- [Announcer] The region's premier medical information program, "Call the Doctor."

- Stress seems inescapable these days.

A certain amount of stress is fairly normal, but too much over time can lead to issues and symptoms that you might not even consider.

We're interested in finding out exactly what stress is, how it affects your mind, but even how it affects your body.

And some practical tips we could all use on how to keep it at bay.

Stress and its effects, on this episode of, "Call the Doctor."

Hello and welcome.

We are so glad you're with us for this season and this particular episode of, "Call the Doctor."

We think it's an important one, we're gonna get right to tonight's panelists.

Really of all the topics that we do, I think this is the topic that's gonna touch a lot of people.

Very happy to have the three of you here.

Could you introduce yourselves please?

- Thank you so much, my name is Ali Chittalia, I'm an internal medicine physician and my clinic is in Mountain Top.

I work at Geisinger Health System.

I am also an informaticist with IT and I also work as the Director of Graduate Medical Education for Diversity, Equity and Inclusion.

- Great, welcome.

Thanks so much for being here.

- Thank you.

- My name is Kylie Oleski.

I am a clinical health psychologist with Geisinger Health System and I currently work in our primary care behavioral health division out of the Geisinger Mount Pleasant Clinic in Scranton.

- I know you are busy these days.

- Yes.

- And what about you sir?

- Hi, thanks for having me here.

My name is Guillermo Rodriguez, I'm a family physician.

I work for Lehigh Valley Medical Group and I'm currently in Hazleton.

- Great, welcome.

And of course if you would like to answer some questions in Spanish tonight, you are welcome to do so.

- Thank you.

- Speak to as many people as we can about this topic.

- Thank you.

- So, okay stress, I mean, we could do four hours on this and still not get through it.

Everybody has stress.

I suppose the first question, I'll start with you, is just where's the tipping point?

How do you know when stress is okay and good and gonna help me through and when it's harming me?

Is there a spot or is that question just ridiculous 'cause it's all over the place?

- No, you are absolutely right.

Stress in an acute phase is good.

It improves performance and the body is geared to take that acute stress, yeah?

The sympathetic system helps you.

It's that fight or flight phenomena where, you know, your heart rate increases, the heart starts to pump blood, your breathing gets faster, your pressure is there too, that you don't collapse and fall, so all that is good.

You know, your body will release those hormones to get you going and face the challenges and then improve performance to be able to strain that.

But it only lasts a few minutes.

Then if the stress continues beyond a few minutes, then it causes harm.

So the acute stress will improve performance.

But if the stress persists, then it causes significant dysfunction.

And then when you talk of chronic stress, that's a different animal altogether.

- So it's our nervous system we're talking about here?

- Yes.

- Or what exactly are we experiencing when we're experiencing stress?

- So stress is a situation where when the body gets stimulus that is, you know, considered dangerous, right?

So the body starts to release all these stress hormones, which is norepinephrine, epinephrine, cortisol.

All these hormones help you get over the acute problem that you're facing to be able to save yourself from that dangerous situation.

So that is an autonomic nervous system that the body has to guide you and to support you during the stressful time.

- So we talked a lot before we got out here, about that mind body connection, about how stress is happening here, but we feel it everywhere.

Could you, Dr. Oleski, kind of go through some, the mind and the body and how everything is connected when it comes to stress?

- Yeah, it's absolutely true that we cannot separate the two concepts and so much what we are experiencing psychologically can manifest physically.

So a lot of the markers of stress that we see could be tension throughout our body, frequent headaches, gastrointestinal upset, sometimes in more extreme forms can manifest like anxiety where we see more shakiness and heart rate changes.

Yeah, those are the definitely the top ones that come to mind, I don't know if.

- Lack of sleep also.

- Lack of sleep, yes.

- You think, I mean, you're gonna find out people consider it's lack of sleep is a physical situation and you're gonna find out that stress, carry sleep.

And following Dr. Chittalia's point of view, I think, what I used to differentiate, when the stress affects your activities of daily living and the stress affects your relationships at home, because you might think, you know, I don't care what my activities of daily living, I'll just power through.

But if you are in a family situation that you say, you know what, if it's affecting the rest of the family, then that stress is, that's the tipping point you say, maybe I should seek help for that.

- Correct, that functional impairment piece that we would really look for.

- Do you find it's often the families or friends who will, I don't wanna say call you, of course the patient will come to you, but is it the family and friend who will get the patient to say, listen, you gotta do something here.

- Many times patients are in denial, you know, everybody feels that, hey, I can deal with this.

And they don't seek the help.

So many times the other families and friends come and approach and convince the people to come and seek help.

Sometimes the patients themselves feel that, it's getting too overwhelming, it is affecting my quality of life, my performance level.

It actually messes up with your mind, your cognition, your ability to make decisions.

I've seen people that come to me for severe headaches, they're tension stress headaches and you know, they get treated as migraines and so many different forms.

So most of the times, some people who actually have realized that it is affecting their quality of life, maybe their work is telling them that they're not performing, their personal life is a mess.

They come to us directly and sometimes the spouses, family and friends urge them to seek help.

- And also there's a huge cultural component to this.

Understand, when you talk a lot, for example, in my case with the Hispanic population, remember there's the classics of the macho men, "Oh no, I have to deal with stress, stress is a good thing.

I not gonna be weak because I can deal with this stress."

So you're gonna find out the Hispanic population, most female patients will be okay, ready to accept their stress.

When you ask the male patients, "Why you are here?"

It's because my wife, my girlfriend says I have to be here.

You know what, so that's the point.

I say, "Well, I'm glad that she cares about you, but tell me what's going on," you see?

And that's the most important thing that we are all trying to do here is make sure that the patient, like I said, one of the things that the patients get frustrated, is they come, I have a headache, I have a stomach pain, I have something and the doctor tells me stress and the doctor tells it's depression, it's anxiety.

And of course that creates a barrier because the patient doesn't wanna accept that.

So the first thing we have to do, as providers over here, we try to say, listen, these symptoms you have are real, we're not saying you're faking any of this, what you're saying, that these symptoms are creating or are part of also a psychological component and you cannot take one of the others.

My classic example said, "Well, how do you think that this could be depression?"

Listen, if you take a knife and stuck it on my back for three months, I'll get depressed.

You know what, you know what, so that kind of opens up the thought of well, yeah, you know, it is part of this, of the process that they're both are related.

- Can you tell me a little, I want you to dive deeper into that, about why is there such a stigma?

I mean that's a million dollar question I suppose, but what do you have to get through to your patients sometimes to say, "We know you're having physical symptoms, but it's originating in the mind?"

- Well, first to add Dr. Rodriguez's point is that it really is about partnering with our patients and hearing and validating that yes, we very much understand that this physical component is happening and then it becomes a both and situation.

Let's also address the psychological component simultaneously to breaking down overall distress.

So in terms of the stigma and where it comes from, unfortunately that's something that's been alive and well in our society for hundreds of years.

It is certainly something that is improving, but a lot of times health seeking behaviors have either not been well received or at least patients experience that it's been, you know, a negative experience or maybe there's cultural factors that don't support health seeking behaviors.

So there's a lot of barriers sometimes to break down.

- Do you see that the younger population or younger generations think differently about it than the older population does or do?

- Yeah, I do.

I think the younger generation basically have, they've grown up in a different environment.

So they accept it easily, they seek help much faster.

And there's so much of information around, you know, the world is a big full pool of knowledge and it's easily accessible.

So I do see the younger generation, their perspective is different and they're more easily approachable.

They will ask for help to us, much faster than what Dr. Rodriguez said about the macho man.

It really is true in many cultures.

So we as physicians have to be truly culturally competent and understand what is stress.

The flip side towards stress is a lot of times physicians just label everything as stress, anxiety and depression and actually forget to investigate the patient, if there's a pathophysiological cause for those symptoms.

So you'd have to balance it out.

You wanna make sure that you're not missing some underlying conditions.

Like I have patients who have been diagnosed with depression and be treated on multiple meds.

All they had is hypothyroid, an underactive thyroid.

So we have to decipher that.

- Well, to the younger population is very interesting because you brought a great point, which is that they read a lot.

The problem is they read from the wrong sources.

So you're gonna find out that the younger population, well guess what?

Marijuana is good for this stress, so I'm gonna smoke 10 joints a day because that will take care of it, you see.

So that's where concerns about substance abuse come in.

- [Julie] Yes.

- Self-medication you know and things like that.

So the thing I always try to express, which you're completely correct, the patients who are more open to talk about the stress and things like that, but they also wanna talk about that their way that they found out on the internet is much better than the way that we have tried to work for years and comes, that's where the partnership comes in, say listen, understand.

It's like saying, well, I wanna build this big house with this very small hammer.

Well, you could do it, but it's gonna take forever, you see?

You want the best tools to be able to do what we wanna reach here.

And trying to create that partnering here is very important.

So you're gonna see that a lot on the young population.

- Since you opened that door, I think we'll walk through the substance abuse.

- [Guillermo] Sure.

- Because, do you see that that in sometimes that that can go hand in hand, Dr. Oleski?

- Absolutely, yeah.

And I think it's important to remember that any sort of substance abuse, many times starts as a method for coping and coping with stress.

So in my experience, I've worked with a lot of patients who might find themselves misusing substances actually inadvertently, right?

A couple glasses of wine each night can kind of become a problem after a certain period of time.

So while the intent often starts, I think in a very good place to mitigate stress and help with coping, it can then lead to some more problems maybe down the road.

- So we've talked about some headaches, possible gastrointestinal issues.

What else am I missing when it comes to physically?

I mean, I imagine you see a little bit of everything.

- Absolutely, to do research for here, I went to where everybody goes to, which is WebMD.

People, we're gonna go to WebMD.

- Dr. Rodriguez went down there.

- And they went and they rang.

Not because I'm trying to learn, I wanna see what everybody sees before they come to my office.

- [Julie] Yeah.

- And when you put WebMD and you put the symptoms, they talk about the number one, they talk about headaches, they talk about back pain, muscle ache, cramping abdomen, sleeping disturbances, all those things.

And yes, all those symptoms could have a physical component, but they will create a psychological reaction.

And the opposite is true.

You could have a very severe, depressed patient that can develop these symptoms too.

So we cannot divorce one from the other.

Let's add to that, that we have to separate our populations.

Like we very well said, the adults on most of my experience come with tension, headaches and back pain.

But my kids come with abdominal pain and nausea and when they come stressed out and when that stress becomes like we very well discussed before, that affects the activities of the daily living.

If a kid gets a tummy ache, you know what?

And they take some and they feel better, they go to school, no problem.

If the kid has missed five days of school because they have abdominal pain and we have taken to doctors and we have not find a source of that pain, that is, we have to rule that out.

We have to start saying, you know, what are we missing here?

So one, we cannot divorce one from the other.

- So stress can look different in a pediatric population than it does in an adult population.

- Absolutely, people think of kids as little adults, no, kids are kids, adults are adults.

From the way we give medications, from the way we give approach, et cetera, et cetera.

That's why with those medications different from children.

And the scary part, there's a huge stigma with management of the pediatric population because of the whole thought about, oh, antidepressants will cause suicide.

You know what, that's the big scare everybody has right now.

And yes, there's stories, there's black box warnings, but all depends again on the history, the evaluation and most important, the follow up.

I'm not gonna start an antidepressant on a child, and say, "Okay, I'll see you back in three months."

No, you have to see a child much faster, a week, because the reactions are different on a child than an adult, it's when they're left to their own devices that we tend to see those problems.

- So good point is, as you said, Dr. Rodriguez and in the adults, you know, chronic stress can trigger heart attacks, strokes, a lot of different health conditions.

It weakens your immunity to infections, you know, because there's a high cortisol level in the body that affects the gut system.

People develop symptoms like IBS.

There's diarrhea, there's panic situation, which is not good for the mind and the body.

And then eventually it causes the cognitive effect.

You know, your brain, the brain fog that we talk about.

You're not able to make simple, rational decisions.

And then they make decisions that are irrational, that causes them more harm in the community, in the society, in their personal life, in their work life.

And that becomes a positive feedback loop of negativity in our life, right?

- [Julie] On and on and on.

- So circles around and it's hard to break away from it unless somebody is actually ready to accept that they have a problem and let me fix it, let me seek the right help.

- And this is exactly where the opportunity for partnership with behavioral health comes into play.

And really, I think good quality, especially cognitive behavioral therapy, helps target that cognition piece and helps patients start examining their decision making and their coping styles and make some changes in those areas.

- Can you explain what that means for someone who might not know?

- Sure, cognitive behavioral therapy?

- Yes.

- So it is a approach to therapy that is very well researched.

It's what we would call an evidence-based treatment.

And it focuses on the connection between our cognition, so our thoughts, our feelings and behaviors.

So imagining a triangle with the interplay between those three factors.

So we would intervene in any one of those areas very naturally speaking, you know, if we are thinking negative thoughts, our behavior tends to follow that, right?

We might not be as motivated, we might be more down.

And that perpetuates sad mood in many cases.

So it's pretty evident how the three are connected.

And therapy from that perspective will help break down those three areas and lead to improvement.

- And one of the things we always have to remember, I mean, we are all here because we all know each other, very caring providers.

We have our training, we have our education, sadly enough, sometimes a patient might not encounter a provider that will provide this information.

Oh, for example, a patient comes with fibromyalgia, oh, that's just depression, you see?

And then the patient itself might say, well if he says depression, I guess I'm faking all of this, et cetera, et cetera.

If you cannot establish that relationship or that relationship is not working for you, doesn't mean you're the problem, means you have to find a different relationship.

And again, I'm not trying to diminish anybody, but many of the times I see brand new patients in my practice happen for years with another providers.

And I ask them what happened?

And they tell me, well, nobody listen to me.

Nobody, they told me I was just faking it, they just told me it's depression.

So that conversation, I mean, if you don't feel comfortable with any service, you will try to find that service somewhere else.

That's what I'm encouraging here.

I mean, we just seek the help.

And if you cannot find the help with one particular situation, seek another one, that's very important.

- [Dr. Oleski] Yeah, absolutely.

- And the symptoms are actually real.

You know, like when the patients come and tell you like, I have muscles tightening, I have headache, it's those, you know, transmitters that the body makes that causes muscle stiffness, tightness, headaches, the back pain.

And then eventually when people become, you know, so much into a sort where they're not doing much for themselves, they go into a rut, they'll get into stress eating, then they gain weight.

Then there is, you know, your body dysmorphic disorders, things like that come out and your overall identity, the feeling of good, is gone.

They're not exercising, the endorphins that the body needs to make you feel good, the dopamine and those kind of hormones that make you feel good, comes with exercises and healthy living.

So when people fall into that rut, it's sometimes then harder to get out of it.

So we have to catch them at an early stage and give them the right help, whether it is management support, psychotherapy, behavioral therapy, mindfulness, being gratitude, all these factors help.

- Very interesting that you said that those are real.

It's not to say that you have stress and you think you have a headache, you have stress and you have a headache.

- Yes.

- Correct.

- Exactly.

And it's so interesting because the medicines approach the same way.

One of the number one medications for chronic pain is Cymbalta.

Cymbalta's an antidepressant, but we don't use it for depression, we use it for chronic pain, The cyclobenzaprine, which is Flexeril, one muscle relaxant, is closely related to amitriptyline, which is an also an antidepressant medication.

So it's very interesting, not only our approach, but even the pharmacotherapy will target both the pain and the depression at the same time.

So many patients would come with chronic back pain, we will always put them on a medication that will cover both pain and depression, to be able to help that.

So that's how real the symptoms are because when we make decisions, we make decisions based not only on the psychiatry, but also on the physical sentence.

- We put two people in the same circumstances, the same stressful circumstances and one can handle it and one cannot.

I mean, obviously you can't answer why, it's a hypothetical, but what is, are people just more susceptible to it?

Is there a hereditary kind of a genetic component?

Why does it affect one person so much and not so much the other?

- Well, I can answer, I always tell my patients, how you handle the stress will depend on your mom and your dad.

And for two reasons, for education and from genetics, you see?

Your mother and your father or your grandma, your grandpa, whoever was the person who raised you, gave you, you know, a certain set of way to do that, deal with that stress, but also gave you some genes.

When we did do the review for family medicine and they say which antidepressant to choose the best?

That's one of the questions we get the most.

How you chose that one compared that one?

And there's only one question that really matters.

We did studies and found out, we chose the antidepressants that worked the best on your family member for you.

- [Julie] For you.

- So for example, if mom, Zoloft work, probably Zoloft is gonna work for you.

If that for example, process work, probably process for you, there is a genetic component that helps and that tends to decide.

And that's one of the first steps I always ask, when I do manage for depression.

So there is the education, but there's also genetic component.

If you ask me what's the percentage, I don't think nobody knows that.

- [Julie] Right, right, right.

- But we have to explore, you know, those two options.

- I would add that there's a very strong behavioral component as well.

What I mean by that is maybe strategies that we've utilized in the past that worked well, we come to learn, oh, that worked, let me try this again, right?

So that might lead to more positive coping or effective stress management.

Similarly, we might have either directly or indirectly learned and observed some behaviors and coping styles that might not be so effective, right?

And then we also carry that forward when we're managing our own stress.

- Yeah, I completely agree with both of them.

So there's a legacy that Dr. Rodriguez defined right?

That you are can made by, come of your genetic component and then the layers around you, the environment in which you have grown up, the exposure, the you know, the education level, your access to healthcare.

There's so many different factors that play into how a person will seek help and how they'll be able to manage the stress.

- I guess with the time we have left here, we know stress isn't going away.

So let's say work is your stressor, you can't just quit your job, right?

So how do you tell your patients to live a good life with this?

- Everybody agrees, number one, exercise.

- Exercise.

- We always mention exercise, okay?

It's very important you exercise.

Minimum 20 to 25 minutes four times a week, okay?

That we, on the very least, if it's more, better, but that should be the starting point.

Interesting enough, I'm a huge encourager of hobbies, but you have to have an active hobby.

Watching TV, reading a book, that's not the hobby we want.

We want something to take it from inside to outside.

You know, if you wanna go fishing or if you wanna work on any art or something that will take that negativity and put it aside.

Many people say, "Well, I only like to read."

I say, you know what, all readers are writers.

- [Julie] Writers, yeah.

- Write everything, write every day, a paragraph to writers.

And the day that you don't wanna write, write, Dr. Rodriguez forced me to write, I hate writing, this is horrendous.

- [Julie] I don't know what to.

- I don't know what to say, but they let it go and that helps them in that particular plan.

I don't know anything else with that.

- I would absolutely build off of that and say actively seeking ways to find and maintain joy and gratitude.

So as Dr. Rodriguez has pointed out, increasing activity and increasing hobbies, that's actually one of the number one ways of treating depression is through this concept of behavioral activation.

And I would add to that, is the joy component, right?

Really doing things that we enjoy and finding opportunities, even though they may be very small to be grateful.

- Yeah and for me, I'm a big believer of gratitude.

It has helped me, you know, calm myself and get me to a level every time.

Like, I always feel my day could have been worse, you know?

Even on my bad days.

So that gratitude really helps.

But in general, to all our viewers, like good nutrition is crucial.

What we put in our body is so important because when we do stress eating and we put on excessive amount of weight, that is one of the worst factors that leads to worsening stress and depression.

And I see a lot of cases, especially with this COVID pandemic, people have stayed home.

We have become inactive and there are a lot of people have gained weight.

- [Julie] It's a whole other show.

- Yeah, it's all across.

And then there is more stress and anxiety that is just gone into, by just choosing an unhealthy lifestyle.

- Yeah, it becomes a lot of self-perpetuating cycles.

- Yeah, self-perpetuating.

- Absolutely.

- I don't think adults experience a lot of joy, I mean, I shouldn't speak for everyone, but, you know, knowing who I know, I wonder if adults don't experience joy as much as they should.

- Being happy is their hardest work to rest.

It takes a lot to be happy.

- [Julie] That's stressful Dr. Rodriguez.

- I know, but it's the truth and that's the thing.

You have to admit to yourself by this society that we have, always they're gonna push for the negativity, the sadness, the anger.

I mean, we can see everyday, - [Julie] Everywhere.

- Everywhere the anger.

And it's so difficult to stay positive.

So the first thing I tell my patients, this is not easy, but it will, it can be done.

And I'm gonna help you get through that.

- Yeah I really want to add to that in, I think so much of our society frames happiness as an end point or a final destination, when really happiness is an emotion experience just like any other.

So it's just as fleeting as anger or jealousy or any other emotion you want to name.

So that's where it goes back to the moments, right?

We have to find the moments of happiness and positivity as much as we can.

- You will get to a point and suddenly have no stress and lots of happiness.

- [Dr. Rodriguez] Exactly, that's right.

- Yeah and you know, like you have your life, enjoy your life, enjoy the life that you're in, in the context and perspective of who you are, with what you have and what you can be, rather than following the social media and looking at somebody else's life.

And there are, that's also real.

People are upset, depressed, anxious, well why this one is having great time somewhere else, and why am I not doing that?

- Because it's all a facade, basically, sadly enough, nobody puts on Facebook, look how miserable I am, everybody puts, this is how great I'm doing.

- [Julie] Look where I am now, yeah.

- And then the people will say, "Oh my God, well I must be miserable person because I'm not that."

And it's very important that, you know, every second that you are happy, don't feel guilty about feeling happy because that's the first thing.

Because everybody says, "Oh, I shouldn't feel happy because there's so much bad in world."

- There's pain in the world, yeah.

- No, trust me, you're gonna be sad very soon.

You know what something will come that way.

- Thank you, these are all really good tips and I hope someone has gleaned something from this show.

I appreciate your expertise very much.

But that's gonna do it for this episode of, "Call the Doctor."

We're so glad you've joined us, for all of us here at WVIA.

We'll see you again next time.

(uplifting music)