Books
Harvard Medical School Guide to
Lowering Your Blood Pressure
Aggie Casey, M.S., R.N., and
(McGraw-Hill, 2005, 256 pages)
Harvard Medical School experts present an
innovative, proven plan to lower your blood
pressure. In addition to offering nutrition
and exercise advice, the book describes
techniques that can help you manage your
stress levels.
Mind Your Heart: A Mind/Body
Approach to Stress Management,
Exercise, and Nutrition for Heart Health
Aggie Casey, M.S., R.N., and Herbert
Benson, M.D., with Ann MacDonald
(Free Press, 2004, 352 pages)
Offers a balanced and holistic approach

to heart health that combines lifestyle
changes with cutting-edge medical
procedures. Discusses the importance of
risk factors such as depression, anger
and hostility, decreased social support,
physical inactivity, and poor nutrition, and
outlines self-care strategies to combat
these problems.
The Relaxation Response
(updated and expanded edition)
Herbert Benson, M.D., with
Miriam Z. Klipper
(Avon Books, 2000, 240 pages)
A groundbreaking book that revealed the
health benefits of stress-management
techniques. This revised classic describes
the therapeutic effects of the relaxation
response and teaches a variety of methods
to elicit it.
Self-Nurture: Learning to Care for
Yourself as Effectively as You Care for
Everyone Else
Alice D. Domar, Ph.D., and Henry Dreher
(Penguin Books, 2001, 320 pages)
Written for women, this book offers a prescription for enrichment and self-nurture
techniques intended to revitalize your life
and reconnect your body to your mind.
Stress Management
43
Notes
44
Stress Management
Notes
Stress Management
45
Other publications from Harvard Medical School

Periodicals Monthly Newsletters and Quarterlies including:
Harvard Health Letter
Harvard Womens Health Watch
Harvard Mens Health Watch
Harvard Heart Letter

Harvard Mental Health Letter
Perspectives on Prostate Disease
Special Health Reports Harvard Medical School publishes in-depth

reports on a wide range of health topics, including:
Alcohol
Allergies
Alzheimers Disease
Anxiety and Phobias
Arthritis
Back Pain
Caregivers
Cholesterol
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A Harvard Medical School Special Health Report

Harvard Health Publications

Heres what you CAN do

Heres what you CAN'T do

referred to as "fair use." However, cover-tocover photocopying is forbidden.

For more information

Aggie Casey, M.S., R.N.

Stress in your life. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Director, Cardiac Wellness Programs,

The major life event stress scale. . . . . . . . . . . . . . . . . . . . . . . . 7

How to prevent and manage stress . . . . . . . . . . . . . . . . . 10

Learning the relaxation response. . . . . . . . . . . . . . . . . . . . . . .

SPECIAL BONUS SECTION:

Published by Harvard Medical School

Journals: Easing stress the write way. . . . . . . . . . . . . . . . . . . . 25

Copyright 2008 by Harvard University. Written permission is

Harvard Health Publications

For the latest information and most up-to-date publication

Ordering Special Health Reports

Harvard Medical School publishes Special Health Reports

The different faces of stress. . . . . . . . . . . . . . . . . . . . . . . 31

How stress affects the body . . . . . . . . . . . . . . . . . . . . . . . 35

Developing your personal plan for stress relief. . . . . . . . . 40

For corporate sales and licensing, please e-mail:

Herbert Benson, M.D.

Aggie Casey, M.S., R.N.

Understanding the stress response

ust what is stress? Does it have positive attributes?

You may define stress as bumper-to-bumper traffic, a

injected that hormone into a second, perfectly calm

The stress response

tisol into the bloodstream. Surges of adrenaline and

exerting its calming influence, the day-to-day business

The positive side of stress

As many people have noted, the stress response can be

Figure 1 The HPA axis and the stress response

Blood pressure rises

Glucose and fats

The hypothalamus, pituitary gland, and adrenal glands make up

Center after the terrorist attacks of Sept. 11, 2001? Or

Figure 2 Yerkes-Dodson law

As stress increases, performance initially rises and then declines.

people appear less vulnerable to stress or even seem to

Stress and its toll on your body

Intuitively, the stress response makes sense. It enables

disease. Another is suppression of the immune system,

Post-traumatic stress disorder (PTSD)

Stress linked to health problems

abdominal pain, muscle pain, joint aches, postoperative

To the extent that stress causes these ailments, the

others and resuming normal life may provide solace.

Anxiety and depression

extreme worry or fear much of the time, or repeated

w w w.h ealt h .ha r va r d.e du

Stress in your life

n the course of a lifetime, odds are good that youll

The major life event stress scale

Several decades ago, two psychiatrists at the University of

Major life event stress scale (out of a possible 100)

Son or daughter leaving home

extreme worry or fear much of the time, or repeated

If you have intrusive thoughts that make