How PCPs can help patients manage the dangerous effects of chronic stress

Key takeaways:

• Chronic stress can lead to a domino effect of health problems, but PCPs can help patients manage their stress.
• Basic wellness pillars like diet, exercise and sleep can be critical to stress management.

Chronic stress can be detrimental to health, but primary care providers can help patients manage its causes and effects, according to experts.

“Stress is one of those things that our culture tends to glamorize — or has in the past, at least,” Russell W. Kohl, MD, FAAFP, a family physician and the speaker of the American Academy of Family Physicians Congress of Delegates, told Healio. “That, ‘Oh, look at how busy they are and how much they're accomplishing and how much they can tolerate.’”

But, after a while, stress-related hormones can have various negative effects on the body, Kohl said. The physiological changes that take place to help people cope with stress — increasing one’s heart rate, blood pressure, respiratory rate, etc. — can be “problematic when they continue long term.”

“It's really hard sometimes to say that chronic stress causes these things, but we know it’s associated with anxiety, depression, fatigue, headaches, upset stomach, weight fluctuations — all of those sorts of things,” Kohl said.

Long-term stress can also “affect peripheral vascular resistance and inflammation in the body,” which, in turn, increases one’s risk for diabetes, dementia and infection, Shannon Scott, DO, an American Osteopathic Association board certified family physician and assistant dean and a clinical professor at the Arizona College of Osteopathic Medicine, said in an interview.

“Chronic stress can be described as a school bus full of busy riders with an undisclosed driver,” Scott said. “Considering the whole person, a PCP should partner with the patient to determine the driver, focusing on the dominant aspect first. Chronic diseases, mental health disorders or social determinants of health risks could be different drivers for each person.”

A study that was recently published in the American Journal of Preventive Medicine underscored the health effects of chronic stress. Tiwaloluwa A. Ajibewa, PhD, an assistant professor at Northwestern University’s Feinberg School of Medicine, and colleagues analyzed data from 3,401 participants and found that, among middle-aged adults, chronic stress was linked to a higher risk for having a CVD event.

“Given the possible longer term physiological implications of chronic activation of the stress response system, this study once again highlights the pressing need for public health researchers, clinicians and interventionists to find effective and novel approaches to reduce stress among adults,” Ajibewa and colleagues wrote. “This, in turn, may help reduce the risk of developing CVD in the long term.”

Coping: ‘The chicken or the egg’

Scott said chronic stress can have a significant domino effect on health. Not only is chronic stress associated with mental health disorders like depression and anxiety, but it can also lead to unhealthy coping mechanisms such as increased calorie intake, which can then lead to obesity.

Kohl also said that self-medication is a major issue associated with chronic stress.

“The bigger issue in my patient population is not always as much as the chronic stress in and of itself, but the unhealthy coping mechanisms that somebody might adopt to deal with that stress,” he said. “They may be self-treating through comfort foods or alcohol or tobacco or excessive drug use or any of those sorts of things, and that can be a real challenge to somebody's health” — a harmful cycle that Kohl described as “the chicken or the egg” scenario.

When primary care providers see patients concerned with chronic stress, Kohl said that it is “not simply about pathophysiology and prescribing.”

“It's about understanding the patient themselves and what the factors affecting their life and well-being are,” Kohl said. “A family physician understands not just what the stress is causing, but what is causing this stress and what it is that we can do to reduce it.”

Managing chronic stress

Kohl said PCPs have many options for treating chronic stress. Self-management — teaching patients to use biofeedback techniques like deep breathing and calming one’s heart rate — can be a good place to start.

“The most important thing that we do in family medicine is anticipating and helping folks prevent the problem down the road,” he said. “Let's not just look at how we improve your stress. Let's look at what's causing your stress and [determine if] is there something we can do that removes those causes of stress.”

But for patients already facing chronic stress, Scott and Kohl both said that PCPs could recommend more exercise, healthy nutritional choices and maintaining quality sleep.

“There are physiological reactions to stress,” Kohl said. “If you are in better physical shape, your physiological reaction is better. So, exercise, sleeping well and eating well are the things I tend to emphasize with folks.”

However, Scott said that making several lifestyle changes at once — what she called “a lifestyle overhaul” — can be overwhelming to some patients.

“Remember to get help and focus on the key drivers, one challenge at a time,” she said.

Kohl said he tells his patients not to be too hard on themselves.

“I think sometimes stress comes from folks not having a realistic goal or expectation,” Kohl said. “I used to be residency faculty, and you can see stress a lot in residents who ... would have these goals of activities in a day that's going to be 28 hours. That's going to cause stress because those aren't realistic goals.”

Another component that is critical for stress management is having a support network, Scott said.

“The most important thing to remember is to reach out for help and talk to someone,” she said. “Support networks include primary care providers, spiritual advisors, counselors, friends and partners. Seeking help is a deliberate act to uncover mindfulness steps, achieve stress relief and improve health.”

Equity

Although chronic stress can affect anyone for a variety of reasons, the American Psychological Association has pointed to disparities in certain patient groups that experience it disproportionately.

In a 2016 report, the association wrote that those with a lower socioeconomic status faced higher levels of perceived stress, “more severe but not more frequent daily hassles,” more frequent exposure to traumatic events and more intense stress across life domains. Additionally, Black and Hispanic people reported experiencing more stress than white people.

Kohl mentioned that factors like having a lower income, exposure to violence, and living in a neighborhood where basic services are not being provided come with their own levels of stress.

Biofeedback is not going to resolve those types of situations, he said. ”It's going to help you manage the impact of your stress. But ultimately, the question is, how do we get to those root causes that are leading to those inequities?”

Scott said that “respecting each patient’s unique experiences underscores the importance of holistic care.”

“Members of the patient’s support network should seek to understand and respect what it might be like to walk a mile in someone’s shoes before offering judgment or advice,” she said.

References:

• Ajibewa TA, et al. Am J Prev Med. 2024;doi:10.1016/j.amepre.2023.12.015.
• Stress and health disparities: Contexts, mechanisms and interventions among racial/ethnic minority and low socioeconomic status populations. https://www.apa.org/pi/health-equity/resources/stress-report.pdf. Published 2017. Accessed Jan. 17, 2024.