Introduction

A young girl talked to her mother about life and how things were so hard for her. She did not know how she was going to make it past her struggles and it seemed to her that when she solved one problem, another was quick to arise.

Her mother took her to the kitchen where she filled three pots with water. In the first, she placed a carrot, in the second she placed an egg, and in the last she placed ground coffee beans. She let them boil without saying a word. Twenty minutes later, she turned off the stove, fished the carrot and egg out and ladled the coffee into a bowl. Turning to her daughter, she asked, “Tell me what you see?”

“Carrots, eggs, and coffee,” she replied. The mother brought her daughter closer and asked her to feel the carrot. She did and noted that they were soft. She then asked her to take the egg and break it. After pulling off the shell, she observed a hard-boiled egg. Finally, she asked her to sip the what had become coffee. The daughter then asked, “What’s the point?”

Her mother explained that each of these objects had faced the same adversity but each reacted differently.

The carrot represents someone who is strong and confident when they first face difficulties, but they become weak and lose their strength when they are subjected to prolonged stress or adversity. The egg represents someone who is fragile and vulnerable at first, but when faced with adversity, they become tough and strong. The coffee beans, on the other hand, represent someone who is able to transform the adversity they face into something positive. Instead of being weakened or hardened by the boiling water, the coffee beans change the water and create something new and better.

“Which are you?” she asked the daughter. “When adversity knocks on your door, how do you respond? Are you a carrot, an egg, or a coffee bean?”

April is stress awareness month and during this month, it is important to learn how to cope with stressful situations and find healthy ways to deal with them. We do hope that this newsletter comes into use when managing your own stressful situations!

Happy Reading Everyone!

Determining the psychological impact of the recent tragedies in Lebanon is extremely complex but results from a study by Salameh et al. (2020) concluded that the combined presence of pandemic-related fears and financial hardship increased stress and anxiety above and beyond the impact of each hardship separately (Salameh et al., 2020).

In another study during that time, sixty percent of those experiencing self-isolation reported that their mental health deteriorated since lockdown measures were enforced in Lebanon (Grey et al., 2020).

In 2020, The Lebanese Non-Governmental Organization EMBRACE, collected data from 903 individuals after the Beirut blast. The data showed that 83% of people reported feeling sad almost every day and losing pleasure in things they used to like.

Following the blast as well, data collected by the World Bank from 3400 individuals showed that the participants identified mental health services as the most pressing need and a nationally representative sample of Lebanese young persons showed that 11.5% had suicidal ideation (Baroud et al., 2020).

In 2019, about one-third of the global population reported feeling stressed, worried or angry (Gallup).

The World Health Organization (WHO) also estimates that approximately 3.6% of people worldwide are suffering from Post Traumatic Stress Disorder (PTSD).

Suicide is the fourth leading cause of death among 15 to 19-year-olds and every year 703,000 people take their own life. However, there are many more people who attempt suicide with 77% of suicides occurring in low- and middle-income countries.

77% to

Suicide is preventable, so if you think someone is struggling, please start the conversation with them.

Many body processes are disrupted by stress, which weakens the immune system and increases susceptibility to illnesses and premature death.

Stress leads to high cortisol levels in the blood which disrupts sleep patterns. In turn, sleep deprivation due to stress can lead to an impaired memory and emotional control making it more difficult to handle additional stress during the day.

Have you ever resorted to eating sweets when stressed? If yes, it is because your stress hormones stimulate the preference for these types of foods for a quick sugar rush. This undoubtedly leads to weight gain but research has shown that the link between stress and weight gain is far more complex than just poor food choices: In a 2022 study from the Biological Psychiatry Journal, women who had one or more stressful events during the previous 24-hours burned 104 less calories in the seven hours following a fast-food meal than women who ate a similar meal but were stress free.

The National Institute of Mental Health indicates that about 25% of people who experience stressful conditions develop depression. Huda Akil, a professor of Neuroscience at the University of Michigan, states that stress throws several brain neurotransmitter systems such as serotonin, dopamine, and norepinephrine out of balance, which negatively impacts mood, appetite, and sleep. Also, people who are permanently stressed have permanently high levels of cortisol which result in brain damage.

Many body processes are disrupted by stress, which weakens the immune system and increases susceptibility to illnesses and premature death.

During chronic stress, noradrenaline secretion causes capillaries in the stomach lining to constrict, resulting in dysfunctional mucosal production and loss of the stomach’s protective mucous barrier. Without this protective barrier, hydrochloric acid breaks down the stomach's mucosa and reaches blood vessels, causing bleeding ulcers.

Stress also stimulates the release of oxytocin and vasopressin from the hypothalamus, constituting a risk factor for irritable bowel syndrome, indigestion, heartburn, Ulcerative Colitis, and Crohn’s Disease. Lastly, by affecting motility, stress delays stomach emptying which causes nausea as well.

Stress induces a fight or flight response: it triggers the secretion of adrenaline, noradrenaline and cortisol which not only increase the heart rate and the heart force but also dilate the blood vessels that direct the blood to the heart, resulting in increased blood pressure. In other words, chronic stress increases the risk of hypertension, heart attack and stroke.

Studies have shown that stress promotes the progression of Alzheimer's Disease by accelerating the production of amyloid-beta and the deposition of amyloid plaques in nerves.

Cultures around the world have been using medicinal plants for millennia to manage their stress and anxiety. Therefore, you may want to try some herbs to relax a stressful mind and get a better night’s sleep! Find below some of the plants or supplements that help relieve the symptoms of stress.

Lavender

Lavender is calming to look at and smell, so it is no surprise that it is used in many stress relief products.

It contains an alcohol called linalool, which gives it its anti-depressant, muscle relaxing, mood lifting and antioxidant properties.

Melatonin is a hormone produced naturally by the body’s pineal gland, which controls sleeping patterns. When dark outside, the body produces more melatonin and helps an individual fall asleep.

Melatonin is available as an over-the-counter supplement in the form of oral and sublingual pills and studies have shown that it can be effective in managing sleep problems. Research has also demonstrated that melatonin can effectively reduce anxiety before surgical or medical procedures. It is not clear however if it can help with other forms of anxiety, such as generalized anxiety disorder, social anxiety and panic attacks.

Lemon balm, or Melissa officinalis, is a herb from the mint family. It contains chemicals that seem to have a sedative and calming effect and is believed to soothe symptoms of stress, boost the mood and reduce symptoms of anxiety, such as nervousness and excitability.

Combining lemon balm with valerian may help relieve restlessness and sleep disorders such as insomnia.

Referred to as "nature's Valium" this herb is commonly used in sleep aid supplements because of its calming effects. It has been used since the Middle Ages to treat sleep disorders such as insomnia as it can help relax and reduces anxiety.

Research suggests its activity is related to the independent and synergistic actions of its compounds: valepotriates, monoterpenes, sesquiterpenes, lignans, flavonoids and low levels of gamma-aminobutyric acid (GABA).

GABA is a chemical messenger that helps regulate nerve impulses in the nervous system.

It is one of the main neurotransmitters responsible for sleep regulation and increased levels of GABA in the body leads to sedative effects. Valerenic acid and valerenol, two compounds in Valerian, can modulate GABA receptors and increase the amount of GABA in the central nervous system. Research also shows that Valerenic acid inhibits an enzyme that destroys GABA.

Compounds in valerian may also interact with receptors for serotonin and adenosine, chemicals that also play important roles in the regulation of sleep and mood.

This flower is known for helping with anxiety and is excellent to have close by when you sleep. It can be taken as tea or purchased as an organic oil.

L-theanine

These bright flowers can help reduce symptoms of worry and stress, and when taken as tea, can help relax the body and increase metabolism.

Peppermint is known to boost alertness and reduce anxiety and fatigue. It contains a compound called menthol, which is often used for relaxing muscles in bath products.

Often taken before bed as a tea, Chamomile has long been known to help with sleep and anxiety. It can also help with inflammation.

L-theanineisanamino acidfoundingreentea. Studiessuggestitmaybe helpful for reducing stress and improving focus, memory and verbalability.

Areviewofninestudies published in November 2019inthePlantFoods for Human Nutrition Journal found that getting200to400mgof L-theanine a day may help reduce stress and anxietyinthoseexposed tostressfulconditions.

So,makesuretobrew yourself a cup of tea: green,black,white,and oolong all contain Ltheanine.

People have used Passiflora incarnata since the 16th century for medicinal purposes, and some researchers believe that passionflower supplements may help treat anxiety, insomnia, and certain forms of pain by increasing levels of GABA. Truly, in one clinical trial, P. incarnata demonstrated results similar to antianxiety medications in mice. Another trial demonstrated that it worked as a natural anti-anxiety medication for patients about to have dental work done.

You can find dried passionflower at many health food stores and can add them to boiling water to create a herbal tea. It is also available as liquid extracts, capsules and tablets.

Magnesium is a mineral that the body uses to regulate dozens of processes, from the functioning of nerves and muscles to the synthesis of protein and bone.

Research shows that magnesium plays an important role in regulating neurotransmitters, which are messengers that send signals throughout the brain and body. In that way, magnesium plays a vital role in neurological health and in regulating anxiety and other mood and panic disorders, It believed to affect a part of the brain called the hypothalamus, which helps regulate the pituitary and adrenal glands, which are themselves responsible for triggering stress responses.

As a supplement, studies show that magnesium produces anti-anxiety effects at dosages of 75 to 360 mg a day.

Yoga is a practice of breathing, mindfulness, spirituality, body, and the connection among these factors. Through its three main components, postures, breathing, and meditation, it appears to be safe and to improve multiple parameters of health and quality of life.

Tai chi is a form of mind-body exercise that originated in China. It involves martial arts, meditation, and dance-like movements that focus on the mind and body connection.

Helps make the body stronger and healthier, undoubtedly improving an individual's mental health as well.

Many cultures around the world integrate meditation into their religious and spiritual disciplines. Transcendental meditation and qigong meditation, which are types of spiritual meditation, have been tested for their effect on stress.

Spirituality and religion can supply a robust and flexible framework for understanding the world and the self, which may foster increased tolerance to uncertainty, enhanced coping, resourcefulness, and optimism. Religions can also offer a community of support, which reduces social isolation.

Centering prayer is a contemporary approach developed in 1974 in which special attention is given to posture, breath, and the space that one occupies. Like mindfulness meditation, the goal of centering prayer is not to empty the mind, but rather to exercise a willingness to let thoughts come and go, while using a sacred word as a refocusing tool.

It is defined as "paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally". Basic elements of mindfulness include self-regulation of attention and taking a non-judgmental stance towards one’s experience. This practice has existed for over 2500 years and it has been, along with its clinical variants such as mindfulnessbased cognitive therapy, used in the treatment of multiple psychiatric disorders.

1st Line: SSRIs- SNRIs

Less sedation and cognitive side effects

Less risk of dependence

SSRI side effects: insomnia, agitation, QT prolongation, gastrointestinal (GI) toxicity, weight gain (except with fluoxetine), orthostatic hypotension and sexual dysfunction

SNRI Side effects: insomnia, agitation, GI toxicity and sexual dysfunction

2nd Line: TCAs, Benzodiazepines, Buspirone, Pregabalin

Prominent side effects and dependence

Limited data regarding use as 1st line

1st Line: Cognitive Behavioral Therapy (CBT)

2nd Line: SSRI, SNRI +/- CBT

3rd Line: 2nd generation antipsychotics, α-adrenergic blockers, benzodiazepines

SSRIs: Fluoxetine, Citalopram and Escitalopram

SNRIs: Venlafaxine extended release.

BDZs:

Long-acting: Clonazepam, Diazepam

Short-acting: Alprazolam, Lorazepam

TCAs: Imipramine, Clomipramine

MAOIs: Phenelzine

Mirtazapine

In individuals who are treated with psychotherapy, the first choice of treatment is cognitive-behavioral therapy (CBT), which uses reasoning exercises or real experiences to facilitate symptom reduction and improve functioning. It generally appears to have comparable effectiveness in stress across gender and socioeconomic status.

CBT uses several techniques that address different aspects of stress and an individual’s response to it, but it is unclear which components are critical for effectiveness. Trials have suggested that some components such as relaxation training and cognitive restructuring may be effective as stand-alone treatments for stress.

CBT is generally provided in 10 to 15-hour-long sessions but can include additional sessions depending on the severity of symptoms, the presence of comorbidities, patient resistance to the approach, therapist competence, and the number of components incorporated into it.

Once the course of CBT has been successfully completed, patients are usually encouraged to monitor their symptoms on a weekly basis and use CBT skills as a form of relapse prevention.

CBT's format often follows a manual that is used as a guide for patient education. The sessions are typically carried out on a weekly or biweekly basis and homework assignments are also assigned.

Other methods of administering CBT have been developed for specific circumstances. For example, group sessions can be helpful for older adults in order to encourage socialization and offer the opportunity for self-disclosure. Modifications are also made for individuals unable to access traditional sessions.

An in-depth, structured interview is the first step in establishing the diagnostic features and details of associated behaviors. Standardized questionnaires can be used to collect data on the domains of worry as well as physical symptoms associated with stress. Such information is particularly helpful for tailoring treatment to the patient.

CBT treatment sessions are typically accompanied by daily homework to be conducted between sessions. Thus, therapy time for the patient is more extensive than the time spent in-session with the therapist.

Treatment typically begins with patient education which includes:

Correcting misconceptions regarding stress, worry and associated symptoms. Identifying causative factors of pathological stress and anxiety. Generating a treatment plan and explaining its rationale to the patient.

Self-monitoring is introduced in the first treatment session and should be maintained throughout the entire treatment. Patients keep track of significant episodes of worry on a Worry Record to be completed as soon as possible during or after each worry episode. The record provides a description of the cues, level of distress, associated symptoms, thoughts and behaviors that the patient may have experienced. Patients also complete a daily mood record to keep track of the overall levels of anxiety.

Learning to observe their reactions from an objective standpoint can help patients better understand their behavior, improve their self-observation skills and chart their progress in therapy.

Relaxation training consists of progressive muscle relaxation of all muscle groups of the body in a systematic manner. Breathing exercises, such as slow, diaphragmatic breathing, may be incorporated into the relaxation training.

Cognitive restructuring involves identifying and modifying inaccurate appraisals that contribute to stress.

Exposure techniques are intended to help patients cope with real-life situations with less avoidant behavior.

Imagery exposure is designed to help patients tolerate the autonomic arousal associated with fearful images that they often attempt to avoid through worry and stress.

Exposure to stress-provoking situations involves repeated exposure to situations that are avoided or engaged in with excessive preparation or checking.

The central focus of CBT is teaching patients a set of cognitive and somatic coping skills to effectively manage their stress as they are repeatedly exposed to stress provoking images and activities.

Problem Solving can help patients combat combat indecisiveness and increase the ability to generate alternative solutions to problems.

Time Management Training and Goal Setting can help facilitate present task accomplishment instead of allowing stress to dominate.

Intermittent Motivational Interviewing has resulted in subjective improvements in stress symptoms in multiple trials.

A final step in CBT is relapse prevention, in which patients are informed that recurrences of stress, anxiety, or avoidance behavior are likely to occur in the future. They are encouraged to view such recurrences as lapses rather than failure, and to reapply their coping skills and reinstitute their practice of exposure to images of negative outcomes and stress-provoking situations.

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