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Integrative Body Functions

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antipsychotic, and/or psychotropic agents are useful and may help the individual participate more fully in therapy. 80–82 In addition, exercise, participation in sports, and physical activity may be beneficial for per- sons with PTSD. 83 Treatment of Stress Disorders The treatment of stress should be directed toward help- ing people avoid coping behaviors that impose a risk to their health and providing them with alternative stress-reducing strategies. Purposeful priority setting and problem solving can be used by persons who are overwhelmed by the number of life stressors to which they have been exposed. Some popular evidence-based nonpharmacologic methods of stress reduction are pro- gressive muscle relaxation, guided imagery, music ther- apy, massage, and biofeedback. Progressive Muscle RelaxationTechniques Practices for evoking the relaxation response are numerous. They are found in virtually every culture and credited with producing a generalized decrease in SNS activity and musculoskeletal tension. According to Herbert Benson, a physician, who worked on develop- ing various relaxation strategies, four elements are inte- gral to the various strategies: a repetitive mental device, a passive attitude, decreased mental tonus, and a quiet environment. 84 Benson incorporated these elements into a non-cultural method that is commonly used for achieving relaxation (Box 9-2). Progressive relaxation, also developed by Benson, is another method of reliev- ing tension. This procedure, which has been modified by a number of therapists, consists of systematic con- traction and relaxation of major muscle groups. 85,86 This procedure involves deliberate contraction, followed by relaxation, of 16 isolated muscle groups. Individuals are instructed to focus all of their attention on their mus- cles, focusing first on the sensations of tension associ- ■■ Sit quietly in a comfortable position. ■■ Deeply relax all your muscles, beginning at your feet and progressing up to your face. ■■ Breathe through your nose. Become aware of your breathing. As you breathe out, say the word “one” silently to yourself. Continue for 20 minutes. When you have finished, sit quietly for several minutes, first with your eyes closed and then with them open. ■■ Do not worry about whether you are successful in achieving a deep level of relaxation. Maintain a positive attitude and permit the relaxation to occur at its own rate. Expect distracting thoughts, ignore them, and continue repeating “one” as you breathe out. BOX 9-2 The Relaxation Response

ated with the muscle contractions, and then focusing on the sensations of warmth, softening, and relaxation when the tension is released. The contraction is to be held for approximately 5 to 7 seconds, and the relax- ation is intended to last for approximately 30 seconds. The ultimate goal is to reduce or eliminate the tension in the body, both physical and mental. The relaxation response has been shown to be an effective tool for treating stress-related disease pro- cesses, particularly certain immunologic, cardiovascular, and neurodegenerative disorders. It has been suggested that common underlying molecular mechanisms may exist that represent a connection between the stress response, pathophysiology of the stress-related diseases, and physiologic changes associated with the relaxation response. 87 Several molecular pathways have been sug- gested including those involving cortisol, norepineph- rine/epinephrine, and nitric oxide signaling. Guided Imagery Guided imagery is another technique that can be used to achieve relaxation. 88,89 It can be used to control pain and anxiety, as a sleep aid, and as a means of cop- ing with a stressful diagnosis or treatment regimens. It also can be used as a method for relieving anxiety in children. It has been reported that children are quick and eager to use imagery as means of relieving pain or relieving the anxiety associated with surgery. Guided imagery is a mind–body technique intended to relieve stress and promote a sense of peace and tran- quility during periods of stress or difficulty. 90 The indi- vidual is guided to focus on creating a specific mental image designed to bring about positive physical and/ or emotional effects. 91 Instructions are given to focus on the present; if possible, it is desirable to tune out all outside thoughts and ideas. Frequently instructions include going to a “special place” in their minds, such as a secluded beach or a babbling brook. Sometimes visualization is used, in which the person is asked to sit back, close their eyes, and concentrate on a scene narrated by the therapist. Whenever possible, all five senses are involved: the person attempts to see, feel, hear, smell, and taste aspects of the visual experience. Guided imagery may be practiced with a coach using a script, or it can be used independently, with or without a recorded message. MusicTherapy Music therapy is used for both its physiologic and psy- chological effects. It involves listening to selected pieces of music as a means of ameliorating anxiety or stress, reducing pain, decreasing feelings of loneliness and iso- lation, buffering noise, and facilitating expression of emotion. 92 Music is defined as having three components: rhythm, melody, and harmony. Rhythm is the order in the movement of the music. Rhythm is the most dynamic aspect of music, and particular pieces of music often are selected because they harmonize with body rhythms such as heart rhythm, respiratory rhythm, or gait. The melody is created by the musical pitch and the distance

Modified from Benson H. Systemic hypertension and the relaxation response. N Engl J Med . 1977;296:1152.