STRESS Sara Bodner, MD /19/2015

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1 Physician memory STRESS issue, post traumatic stress disorders and cooccurring & Burnout In 1905 Sir William Osler noted: Park Royal some Hospital doctors find is a it private difficult free-standing to keep the flame alive, smothered as it is apt to be by the coping dust with and life's ashes challenges. of the daily Inpatient routine treatment is 1

2 Medscape, Physician Lifestyle Report 2013, and a mental low sense health of personal issues. Burnout is defined as the loss of enthusiasm for work, feelings of cynicism accomplishment. Burnout is associated with anxiety and depression. provided Physicians for depression, were asked to rate anxiety, Burnout onmood a scale of disorders, 1 to 7 severity of mental physician health burnout issues. not related to frequency by The specialty. Medscape, Physician Lifestyle Report 2013, 2

3 BURNOUT * Conceptualized by Maslach and Jackson in the 1970s. Park a) emotional Royal exhaustion Hospital is a private free-standing b) depersonalization c) reduced accomplishments professionals coping such with as healthcare, life's management, challenges. law-enforcement Inpatient treatment is and teaching A multidimensional syndrome consisting of: * A common result of occupational stress in service-oriented STRESS Over-engagement Increased emotions Urgency and activity Stress vs. Burnout BURNOUT Disengagement Emotional blunting Hopeless & helplessness 3

4 Abbreviated Maslach Burnout Inventory The abbreviated Maslach Burnout Inventory consists of the following questions: How often do the following statements describe the way you feel about working as a doctor? I. I deal very effectively with the problems of my patients II. I feel I treat some patients as if they were impersonal objects III. I feel emotionally drained from my work IV. I feel fatigued when I get up in the morning Park and have Royal to face Hospital another day on is the a jobprivate free-standing V. I ve become more callous towards people since I took this job VI. Psychiatric I feel I'm positively Hospital influencing other that people's provides lives through Life-changing my work VII. Working with people all day is really a strain for me VIII. care I don't for really adult care what and happens elderly to some patients adults who have trouble IX. coping I feel exhilarated with after life's working challenges. closely with my patients Inpatient treatment is X. I think of giving up medicine for another career XI. provided I reflect on the for satisfaction depression, I get from being anxiety, a doctor mood disorders, XII. I regret my decision to have become a doctor [ie, (6) every day, (5) a few times a week, (4) once a week, (3) a few times a month, (2) once a month or less, (1) a few times a year or (0) never.] 4

5 Abbreviated Maslach Burnout Inventory Cont. I deal very effectively with the problems of my patients I feel I treat some patients as if they were impersonal objects I feel emotionally drained from my work I feel fatigued when I get up in the morning and have to face another day on the job I've become more callous towards people since I took this job I feel I'm positively influencing other people's lives through my work Working with people all day is really a strain for me I don't really care what happens to some patients I feel exhilarated after working closely with my patients Park I think of giving Royal up medicine Hospital for another iscareer a private free-standing I reflect on the satisfaction I get from being a doctor Psychiatric I regret my decision to Hospital have become a that doctor provides Life-changing The care three items for in red adult are for Emotional and elderly Exhaustion. Sum adults the scores who allocated to have the various trouble responses to get the total score. High scores indicate greater emotional exhaustion (and hence more coping burnout). with life's challenges. Inpatient treatment is The provided three items in blue for are for depression, Depersonalisation. Sum anxiety, the scores allocated mood to the various disorders, responses to get the total score. High scores indicate greater depersonalisation (and hence more memory burnout). issue, post traumatic stress disorders and cooccurring The three items green mental are for Personal health Accomplishment. issues. Sum the scores allocated to the various responses to get the total score. High scores indicate greater personal accomplishment (and hence less burnout). The three items in black are a new scale of Satisfaction with Medicine ( McManus, I. C., Smithers, E., Partridge, P.,Keeling, A., & Fleming, P. R. 2003) Burnout WHO can WE be avoided AREby good Stress Management Therapy! Examples of Stress Management Rx: Mindfulness-Based Stress Reduction (MBSR) Cognitive Behavioral Stress Management Balint Groups Medication Management Relaxation Response Training & Muscle Relaxation Therapy 5

6 CBT is an effective treatment for Burnout Korczak and Schneider performed a systematic literature review from 2006 to 2011 which demonstrated that CBT was most effective in the therapy of burnout, in part due to its ability to moderate emotional exhaustion Ruwaard Successfully treated 470 patients with burnout with webbased therapist-assisted CBT program. Web-Based CBT for Burnout is a 16 week online CBT course including symptom awareness training, progressive relaxation, social skills training positive self-verbalization, a rumination intervention, cognitive restructuring, time management training and relapse prevention. Mindfulness Based Stress Reduction Mindfulness = the intentional, accepting and non-judgmental focus of one s attention on the emotions thoughts and sensations occurring in the present moment. It can be trained by meditation. MBSR was developed by Jon Kabat-Zinn (1980s) and uses a combination of mindfulness meditation, body awareness and yoga to enhance mindfulness. A beginner may practice breathing mindfully or tasting a raisin mindfully. Mindfulness practices also contributed to DBT, Mindfulness based Cognitive Therapy (MBCT), Acceptance and Commitment Therapy (ACT) and many others Brain changes have been noted by some, including activation of the medial prefrontal cortex and rosteral cingulum (Zeidan & Coghill 2012, Brown & Jones 2010) and increased grey matter in the hippocampus and parietal lobe (Jensen 2014) Operationalized using several scales such as the Mindfulness Attention Awareness Scale, Kentucky, Freiburg and Philadelphia Scales, Cognitive and Affective Mindfulness Scale and the Mindfulness Questionnaire 6

7 Mindfulness Attention Awareness Scale 1. I could be experiencing some emotion and not be conscious of it until some time later 2. I break or spill things because of carelessness, not paying attention, or thinking of something else 3. I find it difficult to stay focused on what s happening in the present along Psychiatric the way Hospital that provides Life-changing attention 4. I tend to walk quickly to get where I m going without paying attention to what I experience 5. I tend not to notice feelings of physical tension or discomfort until they really grab my 6. I forget a person s name almost as soon as I ve been told it for the first time 7. It seems I am running on automatic, without much awareness of what I m doing Mindfulness Attention Awareness Scale Cont. 8. I rush through activities without being really attentive to them 9. I get so focused on the goal I want to achieve that I lose touch with what I m doing right now to get there 10. I do jobs or tasks automatically, without being aware of what I m doing time 11. I find myself listening to someone with one ear, doing something else at the same 12. I drive places on automatic pilot and then wonder why I went there 13. I find myself preoccupied with the future or the past 14. I find myself doing things without paying attention 15. I snack without being aware that I m eating. 7

8 Medication Management Depression/ Anxiety: SSRIs,SNRIs, DNRIs, TCAs and newer antidepressants Bipolar Disorder: I (Lithium), II (Depakote), DSM-5 Park Condition Royal for Hospital Further Study: is a Depressive private Episode free-standing with Short Duration Hypomania Other care Specified for adult Bipolarand elderly adults who have trouble Panic Disorder -or panic can be specified with another DSM-5 Diagnosis Social Anxiety Disorder - may be associated with performance anxiety Generalized Anxiety mental Disorderhealth issues. Sub-Threshold Hypomania Studies by Jules Angst Subthreshold bipolarity was defined as a shorter episode or decreased number of symptoms than a manic or hypomanic episode Park The Royal lifetime prevalence Hospital of is bipolarity, a private as evaluated free-standing the National Comorbidity Survey, is increased when subtheshold bipolarity is included to 9.0, almost comparable to MDD at care10.2 for (Angst adult and and Merikangas elderly 2010) adults who have trouble coping Subthreshold with life's bipolar challenges. disorder was associated Inpatient with an treatment is increased incidence of panic disorder, disorder, increased substance abuse including ETOH and nicotine and memory increased issue, familial bipolar post disorder traumatic (Zimmermann stress and disorders Angst and cooccurring mental health 2009 Munich Study) issues. 8

9 Angst Studied Burnout in 2015 A prospective community study of 4,547 subjects studied over 30 years at 7 intervals using MBI, SCL-90-R and SPIKE A mood disorder, & combined mood and anxiety disorder predisposed to burnout. Psychiatric Another predictor Hospital was partnership that provides problems. Life-changing Some psychosocial predictors were important. By contrast work-related predictors appeared less important. memory (Rossler issue, and post Angst traumatic 2015) stress disorders and cooccurring Many studies have related psychological factors to Burnout These include: * an escape-avoidance coping style is associated with burnout; Thornton 1992 * stress management workshops improve coping skills and lead to Psychiatric less burnout; McCune Hospital and Sach that 91 provides Life-changing * psychiatric comorbidity measured by the General Health coping Questionnaire with is life's associated challenges. with burnout; Ramirez Inpatient and Gregory treatment 96 is provided * anxiety is associated for depression, with burnout; Turnipseed anxiety, 98 mood disorders, However these associations raise the question of which comes first? 9

10 McManus and Paice yr longitudinal study of UK medical graduates The Maslach Burnout Inventory, the General Health Questionnaire, a personality questionnaire measuring the big 5 personality dimensions of neuroticism, extraversion, openness, agreeableness, and conscientiousness, an approach to work questionnaire Psychiatric and Hospital a workplace that provides climate questionnaire Life-changing were used. stressed provided tended for depression, to take a surface anxiety, disorganized mood approach disorders, to work and had a high perceived workload It was found that neurotic personalities and those who were Those with high personality scores of agreeableness tended to take a supportive receptive approach to work. Coping Strategies may protect against Dolittle 2013 Methods Studied 173 resident physicians with MBI, Carver Coping Orientation to Problems Experienced (COPE) Inventory and the Hatch Spiritual Involvement and Beliefs Scale (SIBS) Results Park Royal Hospital is a private free-standing Strategies of active coping, positive reframing and acceptance resulted in lower Psychiatric emotional exhaustion Hospital and depersonalization. that provides Life-changing Strategies of denial or disengagement resulted in higher emotional exhaustion coping and with depersonalization life's challenges. scores. Inpatient treatment is Personal provided accomplishment for depression, positively correlated anxiety, with the SIBS mood score. disorders, 10

11 New Medications Vortioxetine: 1. Antidepressant approved by FDA in Appears to benefit cognitive function 3. Major Side Effect is nausea; weight gain and sexual side effects are not prominent, although sexual side effects are seen Psychiatric the higher Hospital dose of that 20 mg provides Life-changing agonist, coping 5HT with 1B life's partial challenges. agonist and 5HT Inpatient 1D,3 and treatment 7 is antagonist. 4. Mechanism of action: Serotonin reuptake inhibitor 5HT1a New Medications Cont. Levomilnacipran: 1. an SNRI enantiomer approved by FDA in 2013 for fibromyalgia Psychiatric in US Hospital that provides Life-changing profile 2. and depression in Europe 3. more norepinephrine blockage and favorable weight gain 4. side effects of increased blood pressure and and heart rate 5. must monitor cardiovascular health 11

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