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Practice The Competent Novice

How to handle stress and look after your mental health

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b1368 (Published 27 April 2009) Cite this as: BMJ 2009;338:b1368

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Defining , measuring and managing stress.

Iversen et al define stress as an "imbalance between demands and
resources" or when "pressure exceeds one's capacity to cope" (1). These
definitions lack precision. Furthermore the claim that "meditation-type"
practices
are effective is highly questionable.

Consider the "double blind, parallel group, randomised controlled
trial of a retroactive" prayer on outcome from sepsis (2). Professor
Leibovici reported that the "length of stay in hospital and duration of
fever were significantly shorter in the intervention group than in the
control group (P=0.01 and P=0.04, respectively). His data, which generated
much discussion, suggest that expectations alone might influence outcome
even when testing the most preposterous of hypotheses.

Stress might be more precisely defined as cellular stresses that
deplete ATP by activating AMP kinase and initating a cascade of events to
restore ATP stores in accordance with the Daniel Atkinson energy charge
hypothesis. The stresses known to deplete ATP include heat shock,
metabolic poisons, hypoglycaemia and hypoxia. The stresses to which
Iversen et al refer are, however, physiological stresses activated by
stress hormones, notably catecholamines. The effects of ATP depletion are
five times higher on AMP than on ADP, as Krebs showed decades ago. The
stochiometric inference is that the changes in AMP, and hence AMP-kinase
(AMPK) activity, is accompanieed by equimolar changes in [Pi] and [H+]. In
glial cells these changes are evident from sharp and short-lived falls and
rises in pH.

AMPK switches on catabolic pathways, acutely by phosphorylation of
metabolic enzymes and chronically by effects upon gene expression, and
switches off many ATP- consuming processes. Fatty acid, trigyceride and
steroid synthesis is inhibited acutely. The inference is that
neurotransmitter synthesis might also be inhibited. In the longer term the
activity of those enzymes involved in fatty acid synthesis and
gluconeogenesis are down-regulated. Concurrently glucose uptake,
glycolysis and fatty aciod oxidation are increased acutely. In the longer
term expression of Glut 4, hexokinase and those enzymes involved in the
citric acid cycle and respiratory chain are up-regulated. The degree of
stress can be expected, therefore, to be measured from the changes in the
pH that are induced using the area-under-the-curves to quantify it.

My parents, both GPs, had different methods in managing the stress of
caring for their patients at night. My father would fall asleep within
minutes of going to bed or receving a phone call confident in his decsions
and that he had done all he could do at the time. My mother would lie
awake for ages worring about her patients and second guessing her
decisions. Fortunately her practice did not require her to be on call at
night.

In my first house job I was responsible for all the women on the
vascular unit and all the patients on the cardiothoracic unit. A
contemporary was made responsble for all the men on the vascular unit, a
large case load than the women. I thrived from the word go having adopted
or inherited my father's skills in sleep management. This enabled me to
handle my 90 to 100 hour week with no difficulties. My contemporary seemed
never to finish attending to his patients. In this respect his behaviour
was very similar to that of sarah Craven's reported by Iversen et al. My
contemporary was relieved of his duties after a week in harness, the
physician responsible for staff health having recognized the early warning
signs. Thanks to his early intervention the house surgeon was able to
return and complete his six month rotation.

When I was flying some 100,000 to 200,000 miles a year, mostly
across the Atlantic, I learned to manage my sleeping very effectively by
avoiding alcohol and conversations when flying east and going to sleep
after take-off with the aid of eye-shades and a sleeping tablet. I made a
point of going to bed late and taking a sleeping tablet for the next two
nights to avoid waking up at 2am and being unable to fall asleep again.
That, I found, was the killer. This protocol enabled me to engage in my
professional activities within hours of arrival and resume my clinical
responsibilites when I returned home. Going west was easier.

Sleep management would seem essential in the management of stress.
This might be because sleep is the evolutionary product of the dark phase
in photosynthesis and is essential for intracerebral nutritional and
neurotransmitter stores to be replenished. If depression is the product of
an energy deficit, as previously suggested, then alterations in sleeping
patterns might be another product.

For our understanding or stress, and particulary the post traumatic
stress disorder, to improve it would seem essential to define stress in
metabolic terms and measure it possibly with magnetic resonance imaging
using hyperpolarized bicarbonate in the manner being developed by General
Electric Healthcare. .

1. Amy Iversen, Bruno Rushforth, and Kirsty Forrest
How to handle stress and look after your mental health
BMJ 2009; 338: b1368

2. Leonard Leibovici. Effects of remote, retroactive intercessory
prayer on outcomes in patients with bloodstream infection: randomised
controlled trial. BMJ 2001;323:1450-1451

Competing interests:
None declared

Competing interests: No competing interests

10 May 2009
Richard G Fiddian-Green
FRCS, FACS
None