Clinical management of chronic stress

Stress is a normal part of life. But chronic stress can take its toll on health and lead to more serious issues. Long-term health risks include sleep problems, headaches, frequent colds and coughs, stomach problems, bowel problems, and high blood pressure ¹.

“Stress is how we react when we feel under pressure or threatened. It usually happens when we are in a situation that we don’t feel we can manage or control,” says Jess D’Cruz, information content manager at Mind.

Stress expert and psychotherapist Lina Mookerjee says stress is anything that “the brain and nervous system perceives as threatening or harmful”. “It’s anything of difference. Whether that’s a change of routine, or changes at work – that is the trigger for a reaction,” she says.

David Attwood, a GP partner at Pathfields Medical Group in Plymouth, says it’s important to talk about stress in terms of “normal emotions in response to a stressful life event, rather than in terms of mental health, and medicalised terms such as ‘depression’ and ‘anxiety’”.

Who is at risk of stress?

“Anyone can experience stress, and someone can experience it in a number of different ways,” says Ms D’Cruz. They can experience it as an individual, for example, when they have lots of responsibilities that they are struggling to manage, and as part of a group, if their family is going through a difficult time, such as bereavement or financial problems. And they can experience stress as a member of society, such as during natural disasters or events like the coronavirus pandemic, she says.

Ms Mookerjee finds that more people are experiencing stress since the pandemic. “There’s war, the cost of living crisis, uncertainty in the world, plus social media wrapping everything up in drama,” she says.

“Many things can cause stress, says Ms D’Cruz. “Someone might feel stressed because of one big event or situation in their life. Or it might be a build-up of lots of smaller things. This might make it harder for you to identify what’s making someone feel stressed.”

She says someone may experience stress if they feel under lots of pressure, face big changes in their life, are worried about something, or don’t have much or any control over the outcome of a situation. People may also experience stress if they have responsibilities that they find overwhelming, don’t have enough work, activities or change in their life, experience discrimination, hate or abuse, or are going through a period of uncertainty, she says.

The most common types of stress in the UK are work-related, while financial stress is often experienced by the majority of the population ^{2, 3}. There is also a pronounced generational split in the experiences of stress in the UK. Younger generations, ‘Generation Z’ in particular, report often feeling stressed a lot more than ‘baby boomers’ ³.

Recognising stress symptoms

Practitioners can help their patients to recognise the symptoms of stress. “Stress can affect our emotions, our body and how we behave, in lots of different ways, says Ms D’Cruz. “Sometimes when someone is stressed, they might be able to tell right away. But at other times, someone might keep going without recognising the signs.”

She says if someone is stressed, their symptoms might include difficulty breathing, fatigue, headaches, upset stomach, chest pains, or high blood pressure. Or they may feel irritable, angry, impatient or wound up, anxious, nervous or afraid, over-burdened or overwhelmed, or like their thoughts are racing and they can’t switch off. Mind’s website also has a list of other signs and symptoms to look out for.

“Sometimes, a small amount of stress can help us to complete tasks and feel more energised,” says Ms D’Cruz. “But stress can become a problem when it lasts for a long time or is very intense. In some cases, stress can affect our physical and mental health.”

She explains some types of stress are referred to as ‘acute’ or ‘chronic’. She says acute stress happens within a few minutes to a few hours of an event. It lasts for a short period of time, usually less than a few weeks, and is very intense. It can happen after an upsetting or unexpected event, for example a sudden bereavement, assault, or natural disaster.

Chronic stress lasts for a long period of time or keeps coming back. Someone might experience this if they are under lots of pressure a lot of the time. They might also feel chronic stress if their day-to-day life is difficult, for example if they are a carer, or live in poverty, she says.

With longer acting stress, patients may turn to ‘quick fixes’ like alcohol caffeine and nicotine, and may “feel unwell, that they can’t cope, and a sense of powerlessness and hopelessness”, says Ms Mookerjee.

Actions to help manage stress

Whether a patient is experiencing stress themselves, or is worried about someone else, practitioners can advise that there are some practical steps they can take to help reduce it.

“Unmanaged stress can be really devastating,” says Dr Attwood. “It’s important to develop our own internal ‘barometer’, to recognise when there’s a problem, and to reach out to our family and friends – our natural support network – and talk to them about how we’re feeling. Never bottle things up.”

When patients present with stress, it’s important to really listen to their concerns. “The first part of treatment is active listening,” says Dr Attwood. “Try to put yourself in the position of that person, empathise with them, and encourage them to talk. Active listening is a really useful way in terms of understanding people’s problems.”

Practitioners should try not to medicalise patients’ stress by reaching for antidepressants as the first line of treatment, until they really understand what’s causing it, says Dr Attwood. Then practitioners can ask patients how they think their stress can be addressed, and give them a menu of options that they can draw on, such as signposting them to talking therapies, self-help information and other proven strategies. “Everyone has a different way of recovering from stress, so it’s important to give them options to choose from – one size does not fit all,” he says.

Talking with a trained therapist can help some people find ways to deal with stress, potentially allowing someone to become more aware of their own thoughts and feelings, says Ms D’Cruz. Or they might be able to refer to social prescribing, if it is available in the area, she says, for example, this might include support for loneliness, money problems or physical activity.

While there is no specific medication for stress, there are medications that can help reduce or manage some of the signs and symptoms, such as sleeping pills or minor tranquillisers, if a person is having trouble sleeping, or antidepressants, if depression or anxiety is experienced alongside stress, says Ms D’Cruz. Practitioners may also issue medication to treat any physical symptoms of stress, such as irritable bowel syndrome (IBS) or high blood pressure.

Some people find complementary and alternative therapies helpful in treating signs and symptoms of stress. These could include, but aren’t limited to, acupuncture, aromatherapy, certain herbal remedies and cannabis-based medicines, hypnotherapy, massage, Tai Chi, and yoga and meditation, says Ms D’Cruz.

Lifestyle and diet

To help manage their stress, patients can also look at changing their lifestyle and dietary habits, and cut out, or cut down on sugar, junk food, caffeine, nicotine and alcohol, and drink lots of water, advises Ms Mookerjee. Exercise such as swimming, walking, running or yoga can help to manage stress, she says.

To help ease their sleep problems, patients can be advised to establish a ‘sleep routine’ – going to bed and waking up at the same time every day, and relaxing at least one hour before bed ⁴. They should also avoid watching television or using devices, like smartphones, right before going to bed – because the bright light makes you more awake – and ensure their bedroom is dark and quiet ⁴.

Patients can also be signposted to websites such as Headspace and the Stress Management Society, which offer information and advice on ways to relax, and self-help techniques, including ‘Mindfulness’, which is about focusing on the ‘here and now’ (see resources box).

Preventing stress

“Being prepared for periods of stress can make it easier to get through them,” says Ms D’Cruz. “And knowing how to manage our wellbeing can help us recover after a stressful event. Some of us may refer to our ability to manage stress as our resilience.”

“There are things we can try to build our resilience against stress. For example, taking care of our wellbeing by practicing being kinder to ourselves, trying to find more time to relax, or spending time in nature or on our hobbies,” she says.

“It can also help to identify what triggers someone’s feelings of stress,” she says. “Even if someone can’t avoid these situations, being prepared can help. Knowing what they can and cannot change could help them work out the best way to deal with stress”

Stress ‘red flags’ and signs that patients should be referred for specialist support include alcohol misuse, neglect, and self-harm, says Ms Mookerjee.

For patients experiencing stress, “listening, and responding to your patient is medicine”, says Ms Mookerjee. “During the consultation give them all your attention. And together, look at their stress, and encourage and empower them to be curious about finding ways to help themselves, through kindness and care.”