Hydrocephalus

 Hydrocephalus in Geriatric Population:

Hydrocephalus is a condition in which there is an abnormal increase in cerebrospinal fluid inside the head (Hydro means water; cephalus means head).

Normal Pressure Hydrocephalus:
Hydrocephalus that occurs in geriatric population with average age being 60 years or above causes Normal Pressure Hydrocephalus (NPH) (www.emedicinehealth.com)

Normal pressure hydrocephalus is a type of hydrocephalus characterized by increased cerebrospinal fluid and a widening of the ventricles of the brain, usually without causing increased pressure inside the head.
The pressure is usually normal because the ventricles widen to make room for the extra fluid. Although normal pressure hydrocephalus usually presents without an increase of pressure inside in the head, increased pressure can happen if the condition goes untreated. The widening of ventricles and the increased fluid presses against certain brain structures, damaging or destroying them (www.medfriendly.com).
Normal pressure hydrocephalus is also known as occult hydrocephalus and Hakim's disease (www.medfriendly.com).
Signs and Symptoms:
There are three main signs of normal pressure hydrocephalus that usually occur gradually rather than suddenly. These signs are difficulty walking, difficulty holding in urine, and difficulty thinking.

The parts of the brain most often affected in Normal Pressure Hyedrocephalus are those that affect the legs, the bladder, and the "cognitive" mental processes such as memory, reasoning, problem solving, thinking and speaking. This decline in mental processes, if it is severe enough to interfere with everyday activities, is known as dementia.

Other symptoms include abnormal gait (difficulty walking), inability to hold urine (urinary incontinence), and, occasionally, inability to control the bowels (www.medfriendly.com).

Difficulty in Walking:
The difficulty walking usually presents as a slowed, shuffling walk, in which the feet appear stuck to the ground. The person may appear unsteady when walking, may have difficulty starting to walk, may have difficulty making turns, and may also complain of weakness in the legs. The difficulty walking may lead to sudden falls without a loss of consciousness. Difficulty walking in normal pressure hydrocephalus seems to be associated with increased tension in the extensor muscles of the legs. The extensor muscles are muscles that extend (the opposite of flex) body parts). It should be noted that some patients with normal pressure hydrocephalus only present with a difficulty walking.

(www.medfriendly.com).
Difficulty in holding urine and Stool/feces:

In addition to difficulty holding in urine, the person may also have difficulty holding in feces. This only occurs in rare circumstances, however. In earlier stages, patients may not lose control of their ability to hold in urine or feces, but they may have increased urges to urinate or have bowel movements, and may actually perform these bodily functions more often.
(www.medfriendly.com).



Difficulty in Thinking and Cognition:

The thinking difficulties in normal pressure hydrocephalus are usually characterized by confusion, poor attention, slowed thinking, and memory difficulties. The thinking difficulties can eventually progress into a dementia. Dementia is a mental disorder characterized by a significant loss of intellectual and cognitive abilities without impairment of perception or consciousness. It is estimated that about 5% of all dementias are due to normal pressure hydrocephalus. If treated early enough, dementia from normal pressure hydrocephalus can be reversible. The dementia will initially present as mild and can progress to severe.
(www.medfriendly.com).

Uncontrollable Movements and Tremors:
Patients with normal pressure hydrocephalus may have rigid muscles and tremors (uncontrollable shaking movements).
(www.medfriendly.com).
Speech:
Patients with normal pressure hydrocephalus may have an abnormally weak voice due to in-coordination of the muscles that control speech. They may not be very spontaneous in terms of movements or conversations, requiring other people to act first before they speak or move. Expressive speech may be impaired in people with normal pressure hydrocephalus. (www.medfriendly.com).
Mood:
A person with normal pressure hydrocephalus may have no observable mood. That is, they do not appear happy or sad, but rather indifferent and withdrawn. Their facial expressions may appear to be very restricted. (www.medfriendly.com).


Causes of Normal Pressure Hydrocephalus:


Many times, the cause of normal pressure hydrocephalus is unknown. However, the condition is often caused by a failure of the arachnoid granulations to absorb enough of the cerebrospinal fluid. As a result, the cerebrospinal fluid level increases, even though it is being produced in normal amounts

In other cases, something is blocking the flow of cerebrospinal fluid, causing normal pressure hydrocephalus. Any condition that causes a blockage of cerebrospinal fluid can lead to normal pressure hydrocephalus. Some causes of blocked cerebrospinal fluid include a closed head injury, brain surgery, brain tumors and cysts, and infections in the brain.

This results in the  widening of ventricles which distorts the central portion of corona radiate. Corona radiate is a fan- shaped structure that connects with the fibers of corpus callosum which functions to communicate between the two sides of the brain.

 Normal pressure hydrocephalus general occurs weeks after brain infections such as meningitis. Meningitis is an inflammation of the meninges (the three outer coverings of the brain and spinal cord). Meningitis can cause scarring to the arachnoid granulations, which help absorb cerebrospinal fluid. If the arachnoid granulations are scarred, they will not absorb the cerebrospinal fluid adequately.
A subarachnoid hemorrhage can also cause normal pressure hydrocephalus. A subarachnoid hemorrhage is when bleeding occurs in the space between two of the layers that cover the brain - the arachnoid mater and the pia mater. In the case of a subarachnoid hemorrhage, the blood is what blocks the flow of cerebrospinal fluid. Generally, this blockage occurs in the outlets of the fourth ventricle or in the cerebral aqueduct. The cerebral aqueduct is a narrow opening in the brain that connects the third ventricle with the fourth ventricle, allowing cerebrospinal fluid to flow between these two areas. It can be viewed in the picture above.

In a study the characteristics of chronic hydrocephalus following aneurysmal subarachnoid hemorrhage (SAH) in elderly patients were clarified. Of the 576 surgically treated patients, 289 were aged 59 years or younger, 169 were 60 to 69, and 118 were 70 years or older. The relationship between chronic hydrocephalus and the causative factors was analyzed for each age group. Of the 576 patients, chronic hydrocephalus was observed in 215 (37%), with the incidence increasing significantly with age (p < 0.001) and being the highest in the oldest age group. In elderly patients, the incidence of chronic hydrocephalus was relatively high, even after mild SAH. The study concluded that incidence of chronic hydrocephalus was high regardless of age in patients with severe SAH, such as in those with H&H grades III–IV, SAH grades III–IV, acute hydrocephalus, symptomatic vasospasm, and intraventricular hemorrhage, and in those with vertebro-basilar artery aneurysms. In the elderly, the incidence of chronic hydrocephalus following SAH was significantly higher than in younger patients, even after mild SAH. In elderly patients, careful observation and individualized treatment are necessary even if SAH is mild. (Yoshioka et. al. 2000)

About 10-20% of patients with a subarachnoid hemorrhage will develop normal pressure hydrocephalus that causes noticeable signs. Normal pressure hydrocephalus may take up to several months to develop after a subarachnoid hemorrhage has occurred. Many head injuries cause subarachnoid hemorrhages (www.medfriendly.com).

Although very rare, it does appear that in some cases normal pressure hydrocephalus can be inherited (passed on through the genes of one's parents). This is still debatable, however. Genes are tiny structures that contain coded instructions for how proteins should be constructed and how certain bodily characteristics should develop. For example, genes control the natural color of people's eyes and hair, and whether they will be male or female. Genes are passed on from parents to their children.

The nerve fibers in the corona radiata send nerve impulses to the legs and the urinary bladder, which is why difficulty walking and difficulty controlling the urge to urinate occurs.

Dementia results from distortion of the limbic system near the ventricles which is responsible for proper memory functioning and for producing emotions (www.medfriendly.com; Skoog et al. 1993).
Subcortical arteriosclerotic encephalopathy (SAE) may cause enlargement of ventricles thereby leading to hydrocephalus (Gotto , Ishii, Fukasawa 1981)
Diagnoses:

Unfortunately, normal pressure hydrocephalus is difficult to diagnose.
Computerized Tomography:
CT (computerized tomography) scanning is an advanced imaging technique that uses x-rays and computer technology to produce more clear and detailed pictures than a traditional x-ray for seeing the pictures inside the brain to diagnose hydrocephalus.

Magnetic Resonance Imaging:

MRI (Magnetic Resonance Imaging) scans produce extremely detailed pictures of the inside of the body by using very powerful magnets and computer technology. It is also used for the diagnoses of hydrocephalus.

Cisternogram:
A test known as a cisternogram may show changes of the flow of cerebrospinal fluid in the brain. Specifically, the cisternogram scan may show that the fluid flowed back into the ventricles (openings in the brain that produce cerebrospinal fluid). A cisternogram is a test in which the flow of cerebrospinal fluid can be monitored. This is done by injecting a substance into the cerebrospinal fluid by inserting a needle in the spinal canal. The substance flows throughout the cerebrospinal fluid and emits a signal. A scanner detects the signal and provides information about the flow of cerebrospinal fluid. It should be noted that although cisternograms were used in the past, they are usually not used now days

Although the results of CT scans, MRIs, and cisternograms may be consistent with normal pressure hydrocephalus, they may also be consistent with other conditions. Thus, these tests are not sufficient for a diagnosis of normal pressure hydrocephalus. CT and MRI scans will usually show widening of the ventricles.

Prevalence:
•    A Norwegian study of a population of 220,000 inhabitants found a prevalence of probable idiopathic NPH of 21.9 per 100,000 population and an incidence of 5.5 per 100,000 population; the investigators suggested that those numbers be regarded as minimum estimates (Brean and Eide 2008).
•    A Japanese study found radiological and clinical features consistent with idiopathic NPH in 2.9% of community-dwelling elderly subjects (Hiraoka, Meguro , Mori , 2008).
•    In another Japanese study, elderly individuals (age >65 y) underwent MRI and the prevalence of NPH was 1.4% (Tanaka et. al. 2009)
•    The prevalence of NPH may be as high as 14% in extended care facility patients (Marmarou ,Young, Aygok, 2007).


Treatment:
If a cause for normal hydrocephalus can be identified, the condition can often be treated and the effects can often be reversed. The most common type of treatment is called a shunt. A shunt is a flexible tube that is inserted into the ventricle, which drains the extra cerebrospinal fluid.
The most commonly used shunt (Dalvi and Prem Kumar, 2010) is called a ventriculperitoneal (VP) shunt because it drains cerebrospinal fluid from the ventricles to the peritoneum. The peritoneum is a layer of tissue that lines the belly and covers most of the organs in the belly. Another type of shunt is a ventriculoatrial shunt, so named because it drains cerebrospinal fluid from the ventricles to the atrium of the heart. Each chamber on the top of the heart is called an atrium
A shunt may be placed even if the physician is not certain that the cause of the patient's problems is normal pressure hydrocephalus. The decision on whether to place a shunt will be based on the results of a clinical evaluation by the doctor and the results of a CT scan. If the condition improves after placement of a shunt, health providers are generally confident that the cause of the patient's problems was normal pressure hydrocephalus. It is worth noting that shunting can help decrease the size of the ventricles in 3 to 4 days even if the hydrocephalus has been present for a year, and sometimes more.
Temporary relief of symptoms may be achieved with a spinal tap or treatment with Acetazolamide (Diamox). Acetazolamide is a diuretic medication that can decrease the production of CSF. A diuretic is a medication that helps to release fluids from the body in the form of urine. There is no definitive evidence yet, however, that medication can effectively treat normal pressure hydrocephalus (www.medfriendly.com).

A study retrospectively reviewed the clinical records of 27 patients older than 70 years who underwent endovascular treatment for aneurysmal SAH between January 1996 and July 2002. Thirteen patients with sub-arachnoid Hemorrhage (SAH) and a poor Hunt and Hess grade at initial presentation had been treated by endovascular means. Their outcomes were assessed by the using the Glasgow Outcome Scale (GOS). Two patients (15%) had a good outcome according to the GOS. Three patients (23%) were moderately disabled, two (15%) were severely disabled at the time of discharge from the hospital, and six (47%) died. Five patients (38%) developed clinical vasospasm and underwent balloon angioplasty. Three procedure-related deaths occurred (23%). Endovascular treatment has modified the management of poor-grade SAH in elderly patients, most of whom are high-risk surgical candidates. Endovascular treatment can be administered early after the initial ictus, reducing the risk of rebleeding and providing an option to pursue aggressive triple-H therapy. Symptomatic vasospasm can also be treated by endovascular means in the initial setting (Jain et al, 2004).

References:
1. http://www.medfriendly.com/normalpressurehydrocephalus.html
2. http://www.emedicinehealth.com/normal_pressure_hydrocephalus/article_em.htm
3. Yoshioka H, Inagawa T, Tokuda Y, Inokuchi F .Chronic hydrocephalus in elderly patients following subarachnoid hemorrhage. Surgical Neurosurgery 2000; 53 (2):119-125.
4. Goto K, Ishii N, Fukasawa H . Diffuse white-matter disease in the geriatric population. A clinical, neuropathological, and CT study. Radiology: Radiology 1981; 141: 687-695.
5. Skoog I, Nilsson L, Palmertz B, Andreasson L-A, Svanborg A. A Population-Based Study of Dementia in 85-Year-Olds. New England Journal Medicine 1993; 328:153-158.
6. Brean A, Eide PK. Prevalence of probable idiopathic normal pressure hydrocephalus in a Norwegian population. Acta Neurol Scand.  2008;118(1):48-53. [Medline].
7. Hiraoka K, Meguro K, Mori E. Prevalence of idiopathic normal-pressure hydrocephalus in the elderly population of a Japanese rural community. Neurol Med Chir (Tokyo).  2008;48(5):197-99; discussion 199-200. [Medline]
8. Tanaka N, Yamaguchi S, Ishikawa H, Ishii H, Meguro K. Prevalence of possible idiopathic normal-pressure hydrocephalus in Japan: the Osaki-Tajiri project. Neuroepidemiology. 2009;32(3):171-5. [Medline].
9. Marmarou A, Young HF, Aygok GA. Estimated incidence of normal pressure hydrocephalus and shunt outcome in patients residing in assisted-living and extended-care facilities. Neurosurg Focus.  2007;22(4):E1. [Medline]
10. Dalvi AI, Prem Kumar A.P. Normal Pressure Hydrocephalus: Treatment & Medication.e medicine 2010.http://emedicine.medscape.com/article/1150924-overview.
11. Rajan Jain, John Deveikis and Byron Gregory Thompson. Endovascular Management of Poor-Grade Aneurysmal Subarachnoid Hemorrhage in the Geriatric Population. American Journal of Neuroradiology 2004 ; 25:596-600.

- Dr Smita Pandey

Psychology

What is Psychology?

Dictionaries define psychology as the science of mind and behavior. Based on this definition, psychology is a science that deals with how people think and act. It’s a science because it uses scientific methods in observing and analyzing people’s behavior and helping them overcome any psychological issues that they may have. Psychologists are people who practice psychology.

There are different branches of psychology. Some of these are behavioral psychology or behaviorism, abnormal psychology, cognitive psychology, comparative psychology, cross-cultural psychology, educational psychology and experimental psychology. Behaviorism is the conditioning of mind to help the person learn what you teach or help him alter his wrong ways.

Abnormal psychology deals with abnormal behavior and mental disorders.

Cognitive psychology deals with the internal state of mind like decision making and problem solving. This is helpful for leaders and managers or supervisors who handle people under them.

Comparative psychology deals with the observation of the behavior of animals and how it can be compared with human’s behavior.

Cross-cultural psychology deals with the effect of differences in culture. This is helpful especially that racial discrimination is still rampant at school and even in the workplace.

Educational psychology deals with everything that has to do with school and the students, like teaching methods of teachers, school environment and school rules and policies.

Experimental psychology deals with research on human mind and behavior with the use of scientific processes.

Organizational Psychology is meant to improve the efficiency and effectiveness of business organizations while solving the organizational problems. Not only it’s concerned with business development but also the effectiveness and efficiency in terms of employees’ performance.

Social Psychology is focused on how the role of society and its culture influence in the development of one’s personality. This field of psychology is interested to identify the social situations and the attitudes of the people towards them so as to help the people in altering and improving their attitudes while trying to reduce tensions and making them better human beings.

Clinical Psychology deals with mental, emotional and abnormal behavior of the people. It seeks to help the people come out of their mental disorders. Its practice involves psychological assessment and psychotherapy while various training programs and personality and intelligence tests are conducted under this branch of Psychology for the treatment of mental problems. Mostly, the psychologist of this field work with psychiatrists.

Counseling Psychology are concerned with the problems of every day life, concerning academic, social, emotional, occupational and organizational. They acquire reasonable knowledge of their field and help their clients to overcome situations causing everyday stress and are employed in colleges, universities and hospitals

- Dr Smita Pandey

Stress Management

There are many different ways to manage stress. Basically, it's best to eliminate as many stressors as you can, and find practical and emotional ways to better handle the stressors that are left. The following are among the simplest and most effective stress management techniques, arranged in a simple format.

Stress management strategy #1: Avoid unnecessary stress

Not all stress can be avoided, and it’s not healthy to avoid a situation that needs to be addressed. You may be surprised, however, by the number of stressors in your life that you can eliminate.

• Learn how to say “no” – Know your limits and stick to them. Whether in your personal or professional life, refuse to accept added responsibilities when you’re close to reaching them. Taking on more than you can handle is a surefire recipe for stress.
• Avoid people who stress you out – If someone consistently causes stress in your life and you can’t turn the relationship around, limit the amount of time you spend with that person or end the relationship entirely.
• Take control of your environment – If the evening news makes you anxious, turn the TV off. If traffic’s got you tense, take a longer but less-traveled route. If going to the market is an unpleasant chore, do your grocery shopping online.
• Avoid hot-button topics – If you get upset over religion or politics, cross them off your conversation list. If you repeatedly argue about the same subject with the same people, stop bringing it up or excuse yourself when it’s the topic of discussion.
• Pare down your to-do list – Analyze your schedule, responsibilities, and daily tasks. If you’ve got too much on your plate, distinguish between the “shoulds” and the “musts.” Drop tasks that aren’t truly necessary to the bottom of the list or eliminate them entirely.

Stress management strategy #2: Alter the situation

If you can’t avoid a stressful situation, try to alter it. Figure out what you can do to change things so the problem doesn’t present itself in the future. Often, this involves changing the way you communicate and operate in your daily life.

• Express your feelings instead of bottling them up. If something or someone is bothering you, communicate your concerns in an open and respectful way. If you don’t voice your feelings, resentment will build and the situation will likely remain the same.
• Be willing to compromise. When you ask someone to change their behavior, be willing to do the same. If you both are willing to bend at least a little, you’ll have a good chance of finding a happy middle ground.
• Be more assertive. Don’t take a backseat in your own life. Deal with problems head on, doing your best to anticipate and prevent them. If you’ve got an exam to study for and your chatty roommate just got home, say up front that you only have five minutes to talk.
• Manage your time better. Poor time management can cause a lot of stress. When you’re stretched too thin and running behind, it’s hard to stay calm and focused. But if you plan ahead and make sure you don’t overextend yourself, you can alter the amount of stress you’re under.

Stress management strategy #3: Adapt to the stressor

If you can’t change the stressor, change yourself. You can adapt to stressful situations and regain your sense of control by changing your expectations and attitude.

• Reframe problems. Try to view stressful situations from a more positive perspective. Rather than fuming about a traffic jam, look at it as an opportunity to pause and regroup, listen to your favorite radio station, or enjoy some alone time.
• Look at the big picture. Take perspective of the stressful situation. Ask yourself how important it will be in the long run. Will it matter in a month? A year? Is it really worth getting upset over? If the answer is no, focus your time and energy elsewhere.
• Adjust your standards. Perfectionism is a major source of avoidable stress. Stop setting yourself up for failure by demanding perfection. Set reasonable standards for yourself and others, and learn to be okay with “good enough.”
• Focus on the positive. When stress is getting you down, take a moment to reflect on all the things you appreciate in your life, including your own positive qualities and gifts. This simple strategy can help you keep things in perspective.

Adjusting Your Attitude

How you think can have a profound effect on your emotional and physical well-being. Each time you think a negative thought about yourself, your body reacts as if it were in the throes of a tension-filled situation. If you see good things about yourself, you are more likely to feel good; the reverse is also true. Eliminate words such as "always," "never," "should," and "must." These are telltale marks of self-defeating thoughts.

Stress management strategy #4: Accept the things you can’t change

Some sources of stress are unavoidable. You can’t prevent or change stressors such as the death of a loved one, a serious illness, or a national recession. In such cases, the best way to cope with stress is to accept things as they are. Acceptance may be difficult, but in the long run, it’s easier than railing against a situation you can’t change.

• Don’t try to control the uncontrollable. Many things in life are beyond our control— particularly the behavior of other people. Rather than stressing out over them, focus on the things you can control such as the way you choose to react to problems.
• Look for the upside. As the saying goes, “What doesn’t kill us makes us stronger.” When facing major challenges, try to look at them as opportunities for personal growth. If your own poor choices contributed to a stressful situation, reflect on them and learn from your mistakes.
• Share your feelings. Talk to a trusted friend or make an appointment with a therapist. Expressing what you’re going through can be very cathartic, even if there’s nothing you can do to alter the stressful situation.
• Learn to forgive. Accept the fact that we live in an imperfect world and that people make mistakes. Let go of anger and resentments. Free yourself from negative energy by forgiving and moving on.

Stress management strategy #5: Make time for fun and relaxation

Beyond a take-charge approach and a positive attitude, you can reduce stress in your life by nurturing yourself. If you regularly make time for fun and relaxation, you’ll be in a better place to handle life’s stressors when they inevitably come.

Healthy ways to relax and recharge

Go for a walk. Spend time in nature. Call a good friend. Sweat out tension with a good workout. Write in your journal. Take a long bath. Light scented candles.

Savor a warm cup of coffee or tea. Play with a pet. Work in your garden. Get a massage. Curl up with a good book. Listen to music. Watch a comedy.

Don’t get so caught up in the hustle and bustle of life that you forget to take care of your own needs. Nurturing yourself is a necessity, not a luxury.

• Set aside relaxation time. Include rest and relaxation in your daily schedule. Don’t allow other obligations to encroach. This is your time to take a break from all responsibilities and recharge your batteries.
• Connect with others. Spend time with positive people who enhance your life. A strong support system will buffer you from the negative effects of stress.
• Do something you enjoy every day. Make time for leisure activities that bring you joy, whether it be stargazing, playing the piano, or working on your bike.
• Keep your sense of humor. This includes the ability to laugh at yourself. The act of laughing helps your body fight stress in a number of ways.

Stress management strategy #6: Adopt a healthy lifestyle

You can increase your resistance to stress by strengthening your physical health.

• Exercise regularly. Physical activity plays a key role in reducing and preventing the effects of stress. Make time for at least 30 minutes of exercise, three times per week. Nothing beats aerobic exercise for releasing pent-up stress and tension.
• Eat a healthy diet. Well-nourished bodies are better prepared to cope with stress, so be mindful of what you eat. Start your day right with breakfast, and keep your energy up and your mind clear with balanced, nutritious meals throughout the day.
• Reduce caffeine and sugar. The temporary "highs" caffeine and sugar provide often end in with a crash in mood and energy. By reducing the amount of coffee, soft drinks, chocolate, and sugar snacks in your diet, you’ll feel more relaxed and you’ll sleep better.
• Avoid alcohol, cigarettes, and drugs. Self-medicating with alcohol or drugs may provide an easy escape from stress, but the relief is only temporary. Don’t avoid or mask the issue at hand; deal with problems head on and with a clear mind.
• Get enough sleep. Adequate sleep fuels your mind, as well as your body. Feeling tired will increase your stress because it may cause you to think irrationally.

Methods of personal stress management and stress relief

If you are suffering from work-related stress and it's beginning to affect, or already affecting your health, stop to think: why are you taking this risk with your body and mind? Life's short enough as it is; illness is all around us; why make matters worse? Commit to change before one day change is forced upon you.
If you recognise signs of stress in a staff member, especially if you are that person's manager, don't ignore it - do something about it. It is your duty to do so. If you do not feel capable of dealing with the situation, do not ignore it; you must refer it to someone who can deal with it. You must also look for signs of non-work-related stressors or factors that increase susceptibility to stress, because these will make a person more vulnerable to work-related stressors. These rules apply to yourself as well....
Stress relief methods are many and various. There is no single remedy that applies to every person suffering from stress, and most solutions involve a combination of remedies. Successful stress management frequently relies on reducing stress susceptibility and removing the stressors, and often factors will be both contributing to susceptibility and a direct cause. Here are some simple pointers for reducing stress susceptibility and stress itself, for yourself or to help others:

Stress relief pointers

• think really seriously about and talk with others, to identify the causes of the stress and take steps to remove, reduce them or remove yourself (the stressed person) from the situation that causes the stress.
• Understand the type(s) of stressors affecting you (or the stressed person), and the contributors to the stress susceptibility - knowing what you're dealing with is essential to developing the stress management approach.
• improve diet - group B vitamins and magnesium are important, but potentially so are all the other vitamins and minerals: a balanced healthy diet is essential. Assess the current diet and identify where improvements should be made and commit to those improvements.
• reduce toxin intake - obviously tobacco, alcohol especially - they might seem to provide temporary relief but they are working against the balance of the body and contributing to stress susceptibility, and therefore increasing stress itself.
• take more exercise - generally, and at times when feeling very stressed - exercise burns up adrenaline and produces helpful chemicals and positive feelings.
• stressed people must try to be detached, step back, look from the outside at the issues that cause the stress.
• don't try to control things that are uncontrollable - instead adjust response, adapt.
• share worries - talk to someone else - off-load, loneliness is a big ally of stress, so sharing the burden is essential.
• increase self-awareness of personal moods and feelings - anticipate and take steps to avoid stress build-up before it becomes more serious.
• explore and use relaxation methods - they do work if given a chance - yoga, meditation, self-hypnosis, massage, a breath of fresh air, anything that works and can be done in the particular situation.
• seek out modern computer aids - including free downloads and desktop add-ons - for averting stresses specifically caused by sitting for long uninterrupted periods at a computer screen work-station, for example related to breathing, posture, seating, eye-strain, and RSI (repetitive strain injury).

Note also that managing stress does not cure medical problems. Relieving stress can alleviate and speed recovery from certain illnesses, particularly those caused by stress, (which depending on circumstances can disappear when the stress is relieved); i.e., relieving stress is not a substitute for conventional treatments of illness, disease and injury.
Importantly, if the stress is causing serious health effects the sufferer must consult a doctor. Do not imagine that things will improve by soldiering on, or hoping that the sufferer will somehow become more resilient; things can and probably will get worse.
For less serious forms of stress, simply identify the cause(s) of stress, then to commit/agree to removing the cause(s). If appropriate this may involve removing the person from the situation that is causing the stress. Counselling may be necessary to identify the cause(s), particularly if the sufferer has any tendency to deny or ignore the stress problem.
Acceptance, cognisance and commitment on the part of the stressed person are essential. No-one can begin to manage their stress if they are still feeling acutely stressed - they'll still be in 'fight or flight' mode. This is why a manager accused of causing stress though bullying or harassment must never be expected to resolve the problem. The situation must be handled by someone who will not perpetuate the stressful influence.

- By Dr Smita Pandey

Identifying the Stressors

It may seem that there’s nothing you can do about your stress level. The bills aren’t going to stop coming, there will never be more hours in the day for all your errands, and your career or family responsibilities will always be demanding. But you have a lot more control than you might think. In fact, the simple realization that you’re in control of your life is the foundation of stress management.
Managing stress is all about taking charge: taking charge of your thoughts, your emotions, your schedule, your environment, and the way you deal with problems. The ultimate goal is a balanced life, with time for work, relationships, relaxation, and fun – plus the resilience to hold up under pressure and meet challenges head on.

Identify the sources of stress in your life

Learn about hidden sources of stress

Stress management starts with identifying the sources of stress in your life. This isn’t as easy as it sounds. Your true sources of stress aren’t always obvious, and it’s all too easy to overlook your own stress-inducing thoughts, feelings, and behaviors. Sure, you may know that you’re constantly worried about work deadlines. But maybe it’s your procrastination, rather than the actual job demands, that leads to deadline stress.
To identify your true sources of stress, look closely at your habits, attitude, and excuses:

• Do you explain away stress as temporary (“I just have a million things going on right now”) even though you can’t remember the last time you took a breather?
• Do you define stress as an integral part of your work or home life (“Things are always crazy around here”) or as a part of your personality (“I have a lot of nervous energy, that’s all”).
• Do you blame your stress on other people or outside events, or view it as entirely normal and unexceptional?

Until you accept responsibility for the role you play in creating or maintaining it, your stress level will remain outside your control.

Start a stress journal

A stress journal can help you identify the regular stressors in your life and the way you deal with them. Each time you feel stressed, keep track of it in your journal. As you keep a daily log, you will begin to see patterns and common themes. Write down:

• What caused your stress (make a guess if you’re unsure).
• How you felt, both physically and emotionally.
• How you acted in response.
• What you did to make yourself feel better.

Look at how you currently cope with stress

Think about the ways you currently manage and cope with stress in your life. Your stress journal can help you identify them. Are your coping strategies healthy or unhealthy, helpful or unproductive? Unfortunately, many people cope with stress in ways that compound the problem.

Unhealthy ways of coping with stress

These coping strategies may temporarily reduce stress, but they cause more damage in the long run:

Smoking Drinking too much Overeating or undereating Zoning out for hours in front of the TV or computer Withdrawing from friends, family, and activities

Using pills or drugs to relax Sleeping too much Procrastinating Filling up every minute of the day to avoid facing problems Taking out your stress on others (lashing out, angry outbursts, physical violence)

Internal Stressors:

Identifying self-generated stressors

“Not all stress is caused by external pressures and demands. Your stress can also be self-generated.

Internal causes of stress include:

o       uncertainty or worries,

o       pessimistic att itude,

o       self-criticism,

o       unrealistic expectations or beliefs,

o       perfectionism,

o       low self-esteem,

o       excessive or unexpressed anger,

o       lack of assertiveness,”1 and

o       fears or apprehensions (e.g., fear of fl ying or

o       heights; apprehension about speaking to strangers

o       at a party).

Stressors usually fall into the following categories:

• Emotional stressors, which can also be thought of as internal stressors, include fears and anxieties (such as worries about whether you'll be fired or whether you'll make a good impression on a blind date) as well as certain personality traits (such as perfectionism, pessimism, suspiciousness, or a sense of helplessness or lack of control over one's life) that can distort your thinking or your perceptions of others. These stressors are very individual.
• Family stressors can include changes in your relationship with your significant other, financial problems, coping with an unruly adolescent, or experiencing empty-nest syndrome. 
• Social stressors arise in our interactions within our personal community. They can include dating,  parties, and public speaking. As with emotional stressors, social stressors are very individualized (you may love speaking in public, while your colleague shakes in his boots at the mere suggestion).
• Change stressors are feelings of stress related to any important changes in our lives. This may include moving, getting a new job, moving in with a significant other, or having a baby.
• Chemical stressors are any drugs a person abuses, such as alcohol, nicotine, caffeine, or tranquilizers.
• Work stressors are caused by the pressures of performing in the workplace (or in the home, if that is where you work). They may include tight deadlines, an unpredictable boss, or endless family demands.
• Decision stressors involve the stress caused by having to make important decisions, such as the choice of a career or a mate.
• Phobic stressors are those caused by situations you are extremely afraid of, such as flying in airplanes or being in tight spaces.
• Physical stressors are situations that overtax your body, such as working long hours without sleep, depriving yourself of healthy food, or standing on your feet all day. They may also include pregnancy, premenstrual syndrome, or too much exercise.
• Disease stressors are the products of long- or short-term health problems. These may cause stress (say, by preventing you from being able to leave your bed), be triggered by stress (such as herpes flare-ups), or be aggravated by stress (such as migraine headaches).
• Pain stressors can include acute pain or chronic pain. Like disease stressors, pain stressors can cause stress or be aggravated by stress.
• Environmental stressors include noise, pollution, a lack of space, too much heat, or too much cold.

Using the above list as a reference, write down and note which category the main stressors in your life fall into. You may even find that some of your stressors fall into more than one of these categories.
There are probably items on your list of stressors you can let go of, however. If having to clean the entire house on your day off every week is preventing you from having any leisure time, perhaps you can fit a cleaning service into your budget. If ironing shirts is keeping you up late at night, send them to the cleaners instead. If these seem like luxuries you can't afford, try to reorganize your budget a bit. Remember, your time is valuable, too.
Reducing the strength of your stressors is usually a more viable option than eliminating them entirely. For example, if you are having trouble concentrating on your work because of loud noise in the office, consider buying a pair of earplugs. If your morning trip to work forces you to drive two hours in heavy traffic every day, try another option such as mass transit or carpooling and bring along the morning paper, a good book, or a CD player or IPOD loaded with favorite music.
Coping is no doubt your only option for the majority of the items on your list of stressors. However, this doesn't have to be as hopeless as it sounds. There are several techniques for learning to stay calm and clearheaded under pressure. As you master them, even your biggest stressors will pose less and less of a threat.
Go back through your list of stressors and mark an E for each item you can eliminate, an R for each stressor you can reduce the strength of, and a C for each item you can learn to cope with. For the items marked with an E or an R, jot down any ideas you have on how to accomplish these goals (for example, sending shirts to the cleaners or buying earplugs).

Learning healthier ways to manage stress

If your methods of coping with stress aren’t contributing to your greater emotional and physical health, it’s time to find healthier ones. There are many healthy ways to manage and cope with stress, but they all require change. You can either change the situation or change your reaction. When deciding which option to choose, it’s helpful to think of the four As: avoid, alter, adapt, or accept.
Since everyone has a unique response to stress, there is no “one size fits all” solution to managing it. No single method works for everyone or in every situation, so experiment with different techniques and strategies. Focus on what makes you feel calm and in control.

Dealing with Stressful Situations: The Four A’s

Change the situation: Avoid the stressor. Alter the stressor.

Change your reaction: Adapt to the stressor. Accept the stressor.

-  By Dr Smita Pandey

Factors causing Stress

Factors causing stress:

Internal Factors:

The internal factors are affected by the strengths and weaknesses internal to the individual. Internal factors include poor self esteem, poor body appreciation , poor coping strategies, low resilience (resilience is ability to overcome  loss or health as soon as possible), maladaptive lifestyle, eating pattern, maladaptive behavior, poor-interpersonal relatedness and social support, low or excessive use of defense mechanisms,  lack of creative pursuits,  dissatisfaction from self, less or excessive indulgence in recreational activities, lack of adequate sleep and too much of attachment or too much of detachment.

External Factors:

The opportunities and threats presented by the external environment to the organization.External factors include loss of opportunities, unemployment, too much of work pressure, any kind of illness or disability, lack of time to socialize due to work pressure, natural calamities, domestic pressure or violence, civil wars, wars between the nations, pollution in the environment, life events like marriage or birth of a child, children’s illnesses, illness of a spouse or close relation like parents, disabled child or a parent, any novel stimuli, unpredictable stimuli or stimuli  that is uncontrollable in  terms of the individual or  any socially evaluative threat and socio-economic crises.

Common external causes of stress

Not all stress is caused by external factors. Stress can also be self-generated:

Major life changes Work Relationship difficulties

Financial problems Being too busy Children and family

Common internal causes of stress

Not all stress is caused by external factors. Stress can also be self-generated:

Inability to accept uncertainty Pessimism Negative self-talk

Unrealistic expectations Perfectionism Lack of assertiveness

 

 

Things that influence your stress tolerance level

• Your support network – A strong network of supportive friends and family members is an enormous buffer against life’s stressors. On the flip side, the more lonely and isolated you are, the greater your vulnerability to stress.
• Your sense of control – If you have confidence in yourself and your ability to influence events and persevere through challenges, it’s easier to take stress in stride. People who are vulnerable to stress tend to feel like things are out of their control.
• Your attitude and outlook – Stress-hardy people have an optimistic attitude. They tend to embrace challenges, have a strong sense of humor, accept that change is a part of life, and believe in a higher power or purpose.
• Your ability to deal with your emotions – You’re extremely vulnerable to stress if you don’t know how to calm and soothe yourself when you’re feeling sad, angry, or afraid. The ability to bring your emotions into balance helps you bounce back from adversity. 
• Your knowledge and preparation – The more you know about a stressful situation, including how long it will last and what to expect, the easier it is to cope. For example, if you go into surgery with a realistic picture of what to expect post-op, a painful recovery will be less traumatic than if you were expecting to bounce back immediately.

Major Causes of Stress:

1. Low Self Confidence: Individuals having low self confidence, who are not aware of their positive traits of personality may be in constant state of stress as we could see in the case of Albert described above.
2. Lack of resilience: If you lack positive emotions and resilience like optimism, humor, cognitive flexibility, reappraisal, altruism and pro-social behavior etc. then you would be experiencing more stres

3. Lack of Social Support: The American Institute of Stress reports that the social support that is being valued and recognized is a great stress buster or breaking up the stress. It reduces the risk of coronary heart diseases, cancer and even HIV and AIDS. The institute also reports that social support is simply not being surrounded by people or so called friends. These could only be mere acquaintances. It is the basis for being recognized and valued with appropriate sharing of emotions with each other. In a study it has been depicted that low levels of social support were the most powerful predictors of depression and anxiety in mothers of autistic infants (Boyd, 2002).

4. Maladaptive Life Style and Coping Style: Maladaptive life styles like inadequate sleep, sedentary life style, lack of exercises, irregular eating patterns, eating too much or too less, taking lot of caffeine, chewing tobacco, smoking cigarettes and taking alcohol etc. may prolong your stress rather relieving you from stress.

5. Socio-economic Crisis:  Socio-economic crisis is one of the factors that may lead to stress, even amounting to suicide. The theory of strain proposes four sources leading to suicide: where poverty is one of the factors along with poor coping skills that may lead to suicide (Zhang and Lester, 2008). In India in the state of Orissa several farmers committed suicide due to poverty in the past few years.

6. Job and Work related overburden: Many highly demanding jobs like fire-fighters, ambulance workers, police officers, medical specialists, pilots/astronauts, submarine officers, military officers, high ranking officials of the multi-national companies may be under constant pressure of some kind of specific demands according to their roles and may be  caught for the burnout. This burnout may result in terms of physical impairment or illnesses like hypertension or heart diseases or drowsiness or dullness and difficulties in concentration (Sluiter 2006).

7. Domestic Violence, Abuse and Neglect: Domestic violence is the major stressor in large parts of the world, leading to depression, constant anxiety, physical impairment etc. Lifetime violence was significantly associated with perceived bad general health, disease, abortion, hemorrhage, and body mass index. Recent violence increased the number of doctor visits, and the odds of feeling dizzy, vaginal bleeding, movement and activity problems, pain, taking drugs, and stress significantly (Afifi et al. 2011). Similarly, in a study conducted in USA by Zolotor , Denham , Weil (2009), it was found that Intimate partner violence is a common problem, affecting large numbers of women, men, and children who may have presenting complaints to primary care practices.

8. Life Events and Daily Hassles: Life events are those events that are usually unavoidable part of life causing a change in an individual’s life. The life events could be sad e.g.: death of a family member or happy e.g. the birth of a child, though it is stressful again as it is demanding more time for the family and demanding extra expenditure. Daily hassles are the daily routine where the hectic schedules may cause lot of stress e.g. a packed routine of a general practitioner.

Effects of chronic stress

The body doesn’t distinguish between physical and psychological threats. When you’re stressed over a busy schedule, an argument with a friend, a traffic jam, or a mountain of bills, your body reacts just as strongly as if you were facing a life-or-death situation. If you have a lot of responsibilities and worries, your emergency stress response may be “on” most of the time. The more your body’s stress system is activated, the easier it is to trip and the harder it is to shut off.
Long-term exposure to stress can lead to serious health problems. Chronic stress disrupts nearly every system in your body. It can raise blood pressure, suppress the immune system, increase the risk of heart attack and stroke, contribute to infertility, and speed up the aging process. Long-term stress can even rewire the brain, leaving you more vulnerable to anxiety and depression.

Many health problems are caused or exacerbated by stress, including:

Pain of any kind Heart disease Digestive problems Sleep problems

Depression Obesity Autoimmune diseases Skin conditions, such as eczema -  Dr Smita Pandey

Signs and Symptoms of Stress

Signs and Symptoms of Stress:
Stress is a normal physical response to events that make you feel threatened or upset your balance in some way. When you sense danger – whether it’s real or imagined – the body's defenses kick into high gear in a rapid, automatic process known as the “fight-or-flight” reaction, or the stress response.

Signs of Stress:

The signs of stress may be cognitive, emotional, physical or behavioural.

1. Cognitive Signs: It may include poor judgment, a general negative outlook, problems in attention and concentration and forgetfulness.

2. Emotional Signs: It may include excessive worrying, moodiness, irritability, agitation, inability to relax, feeling lonely, isolated or depressed, social withdrawal, neglect of responsibilities and increased procrastination.

3. Physical Signs: It may include acne, aches and pains, diarrhea or constipation, nausea, dizziness, chest pain, rapid heartbeat, eating too much or not eating enough, neck pains, not sleeping enough or sleeping too much.

4. Behavioral Signs: It may include increased use of alcohol,  nicotine or  drug consumption and nervous habits such as pacing about and nail-biting

Stress doesn’t always look stressful

Psychologist Connie Lillas uses a driving analogy to describe the three most common ways people respond when they’re overwhelmed by stress:

• Foot on the gas – An angry or agitated stress response. You’re heated, keyed up, overly emotional, and unable to sit still.
• Foot on the brake – A withdrawn or depressed stress response. You shut down, space out, and show very little energy or emotion.
• Foot on both – A tense and frozen stress response. You “freeze” under pressure and can’t do anything. You look paralyzed, but under the surface you’re extremely agitated.

Am I in control of stress or is stress controlling me?

• When I feel agitated, do I know how to quickly calm and soothe myself?
• Can I easily let go of my anger?
• Can I turn to others at work to help me calm down and feel better?
• When I come home at night, do I walk in the door feeling alert and relaxed?
• Am I seldom distracted or moody?
• Am I able to recognize upsets that others seem to be experiencing?
• Do I easily turn to friends or family members for a calming influence?
• When my energy is low, do I know how to boost it?

Stress Warning Signs and Symptoms

Cognitive Symptoms

Memory problems

Inability to concentrate

Poor attention

Poor judgment

Seeing only the negative

Anxious or racing thoughts

Constant worrying

Emotional Symptoms

Moodiness

Irritability or short temper

Agitation, inability to relax

Feeling overwhelmed

Sense of loneliness and isolation

Depression or general unhappiness

Physical Symptoms

Aches and Pains

Diarrhea or constipation

Nausea, dizziness

Chest pain, rapid heartbeat

Loss of sex drive

Frequent colds

Behavioral Symptoms

Eating more or less

Sleeping too much or too little

Isolating yourself from others

Procrastinating or neglecting responsibilities

Using alcohol, cigarettes, or drugs to relax

Nervous habits (e.g. nail biting, pac

                                                                                                                       - Dr Smita Pandey