218
U N I T 2
Integrative Body Functions
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-
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
BOX 9-2
The Relaxation Response
■■
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.
Modified from Benson H. Systemic hypertension and the
relaxation response.
N Engl J Med
. 1977;296:1152.
