[Editor's Note: Dr. Flapan, who died of Scleroderma, was a psychologist whose own personal experiences helped him to understand and write about the emotional impact of chronic illness on interpersonal relationships. His articles, which have appeared in many newsletters, have been published in a compilation, "Perspectives On Living with Scleroderma: Voicing the Hidden Emotions of the Chronically Ill."]

When family members or friends ask, "How are you?" they usually want to know if you are in any particular pain or discomfort, or if you are worse or better off physically than before. Seldom do they have in mind your emotional state. Yet at times your emotional reactions to your illness are more stressful than the physical effects.

While you and your family are doing everything you can to treat and cope with your physical ailments, there may be more you and they can do to relieve your emotional distress. You can learn to better understand and accept your feelings - to understand without shame, self-blame, guilt or recrimination.

To promote this understanding, I will describe the commonly experienced emotions of persons with chronic illness, recognizing of course that not everyone experiences all the reactions I will describe. In describing these emotional reactions I may be giving voice to thoughts and feelings you have never expressed or possibly even acknowledged. This may upset those of you who are able to maintain a positive attitude by putting aside disturbing thoughts and feelings. This article is for those of you who need the emotional relief of a shared understanding.

DISTRESSING EMOTIONS

Anger: You are angry for having an illness, but who should you be angry at - God, fate, the whole world? You are angry at doctors because they have no cure for your disease. You thought doctors knew so much, but you now realize they don't. What's more, they don't seem particularly interested in you, except as a case. When you go for a visit, they are either rushed and don't explain enough, or say things that upset or frighten you. You are also angry at family members and friends who at times are unavailable when you need them, and who expect more from you than you can do. You wish they could live in your body for a day or even an hour so they could understand what life is like for you. Then maybe they wouldn't say or do things that hurt your feelings. You are also upset by the thoughts that they might resent all they have to do for you and you feel hurt and resentful in return.

Self-Blame: You may blame yourself for your illness. Maybe you brought on your condition by not taking proper care of yourself. Or maybe God's punishing you for something you did wrong but you don't know what. You just feel it's your fault.

Shame: If you take your illness as a sign of weakness or a reflection of a flawed character, you are ashamed to be ill. If you take pride in yourself in being independent, or on doing things for others, you are especially ashamed if you need others to do things for you. Moreover, if you have a visible disfigurement or deformity, you may be painfully self-conscious and ashamed.

Frustration: If you have a disability that requires you to rely on others for your daily needs, you are constantly frustrated. You are frustrated because you can't do these things for yourself and you are frustrated because others can't do them promptly enough or exactly as you would like. Also frustrating and depressing as well is to be unable to engage in activities you once enjoyed, or to use abilities in which you once took pride.

Self-Evaluation: If you are unable to do what you used to, you not only feel frustrated, but inadequate, too! And if in addition you are a perfectionist with expectations you no longer can meet, you may feel discouraged and even hate yourself.

Self-Pity: You feel sorry for yourself that you can't lead a normal life like everyone else. You feel cheated and unfairly treated if you are unable to finish your education, get married, have or take care of children, earn a living or pursue a career. And you can't help envying and resenting others who can do all these things.

Guilt: You feel guilty if you can't fulfill your responsibilities as a wife or husband. Guilt may be unbearable if you are a mother unable to do all you should for your children. Guilt is intensified if you feel you are a burden to others - especially if you need help in your personal care and hygiene. And should you sense a resentment on the part of family members on whom you depend, you not only feel guilty but hurt as well.

Fear: If your disorder is potentially progressive, you live in dread of the future and are alarmed by any actual or imagined change in your condition. If your condition is life-threatening, a cloud hangs over your head. You are also plagued with fears related to your family. If you have young children, you worry what will happen to them if something happens to you? If you are dependent on your parents or marital partner for personal care, you worry what will happen to you if anything happens to them? Although you know it is unlikely, the thought has occurred to you what if your partner gets tired of taking care of you and leaves? What would you do then?

Emotional Relief: Even though your emotional reactions may be commonplace, if you criticize yourself for your feelings you may be suffering more than you need to be. If that is the case, you gain both understanding and self-acceptance by sharing your feelings with a sympathetic family member or friend who is sensitive to your feelings and knows how to listen. You can even use this article as a basis for talking about your feelings.

You can also lighten your emotional burden by sharing your feelings in a support group or with others individually. If these sources are not sufficiently helpful, you can benefit from professional counseling. Counseling may not only relieve the pains of guilt, apprehension, anxiety, self-disparagement and depression, but may provide new perspectives for living and coping with your disorder. It is important to keep in mind - while you are not responsible for your physical disorder, you are responsible for what you do or don't do to help yourself in living with it. I hope you are a good helper.

[Editor's Note: This material comprises one section of an article, "Stress Management for Patient and Physician," that was prepared by Dr. David B. Posen of Ontario Canada, who is a Lifestyle Counselor and Psychotherapist as well as author of "Always Change a Losing Game." The article was published in the April 1995 edition of "The Canadian Journal of Continuing Medical Education" and can be viewed in its entirety via the title link above.]

What Is Stress?

Dr. Hans Selye, the father of stress theory, defined stress as "the non-specific response of the body to any demand made upon it." The "demand" can be a threat, a challenge or any kind of change which requires the body to adapt. The response is automatic, immediate. Stress can be good (called "eustress") when it helps us perform better, or it can be bad ("distress") when it causes upset or makes us sick.

What Does the Stress Reaction Consist of?

The stress reaction results from an outpouring of adrenaline, a stimulant hormone, into the blood stream. This, with other stress hormones, produces a number of changes in the body which are intended to be protective. The result often is called "the fight-or-flight response" because it provides the strength and energy to either fight or run away from danger. The changes include an increase in heart rate and blood pressure (to get more blood to the muscles, brain and heart), faster breathing (to take in more oxygen), tensing of muscles (preparation for action), increased mental alertness and sensitivity of sense organs (to assess the situation and act quickly), increased blood flow to the brain, heart and muscles (the organs that are most important in dealing with danger) and less blood to the skin, digestive tract, kidneys and liver (where it is least needed in times of crisis). In addition, there is an increase in blood sugar, fats and cholesterol (for extra energy) and a rise in platelets and blood clotting factors (to prevent hemorrhage in case of injury).

What Are Common Symptoms of Stress?

Manifestations of stress are numerous and varied but they generally fall into four categories (this is only a partial list of most common symptoms):

• Physical: fatigue, headache, insomnia, muscle aches/stiffness (especially neck, shoulders and low back), heart palpitations, chest pains, abdominal cramps, nausea, trembling, cold extremities, flushing or sweating and frequent colds.
  
  
• Mental: decrease in concentration and memory, indecisiveness, mind racing or going blank, confusion, loss of sense of humor.
  
  
• Emotional: anxiety, nervousness, depression, anger, frustration, worry, fear, irritability, impatience, short temper.
  
  
• Behavioral: pacing, fidgeting, nervous habits (nail-biting, foot-tapping), increased eating, smoking, drinking, crying, yelling, swearing, blaming and even throwing things or hitting.

What Are the Causes of Stress?

Dr. Selye called the causes of stress, "stressors" or "triggers." There are two kinds of stressors, external and internal.

External stressors include:

• Physical environment: noise, bright lights, heat, confined spaces.
• Social (interaction with people): rudeness, bossiness or aggressiveness on the part of someone else.
• Organizational: rules, regulations, "red tape," deadlines.
• Major life events: death of a relative, lost job, promotion, new baby.
• Daily hassles: commuting, misplacing keys, mechanical breakdowns.

Internal stressors include:

• Lifestyle choices: caffeine, not enough sleep, overloaded schedule.
• Negative self-talk: pessimistic thinking, self-criticism, over-analyzing.
• Mind traps: unrealistic expectations, taking things personally, all-or-nothing thinking, exaggerating, rigid thinking.
• Stressful personality traits: Type A, perfectionist, workaholic, pleaser.

It is important to note that most of the stress that most of us have is actually self-generated. This is a paradox because so many people think of external stressors when they are upset (it is the weather, the boss, the children, the spouse, the stock market). Recognizing that we create most of our own upsets, however, is an important first step to dealing with them.

What Are Some Ways to Master Stress?

[Editor's Note: This material has been taken from an article at "CyberPschologist." It's content has not been altered, but has been slightly rearranged for readability on this forum. The entire article can be viewed at: http://www.cyberpsych.com/stress.html]

Try all these methods and see which works better for you. Some people do better with muscular methods, others with visualization. All these can be learned quite readily and often work very well.

2. Learn how to not turn it on inadvertently in the first place.

In the long run, however, it is better to learn how to avoid getting stressed out in the first place. So how do you do that? Well, the clue is in the visualization method. Thinking peaceful thoughts makes you feel relaxed. In imagining a peaceful place, you have also distracted yourself from whatever thoughts you were having before. This points out the basic premise of cognitive/behavioral psychology, that our feelings and behaviors are largely caused by our own thoughts. This is oversimplified, because there are many feedback loops that make the connection between thoughts, feelings and behaviors sort of like a chicken and egg problem. But the simple version of the cognitive theory is that peaceful thoughts cause relaxation and stressful thoughts cause stress.

In other words, the reason we get stressed out is not what is happening to us and not what happened in the past (at least not directly), but rather, how we are thinking about what is happening. Past experience does influence us strongly, but the medium of that influence is beliefs or thoughts. For example, if you were abused as a child, you might have developed the belief that you are worthless. It is this belief today that is making you feel depressed, not the fact of the abuse itself. This is a really neat, powerful idea because it means we can overcome the bad experiences of the past. It means we have power over ourselves, so we don't have to be victims of the past or of present circumstances!

The best way to manage stress is to learn to change anxiety to concern. Concern means you are motivated to take care of real problems in your life, but your danger alarm system is not erroneously activated. Changing your feelings is largely a matter of learning to identify and change the upsetting thoughts that are the immediate and proximate cause of upset emotions.