Coping with Stress
Stress is a fact of life for everyone. Some stress in our lives is probably a good thing and can help us to achieve more and be better motivated. For instance the stress that we are under before going to a job interview will often help us to prepare well for the interview and present ourselves in the best possible way. Different people will react to stress differently and what some people may find exceedingly stressful others may take in their stride. However excessive stress is not a good thing and can be disabling for people with schizophrenia.
Stress in itself is not a mental health diagnosis however it can make existing mental health problems worse. For people living with schizophrenia stress has a special significance because excessive stress is often a cause of a relapse of the psychotic symptoms and so they must be very careful to manage and monitor the stress in their lives. In addition many people with schizophrenia have observed that they are more sensitive to stress than they were before the onset of their illness.
Causes of Stress
Stress can be caused by a number of factors such as:
– changes in work or home life
– events which put you under pressure such as relationship difficulties.
– Changes in your life
– Things over which you don’t have very much control such as debt
However if you have suffered an episode of psychosis in schizophrenia you may well find that stress can arise from really trivial matters which don’t worry other people and which didn’t worry you before you became ill.
It is a good idea to keep a stress diary for about two weeks and to write down the times that you have felt stressed, what the cause was and how you coped with it. This will then help you to be bettered prepared for your own personal stressors in the future.You may find that you worry excessively about simple things like a trip to the shops and that you spend a lot of time imagining what might go wrong. Often your worries centre around other people so for instance you might worry about conflicts arising with other people on the bus or in the shops. Psychologists call this trait of being excessively apprehensive about things you have to do: “catastrophising”. At its worst this can be extremely disabling and lead to the person with schizophrenia becoming withdrawn and isolated.
This process of catastrophising can be made even more complicated if you still suffer from residual symptoms of paranoia or hallucinations like hearing voices.
If you are affected in this way it may well be worth speaking to your GP and asking about one of the anti anxiety drugs (called anxiolitics) available. Benzodiazepines such as Diazepam (Vallium) and Lorezapam (Ativan) are anxiolitics often prescribed in combination with antipsychotics in schizophrenia to try to reduce anxiety and agitation and to help with sleep. There is some but modest evidence as to their effectiveness and in any case they are addictive so have to be used with great caution.1 In the past doctors have been accused of over-prescribing these drugs and so are very careful with them nowadays.
There are other anxiolitics available such as Flupenthixol (Fluanxol) which is also an antipsychotic and Pregabelin which may be preferred by the doctors as they are not addictive.
Signs of Stress
When we feel stressed our bodies react by releasing hormones like adrenaline and cortisol which cause physical changes in addition to the mental ones that we notice. Some of the physical changes that you might notice are:
– Biting your nails (although not everyone does this)
– Changes in your weight (you may lose some weight or you may gain weight if you start to comfort eat)
– Lack of motivation
– Difficulty in concentrating
– Lack of libido (or sex drive)
– Loss of interest in social contact
– Loss of your sense of humour
– Dry mouth and grinding teeth.
– Loss of appetite for food
– Aches and pains in the shoulders and neck
These are all normal reactions to stress that anyone may experience and are not limited to people with schizophrenia.
Manage the Causes of Stress
Although there is little that we can do about irrational catastrophising there is quite a lot we can do to manage the causes of stress in our lives by making practical changes to our lifestyles. Stress management is not just about learning to live with stress it is also about learning how to avoid it in the first place.Organise Your Time
Make a daily list of the things you have to do, keep a diary, leave plenty of time for journeys to appointments etc. Poor time management is a major cause of stress for a lot of people. See our advice sheet on organising your time for more about this.Manage Your Finances Well
It is vital that you manage your money well as this is often a significant cause of stress for a lot of people and if you don’t manage it well you risk problems with housing and debt which may have implications for many years to come.
However much you have coming in, learn to spend within your means and avoid getting into debt. If you are already in debt then take steps now to get it under control by getting in touch with one of the debt advice services such as Citizens Advice or National Debtline. Both of these organisations are registered charities which give free and impartial advice on debt.
Learn to budget your money. The Money Advice Service has some useful guidance on this. It is a free and impartial service run by the government.
Make sure that you pay all of your household bills e.g. rent or mortgage, council tax and utilities on time and before you make any other payments so that you do not get into problems with housing later on. Try to set aside a regular time each week for managing your finances.Don’t Neglect “Me Time”
Try to set aside one day a week (say Sunday) for just chilling out. Do not make any arrangements on that day and avoid doing any housework. Keep the day for relaxing and doing things that you really enjoy. Explain to the people that you live with that you are doing this and ask them to help you by not putting you under any pressure to do things on that day.
Learn to be Assertive
Try not to become a “people pleaser” and take on board excessive responsibilities to help others out. Learning to say “no” in a polite way that doesn’t offend is a skill that has to be learnt but is not impossible. Try and achieve a balanced relationship with your family and friends so that they are helping you as much as you are helping them. If you try to do too much for them you will soon begin to resent being put upon and this may lead to conflict
Work on sleeping well. If you do not sleep well, perhaps having little or broken sleep, then you will feel stressed the next day. Most people with schizophrenia have some sort of sleep problems. This shouldn’t be a surprise since about a quarter of the general population also have problems of some sort with their sleep. Our information sheet on Sleep Problems gives some useful information about coping with sleep problems. Try to achieve a regular habit of around eight hours sleep each night and try to sleep during the night and keep the daytime for being active. If you are having problems with sleep then don’t suffer in silence, discuss it with your GP or community psychiatric nurse (CPN).Low Level Stressors
We can also feel stressed if we are not keeping up to date with the minor things in our lives that sometimes seem trivial but which can have a cumulative stressful effect if we neglect them such as laundry and housework etc. Don’t underestimate the insidious effect that these low level stressors can have. Keep up to date with housework and make sure that you attend to your post every day. Try to set aside a regular time each week for housework.
Coping with the Effects of Stress
Even when we have done our best to remove sources of stress in our lives we will still be left with things that cause us anxiety and for people with schizophrenia the anxiety caused by stress can be very intense indeed. It is very difficult to describe the abject terror that a person with schizophrenia may experience when facing the prospect of an interview at the Jobcentre or a date with a new partner. For many people with schizophrenia anxiety of these sorts of levels is sadly a fact of life. However stress is not something that you have to endure needlessly. There are a number of techniques that can help you to cope better.
A regular session with a good counsellor can help you deal with problems caused by relationships or friends. It can also help you make sense of the ordinary things happening in your life which cause you stress and help you to cope better although it can never remove the causes of stress in your life. In some areas GPs can refer you to local organisations that provide counselling services or failing that you can access counselling privately. Private rates for counselling tend to be around £30 to £50 for an hour’s session depending on the area. Try to find a counsellor who comes well recommended and who is accredited with the British Association for Counselling and Psychotherapy. If you have difficulty affording a counsellor you could try applying for a Personal Health Budget through your local authority adult social care service or applying for a Personal Independence Payment.Relaxation
Relaxation techniques can help you to cope with stress and improve your frame of mind so that the stress does not lead you into a vicious circle of high anxiety leading to poor performance and poor sleep patterns.
There are some good relaxation techniques on the NHS Choices website. You may also find that your local branch of Mind or Rethink run relaxation courses. Again if you think this would be helpful to you then speak to your GP who may know of local courses or try asking at your local library.Exercise
Getting more exercise will help to reduce stress, improve relaxation and sleep patterns and improve mood. It will also help to improve motivation and self esteem.2 How this works has been the subject of some debate amongst the researchers. Some have suggested that the benefit comes from changes in the brain’s chemistry brought about by increased exercise whilst others have proposed that the change is caused as much by psychological and social factors for instance better social contact involved with say joining a fitness class3. It is thought that all types of exercise such as running, swimming and gym work have a similar effect and the more exercise you get the greater the benefit4. However over-exercising has been found to have a negative effect as it may increase anxiety levels.
Mindfulness is a form of meditation practice whose theories have proliferated in recent years and practitioners have advocated its efficacy for a wide range of mental health problems. It is now widely available in most areas of the UK although not usually on the NHS.
Following some early studies of people with psychosis who experienced mindfulness therapy, many psychiatrists concluded that mindfulness was at best ineffective and at worst positively harmful for people with psychosis. However more recent work outlined by Paul Chadwick in the British Journal of Psychiatry and with colleagues in a subsequent publication5has suggested that mindfulness can be therapeutic in helping people with psychosis. Some work has found that not only is mindfulness effective at helping people cope with stress but that it can also help people with schizophrenia cope with hallucinations like hearing voices and paranoid delusions.
It should be noted that mindfulness will not reduce the amount of stress but will simply change the way the person reacts to it and thus make it less disabling. Bear in mind that existing research data is not large and most studies are based on small numbers of participants but clearly this is a promising area and one in which more research is needed.6 It should also be noted that some research has found that mindfulness therapy in people prone to paranoia may promote false memory experiences and clearly if this is a problem the therapy should not be continued.
Avoid Drugs and Alcohol
Street drugs and alcohol will provide only a very temporary feeling of wellbeing and in the long term may make your stress worse by exacerbating your schizophrenia symptoms and increasing problems like debt. In addition they will distract you from the important task of dealing with the issues in your life that are causing the stress.
Talk to Someone
Stressful events can become much easier to cope with if you have someone close to you who you can discuss them with. This may present problems for many people with schizophrenia who are socially isolated or who may feel embarrassed talking about their problems. This is where the value of a really good support network is seen. In the long term try to gather around you a circle of friends who you can talk to in confidence when you are having difficulties with stress.
If you are not working at the moment then activities like voluntary work or studying can help to occupy you and distract you from stressful thinking. Many people find this useful and preferable to being at home all the time where they may simply dwell on their problems. In addition physical activities such as gardening or conservation work in the open air will help you to relax and improve your sleep pattern. The Conservation Volunteers charity run a scheme called the Green Gym. which aims to get people with long term health conditions out into the countryside and working on conservation projects. Read our advice sheet on Volunteering for further guidance.
If you are working and work is a source of your stress then think about discussing it with your GP, your line manager or with the occupational health service provided by your employer. It may be that some time off work is needed perhaps with a phased return. In the longer term you could ask your employer to make adjustments to your working arrangements to better accommodate your vulnerability to stress perhaps by arranging flexible hours or part time working. If you are in a trade union then you should contact your union representative to discuss the issue with them. If you are not in a trade union then this might be a good time to think about joining one.
If you are under stress and you start to recognise a return of your psychotic symptoms, for instance you may start to hear voices again or you may start to have paranoid thoughts about people close to you, it is vital that you react quickly to prevent a relapse of your schizophrenia. Try to remove yourself from the source of the stress as quickly as possible and get in touch with your GP or CPN. If you have an emergency plan worked out with your doctor beforehand then now is the time to activate it.
1. Fuller Torrey E, 2013, Surviving Schizophrenia, Harper Perennial. P195
2. Burton N, 2012, Living with Schizophrenia, Acheron Press, p90
3. Harvey S, Hotopf M, Overland S, Mykletun A, 2010, Physical Activity and Common Mental Disorders, published in the British Journal of Psychiatry.
4. Leith L, 1994, Foundations of Exercise and Mental Health, Fitness Information Technology Inc, p35.
5. Lopez-Navarro E, Del Canto C, Belber M, Mayol A, Fernnadez-Alonzo O, Luis J, Munar E, Chadwick P, 2015, Mindfulness improves psychological quality of life in community-based patients with severe mental health problems: A pilot randomized clinical trial. Schizophrenia Research October 2015
6. Chadwick Paul, 2014, Mindfulness for Psychosis, British Journal of Psychiatry.
7. Unless otherwise referenced the content of this advice sheet is based on the author’s personal experiences.
Copyright © December 2015 LWS (UK) CIC.