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11/17

dr wilson

Stress Management

obviously a timely 
lecture

causes of student stress: 
-exams, grades, money
we've defused 
the grade issue - 3.8 vs 3.3 isn't important. learn the material. don't 
study for a grade. GPA over 3.6 is not wanted. 
-interpersonal conflicts 
with classmates, spouses, significant others
-completion of career goal, 
matriculation into the Real World. 
-loss or serious illness of a loved 
one (spouse, parent, child, friend, pet)

causes of veterinary stress:

-loss of a patient (especially unexpected)(and you have to explain to 
owner)
-staff disharmony (drives a lot of vets out of practice ownership)

-jobs for two people
-loss or illness of a family member
-pain in the 
butt clients
-long work hours
-financial worries
-career changes
-major 
geographic relocations
-the huge volume of life or death decisions you 
are forced into making - "what would you do if it was your pet, doc?" 
well, it isn't your pet, but they will do what YOU say.
-euthanizing 
treatable animals b/c of inadequate bonds, insufficient money, 
inappropriate behavior

stress: some background
-stress is essential for 
immune and endocrine systems, to maintain good health!
-we need some 
stress in our lives!
-however, too much stress --> distress. 

signs of 
too much stress are emotional and behavioral:
-increased irritability

-overreactions, taking it out on the wrong people
-difficulty 
concentrating, fatigue
-stuttering, swearing (Dr Wilson remarks the women 
surprise him the most)
-accident proneness
-impulsive behavior: shopping 
sprees
-loss of appetite
-nervous tics
-increased smoking or drinking, 
use of other recreational drugs
-decrease in sexual urges or impotence 
(he said something about his wife..you do not want to know)
-insomnia, 
sinus problems, allergies, GI problems, ulcers, colitis
-lowered 
resistance to infxn, hypertension, migraines, PMS, missed menstrual 
cycles.  (another story about his wife)

Now that we know the signs of 
stress, George Lewis will explain how to handle it. Beware of the 
consequences. (Aaron Katcher was supposed to speak, but he succumbed to 
stress).

he's not going to tell us how to manage stress. if someone 
could do that it would undermine the drug industry of the US and the 
psychiatric professions. Prozac and valium would not be needed. 
Antidepressants and anxiolytics would be thrown away (you know what? i 
think he's oversimplifying. but heck, what do I know?)

some context for 
understanding stress - an evolutionary context. 
related to our 
evolutionary development, and the problems created by thinking. 
let him 
begin by saying the autonomic NS - sympathetic branch, key for the stress 
responses, was really designed to prepare the body for violent exercise, 
as you know. so, it was designed for the three Fs which are fighting, 
fleeing, and sexual activity. if you think about the years - millions - 
of years of human evolution, for all but the last few thousand people 
were living out there contending with animals and each other and the 
periods of excitation of the sympathetic NS were short- you were pursued 
and eaten, or you escaped. takes a few minutes. sexual activity, alas, 
from what we know about chimps, may be frequent, but also relatively 
short lasting a few minutes. intraspecies dominance contests also very 
brief. now, it wasn't until humans developed the capacity to maintain 
internal dialogues that stress, as we know it, was extended over long 
periods of time. even battles, when you consider it, and these are only 
probably about 8000 yrs old, up til thenpeople lived in groups of 50. but 
even a battle lasted only a few hours. so stressors until we got this 
internal dialogue ability were short lived. this is the key.

if you look 
at stress activation curve typical for the kind of stress that is benign, 
or that we enjoy, you find a sharp and signalled onset, a short duration, 
and a predictable termination. when that occurs, interestingly, there is 
a post-stress period in which activation levels go below baseline. this 
describes the curve of for example most recreational stress. Horror 
movies, downhill skiing, american sports - all chopped up into short 
bits. horror isn't sustained. roller coasters are short. skiing is short. 
few of our excitements last that long. blackjack - short periods of 
excitation (each hand). sports on TV - football, baseball, etc - short 
periods of activity. you have it under your control. when you have this 
stuff under your control, and when you endure them or enjoy them with 
others, it's all benign and recovery is complete. sexual excitation  
-same curve. cigarette, cocaine - same curve. so that if you want to look 
at benign stress, what you have to do is carve up periods of stress into 
short units. 

if you look at our lives, the periods of time in which 
they are actually under threat are very brief. walking to 40th st at 2 
am, you do that quickly. you may be in an operation where things get 
tense - doesn't stay that way a long time. there are few periods of time 
when people are exposed to constant, unremitting threat, for long periods 
of time. modern battle is one of those times. but that's not common. what 
you are exposed to, and what maintains and makes toxic stress activation, 
is your ability to mentally sustain the threat inside your head. to 
worry, ruminate, anticipate trouble, ponder, feel the sting of failure or 
rebuke long after you fail or are rebuked. that internal dialogue does 
the damage. that keeps you off the regular curve and on a big sustained 
plateau. 

the trick of life is not to avoid being activated. the trick 
is to get yourself deactivated. if you don't, then stress sympathetic 
activation significantly inhibits the immune system, and you begin to get 
problems. now, what you have to figure out, is how not to avoid being 
turned on, but how to turn off effectively, and hopefully without the use 
of "substances." (eh? substances? oh PLEASE.). you have to learn to 
inhibit and manage your internal dialogue.

ok, he talked about 
activation stress, similar to fight/flight response - what you feel when 
someone gets in your face and starts to yell, or the prof says you have 
flunked and should get out of school. that's easy to understand.

another 
insidious more dangerous kind of stress activation is depression. 
depression - the name makes you think that the CNS is inactive but...
the 
highest levels of adrenocortical activation are recorded during 
depression. 
one test for bipolar dz is that the adrenal cortex loses 
ability to inhibit secretion of pituitary hormones, so you break the 
feedback loop and corticotropin isn't inhibited by high levels of 
circulating cortisol. in depression, you get maximum inhibition of immune 
system as well.  the problem that will get most people in helping 
professions in trouble, is transition from stress activation and 
depression. because, that is what burn-out is. already, some of you are 
partially burnt out. you're moving from stress activation to depression. 
why? many reasons. some of it relates to your background, some of it 
relates to the peculiar situation of veterinary school and faculty.


background - you are all preselected to be vulnerable to depression b/c 
you spent your life pleasing people, being good, etc. if your first grade 
teacher told you do this, you did. if your high school teacher told you 
memorize this, you did. in college, same thing (uh, maybe some of YOU 
did...). you did a lot of stuff to win you the praise and high regard of 
other people .that is how you got here. if you didn't do that you 
wouldn't be here. the vet school doesn't recruit sociopaths (except for 
faculty positions) or people with C minus averages. (oh yea?)

so 
therefore, you must place a very high reward, it is very rewarding for 
you, to have the high esteem and praise and goodwill of other people - 
(ok that's true.). depression is - a threat occurs - we feel we have lost 
the high regard of other people, or we've actually physically lost people 
through death or disappearance. so those in helping professions are 
vulnerable, b/c if you didn't need high regard of others, why would you 
be so helpful, anyway?

re: veterinary school - up til now, there was no 
challenge you couldn't master. you got As, you did all your other 
activities, everyone loved you, etc. now you get here and what happens? 
the typical lecturer will say he's going to lecture on the metabolism of 
the 15 toed sloth and that any vet student worth shit should master this, 
but obviously since he only has 15 minutes to talk, he will not talk 
about it, so you won't know what you need to know. if you took a PhD in 
the subject, you might acquire some of the needed information. so you 
should realize, you can't master the veterinary curriculum, it is simply 
not possible. you must face entering practice knowing less than you ought 
to know. in fact, one professor likes to say, between the Rio Grande and 
Hudson Rivers is the difference b/w vets and drs. MD students are 
learning deeply about one spp, vets a more shallow amount about many spp. 
this puts you into a new situation. that increases your vulnerability. no 
matter how good you are you can't excel in a situation like that. by 
definition it is impossible.

what is burnout?
first of all, people who 
experience burnout cascade have to be activated to begin with. you all 
were, and will be when you start practice. so your expectations will be 
high. some expectations may be getting lower and lower as we go on though 
:). there is good data that people in year 3 and 4 of vet school are 
starting to experience burnout b/c of difficulty mastering curriculum and 
growing realization of financial difficulties of the profession.
you are 
the kind of person who wants to master the challenges. for some of you, 
veterinary practice will permit you that kind of mastery experience, 
provided you enjoy the business of veterinary medicine and working with 
people. if you do not enjoy those things, then you are going to find 
yourself potentially in difficulty, b/c the paperwork is (btw, re: 
paperwork - the phrase implies this is all very boring. paperwork isn't 
writing out deposit slips, but rather filling out insurance forms) but at 
any rate, given that you do not enjoy those two aspects of practice or 
you find yourself ina  practice where there is internal conflict orwhich 
isn't rewarding for some reason, your activation can phase over into 
disappointed expectations. in turn, this phases over into frustration at 
not being able to master the task, not being able to do what you want to 
do, and really it is a kind of chronic anger. as Dr Wilson mentioned, it 
is that phase of chronic dull anger and frustration that characterizes 
many people in the earlier part of practice. they feel smething isn't 
right but do not know how to fix it. there you see that the first signs 
of this may be more available to the family - the signs are a carryover 
of activation into areas in which it is no longer appropriate.

you get a 
prolongation of activation - take it home with you. can't stop at the end 
of the day. how can you tell when this happens? George here is a very 
mild mannered, polite driver. however, when he's reached his limit, he 
has an odd response to someone honking the horn behind him. he turns off 
his car. this means it is time to reevaluate life. other common signs: 
inability to wait in line, inability to tolerate any frustration at home 
or elsewhere - it's a leakage, a failure to turn off. one thing patients 
are asked to think of - difference in way they talk to their spouse and 
way they talk to their animal when upset. You don't come home and yell 
"Dammit, Rover, i've had a horrible day!" but you might do it to your 
spouse. and your spouse wouldn't leave the room. people talking to 
animals have lower BP than people talking to people b/c we have a 
different style. people lose the activation more easily after talking to 
their pet as opposed to spouse - they don't expect the dog to do anything 
about their problems, for one, plus the touch/talk dialog with the animal 
inherently decreases the activation. so much of what happens sustains 
activaation and makes us dissatisfied by conditions in our home. 

ok. 
people can go along like this for years. in the state of improving on 
vacation, maybe some job shifting, etc. but if spouses are tolerant, they 
get along like this for years. but some individuals are prone to 
depression. then the activation and chronic anger will lead to social 
withdrawal, withdrawal from colleagues, -- in business environment, can 
detect this -- one way of detecting this in your boss is when he or she 
starts managing by email (eh?). one of the signs of this chronic stage is 
the inability to tolerate face to face interaction. email facilitates 
social withdrawal (ok, this is just WRONG.)
in part, because you can vent 
frustration over email with less physiological response. you can type a 
nasty email without your HR going up; face to face, no. (this is NOT 
TRUE! i have shattered keyboards to prove it)

management, to be 
successful, requires coaching. coaching to be successful requires 
frequent, face to face, interpersonal interaction and when you are 
chronically depressed you can't do that. that's one reason why many 
managers have turned to 6 month evaluations. that's pretty useless, 
though. you need frequent interpersonal interaction.

but withdrawal from 
management, from colleagues, etc...
increasing use of drug/alcohol

increasing use of television
these facilitate social withdrawal. 

internet - way to avoid face to face contact with people.


at this 
stage, when you are getting to social withdrawal, you are getting into an 
area where depression takes its toll. stress activation at least keeps 
you on the job. as long as you are in the stage of wanting to do a good 
job, no matter how frustrated you are you still perform. once you get 
depressed, you no longer care. that's when the real damage to yourself 
and the practice begins. so depression, the transition from stress 
activation to depression, is burnout. you lower your expectations nad 
your own work becomes less valuable. this process (burnout cascade), is 
also complicated by substance abuse as way of managing anger and 
frustration. the key point is, your vulnerability to this problem is - 
dependent - upon your life being captured by your practice. the more you 
have in the way of breadth of interest and social support, the less 
vulnerable you are, because two strong social predictors of illness in 
society are education (the more you have, the longer you live, less 
vulnerable you are to stress related disorders) and social support (same 
thing - more you have, less vulnerable you are.)

mortality rate is 
higher in people who have no confidante.
pets do count as confidantes. 


your task is to figure out how to get out of the stress situation, not 
what got you in. provide for yourself essentially periods of time in 
which you are not activated or in which if you are, it has the normal 
curve. 

[he's gone so far past his time, that i am just taking a typing 
break, so as to prevent wrist pain]

[not taking notes on the "personal 
inspirational story."

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