Nadia Haddad, MD, MS on a Practical, Holistic Approach to Stress & Wellness in a High Pressure World

Thanks to everyone
for coming, as well. So I wanted to talk a little
bit about the introductions here to get us started. First and foremost,
like Nora said, I’m a psychiatrist
here at Stanford. I also work at the
Stanford Center for Integrative
Medicine, which is here on the second floor
of Hoover Pavilion. And my interest
and my training has been in both sort of modern
medical science, with my MD, and then also a master’s of
science in Chinese medicine. And so my interest– I studied
and I practice acupuncture here as, well as serve a
more holistic approach. And what I really
am interested in is the intersection
of those two things. So what I hope you’ll get out
of today is both the research side of what it
means to be stressed and what that does
to us, but also, I want to take a slightly
different tack on this as well, and talk a bit about
what we can learn from our own internal
experience of stress, and what our body is
trying to tell us. So I’m going to try to balance
those two things here today. Stress. We all know it when
we feel it, right? So when someone says
to us, I feel stressed, I don’t think there’s a person
in this room that would say, I don’t know what that is. Right? But what is it exactly? It’s physiological and
psychological pressure that disturbs the
body’s equilibrium. And we’re going to talk a little
bit more about equilibrium in just a moment
and what that means. But I want to point
out here that it really is an important adaptive
response in the short term. So what that means is that
stress is there for a reason. It helps us to adapt
to our circumstances. I’m sure some of you remember
your high school biology class, where they talked about
fight-or-flight response. And so, that’s part of
what stress helps us do, is get prepared. If something, you know,
terrible is happening, we can do something about it. And we actually know that
learning can be enhanced by optimal levels of stress. So let’s talk a little bit
about this equilibrium piece. So many processes in our
body have a set point, where the body
operates optimally. There are core processes. So these are things like
temperature, pH, oxygen, carbon dioxide, but also more
complex processes, so things like our sleep
duration, the timing of our sleep cycles, the
amount and the types of food that we’re eating, the
amount and the type of physical activity
that we’re doing. And really, the quality and
amount of social interactions also has a set point for
each of us individually. But many of us know that
one of the hallmarks of the high-pressure
work environment is really the
glorification of stress. So this isn’t
just, you know, I’m stressed in this
particular moment when something scary is happening. Right? Someone hits me with their car,
or a very stressful situation is happening right now
in the finite moment. We have a work environment
where we expect stress. And, in fact, it’s sort
of a badge of honor. Right? We like to tell each other how
little sleep we can subsist on. Right? Oh, I only really need five
hours of sleep at night. I don’t really need
more than that. Or how many 16-hour
days in a row we can do. Or how many
all-nighters we can do. Or how many
multitasking projects we can do with our kids
and our full-time jobs and all of these things. And really, what
this comes down to is that we’ve started
to develop a mentality that if I’m not stressed,
I’m actually not working hard enough. So I have this sort
of set point that’s like, I need this optimal
level of adrenaline going at any particular
moment in time. And really, the outcome
of this is what I’m going to call the work bleed. And so this is incomplete
separation between work and our social or
our relaxation times. So as you can see, it just
sort of kind of bleeds in. We’re always kind of working. We’ve always got her phone on. We’re always on call. And if we really
think about this, we’re working more because we
want to be more productive. We think that that’s
what’s expected. But all this excess work
actually makes us tired. Right? And we’re also over-stimulated,
because we’re working too much. So that makes our
mind overactive. And we’re all
psychologically amped up, because that’s what
happens with stress. And we have poor sleep
and anxiety as a result. And then we become
emotionally sensitive and have difficult
social interactions. And all of this combines
to make our concentration poor, our focus and our
motivation impaired. At the end of the day, when
stress goes on too long, our work performance
actually goes down. So then what many
people end up doing is they end up
compensating for it. Which makes sense, right? I’m stressed out. I am tired. I am not sleeping well. But I need to go on
about my life, right? So what am I going to do? I’m going to drink
another cup of coffee. Right? Or for many people, it’s energy
drinks that they find useful. So we’re trying to combat the
sleep deprivation or sleep cycle disruption
that’s happening. We’ll drink a couple glasses of
wine when we go to bed, right? Or in the hours
before we go to bed. Or we’ll use Xanax or
Ativan or Klonopin, which are these benzodiazepines
that can help us calm down in the moment. Or sleep medications. We feel like we need
Ambien every night. For many people, marijuana
serves this purpose. So they feel like they can
slow down a little bit, be in the moment. It’s like a meditative
experience for many people and helps them sort of
reconnect with their creativity. Or stimulants, and
I mean specifically when they’re not
prescribed for ADHD, but when they’re prescribed
for productivity and focus. People are like, well,
I need to concentrate. I need to get to work. So we’re sort of playing
around with this, trying to get more a
handle on the stress. But at the day,
what does it matter? Right? Because stress is
just in our heads. Well, what we tell ourselves
is, if I were tough enough, I wouldn’t get so stressed. So just be tougher. Or we say, pushing through
is a sign of strength. Or stress is just
a sensation, right? So the best approach is
just to block it out, just like I might block out
sleepiness, fatigue, anxiety, boredom, irritation,
these other feelings that don’t really feel like
they’re serving me right now. They just feel bad, and I don’t
know what to do with them. And I think this all
comes from something that I think is really prevalent
in this high-pressure world mentality, which is
the control mentality. And it’s this idea that
I am the boss of my body. OK? I can and I should
be able to make my mind and body do what I want
them to when I want them to. And substances, like
all the substances we just talked and talked
about, and willpower are my tools to control my body. But I hope that by the
end of the talk today to convince you that
actually ignoring stress is not the same thing
as not being stressed. So let’s take a look
at that research. Let’s take a look at
what’s actually happening. So we said in the short term,
stress is very adaptive. It works well for us. But in the long term, when
we have chronic stress, we actually have
a lot of research that shows that this actually
does affect our bodies. We have a decreased
immune response, an increase in the
inflammation in our bodies. We have an increase in
cardiovascular diseases. So these are like
high blood pressure, strokes, heart attacks. Psychiatric symptoms
naturally follow, so things like anxiety,
insomnia, depression. Endocrine system problems. So for women, this can be things
like menstrual irregularities, fertility issues,
and also weight gain. And then digestive dysfunction. So stress can actually change
the microflora in your gut. So those are the good
bacteria that are in your gut, helping you digest food and take
the nutrients from the food. And the balance
of those bacteria can change in chronic
stress environments. And then, actually cancer can be
associated with chronic stress over the long term. So what do we do
about it, right? Because our world
is high pressure. And most of us are not
going to leave our jobs. So we have a couple of choices. We can just continue to ignore
the stress, as many of us do. We can complain
about the stress, which maybe is a
little more adaptive but doesn’t get us very far. Or we can try to manage
and reduce the stress. So how do we go about that? So let’s talk about the basics. So throughout this
talk, I’m going to be referring
back to this idea that we are actually
rhythmic beings. And this flies in the face
of our control mentality. I should be able
to do what I want to do when I want to do it. But actually, our body
has its own rhythm. We have a physiologic rhythm. So this idea of homeostasis,
back to high school biology again. Right? That’s our innate ability
to maintain balance in the critical
systems in our body. So that’s, again, that oxygen,
the body temperature, the pH, and all of those things. But this is actually
an active process. And it coordinates multiple
systems in our body. And what we know is that
all body systems that regulate homeostasis show a
rhythmicity through the course of a 24-hour period of time. So just because we want to do
something at a certain time doesn’t mean that our body
wants to do it at that time. So how do we support
our natural rhythmicity, because that is the
key to reducing stress. Our stress is pushing against
our body’s natural rhythms. And to reduce it, we
have to get more in sync with our body’s natural rhythms. So we actually do this through
sort of the basic things we do every day. Right? So this is sleeping,
eating, physical activity, regular downtime, and
social interactions, and other external cues that
help us maintain and develop this rhythmicity. So how do we live in rhythm? We actually have an
internal compass. This is things like sensation,
so when we feel hot, we feel cold, hunger,
thirst, fatigue, and so on. We also have emotions that are
part of our internal compass. We’re in love. We’re happy. We’re sad. We’re angry. We’re bored. And also intuition and
gut feelings help us. So these are things like,
that guy feels like trouble. I’m not sure what it’s
about, but I’m feeling it. So part of this is
about developing an awareness of this
internal compass and learning how to
interpret the messages. I think a lot of
us get to a place where the sensations, the
emotions, the intuitions are telling us things that
we don’t really want to hear, that aren’t really
helpful to us. And so what we do is
we push them down, and we learned over
time to push them down before we even listen to
what they have to say. And so what we’ll talk
about throughout this is I’m not suggesting
that as soon as you have an
intuition or a feeling or a sensations that that’s
something you act on. I’m suggesting finding a
middle ground where you’re able to listen to what
your body has to say, and then you’re able
to make a choice, instead of automatically
shutting it down and saying, no, I’m going to do
what I want to do. So let’s talk about
this internal rhythm. So internal rhythm, your
sleep, food, physical activity, and downtime. So circadian rhythm. This is the idea–
I start by asking, when patients come
into clinic, and we’re trying to get a feel for what’s
happening with their sleep, I will often ask them,
if you were on a vacation and you had no set obligations,
when would you go to bed? When you wake up? This is actually a clue
to your circadian rhythm. Are you something
called an owl, which is someone whose body naturally
does better staying up late and naturally needs
to sleep in a little later? Or are you a lark, which is
someone who naturally gets really tired 8:30,
9:00 o’clock at night and wakes up naturally at
5:00 o’clock in the morning? For those of you who are unclear
about what your natural rhythm is, sometimes it’s
helpful to take this morningness-eveningness
questionnaire. And we can talk more
about this later. But it can help you
figure out, you know, when is my natural sleep cycle? When should I be sleeping? And what I want
to point out here is that most of our
society is actually built around the schedule of larks. And as you may realize
from this conversation, not everybody is a lark. So owls struggle a
lot with something we call sleep cycle mismatch. And that’s when the timing
of your life obligations is actually mismatched
to your circadian rhythm. So an owl having to go to
work at 6:00 AM or a lark working the graveyard shift. Right? Those are examples of
sleep cycle mismatch. And it doesn’t have
to be so dramatic. So sleep cycle
mismatch has actually been studied in both
performance and the development and progression of
cancer and obesity. So a couple of facts here. We know that women
working night shifts are at a higher risk
for breast cancer. We know that shift work
disrupts circadian rhythm. I’m sorry. Shift work that disrupts
circadian rhythm is actually a probable human
carcinogen, meaning it probably increases the risk
for the development of cancer. And we actually also
know– just kind of on a performance front,
because a lot of stress comes from feeling like we
need to perform better– that there’s actually
measurable loss of brain volume and impaired performance
in visuospatial tasks and poor reaction times that
happened just with sleep cycle mismatch. So I’m not talking about
sleep deprivation, which we’re going to get
to in a moment, so having less sleep than
what your body wants. I’m just talking about sleeping
at the wrong time for when your body wants to sleep. So let’s talk about
sleep deprivation. So that’s the idea
of sleeping less than is optimal for your body. And studies show
that most adults require at least seven hours
of sleep per night, even people who say and think that
they are final on less. Many of our bodies’
homeostatic systems are affected by
sleep deprivation, and is actually associated
with both emotional reactivity and impairments
in your cognition. So let’s take a look
a little bit closer. What happens when we do
sleep less than seven hours per night? You actually have an increased
risk, again, of obesity. OK. Also diabetes, high
blood pressure, heart disease, and stroke. So there actually are measurable
medical phenomena that come out of sleep deprivation over time. There’s overactivation that
fight-or-flight response we talked about earlier. And we have an
increased appetite. That’s where the
overweight comes in. We can have more stress. And we also have an increase
in all-cause mortality. And what that means is
dying from any cause is increased if you’re regularly
sleeping less than seven hours per night. So what do we do with this? That’s pretty scary, right? And so we look at this
and say, well, there’s some things maybe I
can change, but there’s a lot of things I can’t change. So let’s first take a look
at the things I can change. So the first thing I
always want to ask myself– and I try to help
my patients ask– is are you making choices
that are consistently interfering with your sleep? So in other words, can
you shift your sleep cycle to be a closer match to
your circadian rhythm? So I often see, for instance,
graduate students in my work here at Stanford. And many of my graduate
students actually don’t have a set
time that they have to be at work or a set time
that they have to be a lab or whatever else. So what happens is they
just think in their minds, you know, when I’m
supposed to be getting up is 6:30 in the morning. I’m supposed to
be waking up them. I’m supposed to be
getting on with my day. And they don’t actually
know when the best time is for them to sleep or
the best duration of sleep for them. So if you can shift it, if
you’re in that position, then that’s something you
want to try to think about. Another thing is to maintain
a regular sleep and wake time throughout the week,
including the weekends, to reinforce the
circadian rhythm. In the same vein of
changing what you can, you want to avoid
the vicious cycle. And what I mean by that
is caffeine or stimulants in people who are
having sleep trouble is often counterproductive. So it makes sense. It’s that compensating mechanism
that we like to do, right? Where we like to
say, OK, I’m tired. I didn’t sleep
enough, so therefore let me have some caffeine. But we know that caffeine,
even early in the day, can actually disrupt
your sleep at night. Caffeine at 7:00 AM
was actually associated with less efficient sleep
by EEG and less total amount of sleep the following night. So the idea is, it does
stay around your system. So if you don’t have
sleep trouble, no problem. Right? Caffeine’s OK. But if you’re having
a lot of sleep issues, consistently over time, you want
to think about your caffeine intake and not just say,
well, I had my two or three cups of coffee before
noon, and therefore it must not be
affecting my sleep. So what I tell people who
are having sleep trouble is you want to try to avoid the
caffeine and the stimulants, if possible, or try to switch
to a more tolerable caffeine, like the one in tea. So tea, like green tea,
black tea, oolong tea, has less caffeine
than coffee per cup, and it also has other
constituents in it that are actually calming. So the overall effect is that
the effect of the caffeine isn’t so strong in your body. And this one’s a sad
one for many people, but actually alcohol
is asleep disruptor. So there’s no doubt that
alcohol helps you get to sleep. Right? So if you have a glass of wine
or two before you go to bed, you will have no trouble
getting to sleep. It may help you get to sleep. But what happens
is alcohol actually has a very short half-life. And so it stays in your
body not very long, and you start withdrawing. You have like a mini
withdrawal from the alcohol while you’re sleeping. And then what
happens is you will wake up and have more
interrupted sleep for the rest of the night. So again, if you don’t have
trouble sleeping, fine. But if you’re having
trouble sleeping, you want to be thinking about
your alcohol and your caffeine use. What do you do when you
can’t change things? Many of us are in
situations where there are many things
about our schedule we just can’t do anything about. So a couple things I like
to talk about with people. So I’m going to start
with the bottom two. The first is early
morning light. So we know that light actually
affects our circadian rhythm. And even though
it’s the last thing that owls want to do– people
who want to stay up late and wake up late– the
last thing they want to do is like throw the curtains
open early in the morning and have that bright
light in their face. But that’s actually
one of the best things you can do to try to
get yourself up and going. Turning off your screens. I think a lot of
you have heard that. Right? At least one hour
before bedtime. And no screens at
all in the bedroom. One of the questions I
got– I did this talk for a webinar for some
tech companies in the area last week. And one of the questions
I got was, well, what if I have this blue
screen filter on my computer. Can I take it to bed with me? And my answer was, I
think that’s cheating. Right? Because at the end of
the day, like, yes, the lightest part of it. Because we said light helps
set our circadian rhythm. And so early morning
light helps us. Light at night will
harm our sleep. But the other part of it is that
it’s also just being activated. Right? You’re just sitting there. You’re on CNN, or you’re doing
your work emails, or whatever it is that you’re doing. You know, you’re activated,
and that’s part of the problem. So regardless, take the
screens out of the bedroom. And then the final thing I have
in this slide is melatonin. Melatonin is this
safe supplement that you can use to try
to shift your sleep cycle. So if you’re someone
struggling with this, 3 to 5 milligrams an hour before
your preferred sleep time is something to try,
if you haven’t already. So what I recommend to people
is to try it consistently for at least a week, to see if
you can try to shift your sleep cycle a little bit. It’s not something
that’s going to help you right away that first
day you take it. And it’s not like an Ambien. It’s not like a
sleeping medication. So it’s not going to
knock you out right away and make you sleep
through the night. It’s really meant to help
signal your sleep cycle. Moving on from sleep. So I just wanted to put a
plug in here, a brief slide on eating. So there’s a couple
of basics here. Eat regularly. So this, back into
the rhythm idea. The rhythm of your energy
is your metabolism. The way you keep your metabolism
moving is by eating regularly. If you’re someone who
gets stuck not eating for long periods of
time during the day, you’re actually kind
of messing around with your ability to keep
your energy levels going. You want to eat a variety. So this is a variety
of the macronutrients. So you’ve heard of
carbohydrates and proteins and fats, but actually
also just a variety of micronutrients, a
variety of everything. So you want to change
up what vegetables you’re eating, what
fruits you’re eating, and so on and so forth. Another basic, avoid
processed food, if you can. And include foods with high
omega-3s, if you can, as well. So fish, flaxseed has
higher levels of omega-3. And we can talk more about
why omega-3s can be helpful at the end or some other point,
if that’s of interest to you. And a bonus I threw in here is
if you don’t already know how, and you have some
interest, if this is somewhere along
what you like to do, think about learning
how to cook. It’s not only good for just kind
of eating healthier than eating out all the time, but
it’s actually a great way to just sort of have a hobby
that really literally heeds you. Right? But it also just sort
of feeds creativity and can be a really
great thing to do. So there’s lots of videos on it. There’s lots of TV shows on it. And there’s actually
local places that offer cooking
classes, if that’s something of interest to you. Physical activity. OK. Your body and mind need
this, and a lot of it. The question here is
what do you enjoy? There’s no judgment. So is it that you like
synchronized swimming? Or is it that you
like ping pong? Or do like to take
strolls in the park? What is it that you
particularly like? Whatever the movement type is. The point is move around. OK. It doesn’t have to be, I’m
jogging on the treadmill. You want to move in ways your
body doesn’t normally move. OK. So often, when we go to the
gym and we jog, and then we lift our weights– so
it’s all of the same plane. Right? We’re all doing the
same sorts of things. So the idea here
is, as much as you can add different kinds of
movement into your daily life, this will keep you healthy
and reduce your stress over the long term. OK? So classes can be good for this. So if you have an interest, if
you have an interesting dance or yoga or martial arts,
this can be a great way to really introduce
new types of movement into your daily routine. The other thing I
wanted to point out is that these skill-based
workouts can actually engage your body and
mind simultaneously. Right? So it’s not just I’m
jogging– which is great. If you love jogging, do it. But it’s also, I’m
learning a skill. Right? If I’m doing martial arts
or I’m doing yoga or dance, I’m learning not just how to
move my body in a certain way, but I’m actually
also having to engage my mind in what’s happening. Space, otherwise
known as a downtime. So I went a Tibetan
medicine conference a couple of weeks ago here at Stanford. And I didn’t know much about
Tibetan medicine before I went, but there are some overlaps
between Tibetan medicine and Chinese medicine,
as you might imagine. And one of the overlaps is
that both Tibetan medicine and Chinese medicine, one of
the ways they conceptualize the world is this idea of
there being five elements. But in Tibetan medicine,
the five elements are earth, fire, water,
and air, our standard ones. But our fifth is actually space. And I thought this was
really interesting. So we have air, but
we also have space. So this idea of the lack
of something, right? The lack of something
is important. And this is true for
your life, as well. OK? So this is adding things into
your life that give you space. So fun. Having fun. And I’m not talking about,
I’m going on a backpacking adventure, 30 miles,
carrying my 80-pound pack, and doing all that. That’s great, if
you want to do that. But I’m talking about the
silly, mindless kind of fun. You really want to add
that back into your life, if you don’t have enough
of that right now. Meditation is also a
great way to add space. So this is clearing
your mind, learning to be present in the moment. There are some great ways
to involve meditation in your daily life. One is that we do have a
mindfulness course here at the Stanford Center
for Integrative Medicine, if you’re interested
and you like to do kind of hands-on
course with people in the room with you. There’s actually many apps
too, if you are on the internet and you have your phone. And it’s something that
you can do privately for 10 minutes a day. And really, it can
make a difference, 5 to 10 minutes a
day in your life. So let’s talk about
external rhythm now. So I included in this
category social you, and also I wanted to add
a little bonus in here for music and dance,
because there’s actually some interesting research on
music and its role in stress and regulating your emotions. And it’s an easy sort of
thing you can do yourself. So let’s start with
you as a social being. OK. This is inherently part
of us as human beings. And we know that
high levels of stress come from interpersonal
friction, right? Whether it’s a boss
or your coworkers or a spouse or a parent. And really developing
your internal compass– I’m coming back to
that again– is a key to your social interactions. So having a sense for who the
people are in your life that are feeding you, who the people
in your life who you really love and you think are
wonderful, but are causing you some stress, and
how to manage that, is something that you really
have to develop internally. If interpersonal
frictions are something that’s causing you stress, you
can consider psychotherapy. And I’m not talking about
long-term psychotherapy. I’m talking about sometimes
it can be eights sessions, six sessions, something like that. So sit down and try to
understand a little bit better what your own way of
interacting with people is, and how other people are
interacting with you. So it’s a way of developing new
ways of dealing with conflict. Another piece of this
is the amount of time you spend with others
actually varies by the person. So some of us like to be out and
about with people all the time. Some of us are introverts
and really need to be at home to recharge. And all of that
is good and fine. But what I would
suggest to you is that you seek out meaningful
connections with people. OK? So this is people you
can be yourself with. This is people who can roll
with your negative moods, so anger, sadness,
stress, those type of sort of uncomfortable
moods to be around, not just your positive moods. It’s important,
because how are you going to be tuning in to
your own internal compass if you’re surrounded
by people who can’t tolerate it if
you’re feeling sad or angry or stressed. Right? A couple more. You want to be around people who
like you and also with whom you feel good about yourself. Now, I know this one
sounds obvious again, but there’s a lot of times that
we find ourselves in situations where we like someone
else, but maybe we’re not getting a lot of feedback
that either they like us, or we just don’t feel
good around them. We like them, but we don’t
feel good around them. Right? So that’s information that we
need to be paying attention to. And my final plug
here is people you don’t need to be
intoxicated with to enjoy. OK? So I think many of us, at
some point in our lives, had friends like that, or
still do have friends like. Right? Moving on. Music and dance. So music. So we know that
listening to music actually has the ability to
alter our emotional state. It can alter our
brain waves, actually. And it causes
measurable alterations in neurotransmitters, our stress
hormones, and our endorphins, as well as blood pressure,
heart rate, respirations, and our immune function. So music, just
listening to music, can do all of this for us. But what the research
shows is that it’s dependent on
whether the music is pleasant or unpleasant for you. If it’s slow, if it’s
hypnotic, all of those things affect what your own
personal response is going to be to the music. And again, dance, so this idea
of syncing both mind and body– it syncs music,
and those effects it’s having on your mind,
and movement in your body. So music in stress
management, how do we use it? Your preference is
what’s important here, the types of music you like,
not what your spouse thinks you should like, not what
society thinks you should like. What you like. And remember that
music has the potential to both increase or
decrease your stress levels and can actually change
your emotional state. Right? So you want to make
sure that you’re choosing something that
actually reduces your stress and not adds to it. So this all brings us back again
to sort of fundamental concepts that we’re talking
about today, which is we need to learn to
get to know ourselves. This is the idea of
developing our self-awareness or intuition. And as I was saying
earlier, most of us learn to shut this off
entirely, because it’s really often telling us things we
really don’t want to hear. But I would put
forth to you that without your internal compass,
without your negative emotions I should say, your internal
compass is actually weak. You can’t have an internal
compass that only points you towards positive things, right? That’s not going to actually
be a helpful compass. So things we need to
ask ourselves are, when is stress OK? And when is it too much? So some things you
can ask yourself are, am I chronically using
substances to get by? Is my mental or physical
health suffering? What does my gut
tell me about this? And then specifically,
what sleep patterns, eating approaches,
and social activities are most compatible
for you, personally? So I hope that what I
did today is give you sort of a big picture
understanding of stress and why it’s important. But also I hope
some practical ideas of what you might be
able to do yourself to try to tweak certain things
that maybe aren’t working well for you right now. But all of us at some point
could use some guidance, so I wanted to give you some
tips about where you might seek some guidance if
stress is something that’s been a problem for you. So one is psychotherapy. I already mentioned it earlier. So this can be just a couple of
sessions, all the way up to 8, 12, 16 sessions, to long
term, if it’s something that you find useful to you. But really, the
important points here, if you’re thinking
about psychotherapy, is you really want to
look for a therapist that you can relate to and
that you can be honest with. If you don’t feel like you
can be honest with someone, then you’re not going to
have a useful psychotherapy experience. Many different styles
of psychotherapy exist. So this is cognitive behavioral
therapy, psychodynamic therapy. You’ve probably heard
these terms thrown around. At the end of the day,
if you know about them, and you have a particular style
you’re attracted to, great. But I want to point you back
to that first point, which is that at the end
of the day, what’s most important is your
connection with that person. OK? I wanted to talk a little
bit about acupuncture here because of my
background in acupuncture. And I also think it can
inform our conversation about rhythm and about stress. So acupuncture was
developed through the system of Chinese medicine. Right? And that’s a really healing
system about balance and proper flow and movement. That’s kind of
what it’s based on. We know that acupuncture,
when we look at the research, affects our neurotransmitters
and neuropeptides involved in stress, mood,
anxiety, and so forth, as well as our
perception of pain. We also know that it can
increase the beta-endorphins. That’s one of the mechanisms
by which it reduces pain. So beta-endorphins are
our natural opioids. You’ve heard of
morphine and heroin. Those are all hitting
the same receptors as our sort of
natural endorphins. It can decrease
inflammation, and it actually affects melatonin secretion
and circadian rhythms. It can improve sleep, reduce
anxiety, improve your mood, and actually increase quality
of life in certain populations. So just talking a little bit
about acupuncture here, what to expect if you’re
thinking about acupuncture and you’ve never done it before. What I tell people,
again, when I’m here at the Stanford Center
for Integrative Medicine, is I tell people that generally
a six- to eight-week treatment course for weekly treatments
is where we start. We know that there are
responders and non-responders to acupuncture. About 70% of people
are responders. About 30% of people
are non-responders. And that’s actually
across both human studies and across animal studies. So it’s about how much
you want it to work or how much I want it to
work or whatever else. It’s really just kind of
a function of your body. So what I tell people
is you come, we try it, and after three
to four sessions, if it feels like
you’re not really responding to it,
then maybe this isn’t the best modality for you. But really, by six
to eight treatments, usually most people
are plateauing. And if they’re going
to get a response, they’re getting a good response. It uses thin, single-use,
disposable needles. It’s not supposed to be painful. If it is painful, then that
needle should be removed. OK? But what you should experience,
or you could experience, are sensations. So this is heaviness,
tingling, numbness, feelings of sensations
moving about your body. These are all normal
sensations in acupuncture. We leave the needles
in for 20 to 30 minutes while you’re relaxing. And really, the way that
most people, if they’re going to respond acupuncture,
the way that most people respond is they may
or may not feel something after the first treatment. And then if they do you feel
something, it’s usually, I might feel a
little bit better. You know, I slept a little bit
better that first night out from acupuncture, and then it
just went right back to normal. And then the next
time you come in, maybe it’s two nights that you
have a slightly better sleep or you have less anxiety
or so on and so forth. And it sort of
expands over time. That’s how most people
end up seeing a response, if they’re going to see
it with acupuncture. What are you using
the acupuncture for? Stress too? So you can use it for stress. But usually, when
people are stressed, they’re having actual
symptoms of something. So sometimes when you
say you’re stressed, that means something
to all of us. But everybody’s
experience of stress is going to be different. Right? So for some people,
when they get stressed, they get like a knot
in their stomach, or their digestion kind
of goes out of whack. Or for some people, they
start to feel really anxious, or their sleep gets off, or
their mood starts to tank, or they feel irritable. Right? So there are often symptoms. If you didn’t have
symptoms, you wouldn’t be coming to see me for stress. Right? So what we’re doing is
we’re targeting whatever the symptoms are that
you’re experiencing that is related to stress. And then the side effects
are quite minimal. So these are pain on
insertion of the needle, bleeding or bruising
at the insertion site. Not super common, but cosmetic
and transient side effects. Also wanted to put a
plug in here for massage. When it’s performed with
at least moderate pressure, it can reduce stress,
depression, anxiety, and stress hormone levels. And it can enhance
your immune function. So if you like massage,
treat yourself. It can be good for you. So let’s summarize. Let’s pull it all
together today. Stress, I hope I’ve convinced
you, is not just in your head. Chronic stress can cause
wide-ranging effects on your health. And reducing stress
is about supporting your body’s natural rhythm. OK. This is sleeping, eating,
physical activity, space, social interactions, all of
that that we talked about today. A big piece of
this is developing your own internal compass. And here are some
tips for developing your internal compass. You want to try to notice your
emotions and your gut reactions before you judge them. Right? That’s what we were
talking about earlier. But the idea here is not
let’s not act on everything all the time, right? That’s not the
point of developing your internal compass. It’s that before we push it
down out of our consciousness, let’s take a look at it. Try to accept the negative,
because the negative emotions, whether they’re anger, or
sadness, or stress, or boredom, or irritation, or
whatever, are actually necessary, and just as
necessary to your compass as the positive emotions. And if you’re
someone– and there are many people who fall
into this category– that struggle to name or feel
emotions or gut reactions, that is perfectly normal. It happens to many people. And it’s something you
can actually, like I said, explore in psychotherapy. Meditation can help
you create space. Music can help your mood, if you
choose something that you like. And there is help, support,
and guidance out there. So this is friends and family,
psychiatry, psychology, psychotherapy, and also
integrative medicine. So we talked today about
acupuncture, massage, but there are other holistic
modalities, as well. So I wanted to be
practical here and talk about how you might
think about getting started if stress
is something that’s bothering you in your life. So what I would recommend
is that you actually choose two doable
things, and work on those for the first week. And there’s no time
like the present. So if you’re thinking about
it, you might as well just choose them now. OK? And I’m going to give you a
reminder of all the things that you could be thinking
about in just a moment. But just another tip is you
want to make them small, measurable tasks. So reduce your coffee from
three cups to two cups per day, for instance, or practice
meditation for 10 minutes every day, or so on. So here are the areas that
we talked about today. So for instance, one
task you might do is figure out what your
circadian cycle is, if you don’t know what it is already. That could be a task. And then try to sleep more
aligned with it, if you can, and so on. I wanted to give
you some resources, so there’s the Stanford Center
for Integrative Medicine. That’s where I am. So we offer comprehensive
evaluations. We offer nutrition,
counseling, acupuncture, brief psychotherapy, usually
like six to eight sessions max, stress
management, counseling. We also do referrals. So you’ve come to us, we do
a comprehensive evaluation, and we think, actually,
this is something that you would do better– you
need to talk to neurology, so on and so forth. We refer out. We do have massage, as
well as meditation courses. Also, Stanford Psychiatry,
which is another place that I’m working out of. So there would be more
for psychiatric evaluation specifically, and treatment for
depression, anxiety, substance abuse, if that’s a
problem, or suicidality. And really, psychotherapy
and medication management is what the Department of
Psychiatry primarily does. So that’s that. I wanted to give you some
resources where you find me. So obviously, I said
at the Stanford Center for Integrative Medicine. But also, if you’re
hooked in online, I’m on Twitter and on Tumblr. I have a blog devoted to
holistic psychiatry, where I talk about various topics
every couple of weeks, take a look at what the
research says about, say, sleep deprivation therapy,
or about vitamin D and its role in depression,
and so on and so forth. So that’s it. Thank you so much. I really appreciate
y’all coming out tonight. And I wanted to open up
the floor for questions. And when you’re going
to have a question, I’m going to bring you the mic,
because we want those to be picked up for the videotape. You won’t be seen, but
your voice will be heard. And then Dr. Haddad
can answer it. So when you have a question,
I’ll walk the mic over to you, and just hang on till
I give it to you. OK? Question? I really liked your topic
and your discussion. And you said you’ve done some
research on Tibetan medicine and so forth. And you mentioned
meditation, and I was pretty surprised
as I wrote down a lot of the diseases
and stuff like that, to cancer and diabetes and
some that relate from stress and so forth. So has there been much research
in the area of the mind, as far as meditation
and use of the mind for healing, and
actually also how it can be destructive and in
a reverse way and so forth, with negative
thoughts and so forth? Yeah. So definitely, there’s
research on meditation, and sort of the positive
effects of meditation, including reducing stress,
and so on and so forth. And then the other piece
of that is is there research on the negative side? So if you have, like, a
lot of negative thoughts or depression, certainly. I mean, absolutely. We know that people
who are depressed are at higher risk for
certain diseases and problems. For instance, yeah– so yes. The answer to your
question is yes. There is research on that. What I would want
to say about it is that it’s sort of a field
that is emerging right now. I think that some of
the research, it’s sort of challenging to
do some of this research. Why is that? I think whenever we’re talking
about subjective experiences, it can be hard to
do the research. So I think, for instance,
even acupuncture is something that we are challenged in
doing good research in. The reason that acupuncture
is hard to do research in– What you’re noticing
right now, I’m having trouble with my words, is
that this is off my sleep cycle right now. Trying to work
late in the evening doesn’t work well for me. When I gave this talk in the
morning, I was like super spot on. OK. So like, after a long
day, I’m like finding it hard to find the
words right now. OK. So I was saying acupuncture. So the reason that acupuncture
is hard to do research in is because, you know, it’s
hard to have a control condition for acupuncture. Right? I mean, how do you compare
an intervention where you put needles into the skin, and
then try to fake people out and pretend that they have
needles in when they don’t. So there’s all sorts
of ways that they’ve tried to do a sham intervention,
or a control intervention for acupuncture. But there’s been problems
with a lot of those. And so in the same
way, I think if you’re thinking about how would I test
if people’s negative thoughts are affecting their health,
I think the question becomes, well, how do we measure those
negative thoughts, right? I mean, it becomes
self-reported measure. Well, I have negative thoughts
two hours of every day, or something like that. Right? Or my negative thoughts
are, I’m stupid, and I am not– so it
just becomes challenging, I think, for that reason, more
so than I have a medication A, and is it as good as
medication B. Right? Those are the easier
studies to design. Interesting. Thank you very much. Yeah. Absolutely. Thank you. Just a short one here,
concerning vitamin D levels. Yeah? And there’s so much out there
discussion all over the place, and I’ve been trying to
get my arms around kind of where I should be myself. And in my lab work, it shows
that I’m in a normal range. I guess we all have a little
depression here and there, but I don’t consider myself
having really any depression issues. So I’m wondering what
your thoughts are. And a lot of it, that’s
all individual, I guess. Absolutely. Your exposure to the
sun, and so forth. But I had been taking
like 1,000 every day with a few other
supplements I take. Would you consider that to
be a reasonable thing to do? Or it’s hard to say on an
individual, not knowing more [? on that ?] basis? So what I would say
about it, I think there is some evidence–
so it’s not the strongest evidence in the
world– but there is some evidence for the
idea that vitamin D and mood are connected. So decreases in
depression can be associated with increased
vitamin D levels. So when you look
at the literature, it’s sort of mixed about
exactly what point we’re talking about for vitamin D levels. But what I will say is
that that number that is in the lab that
says, like, this is the cutoff for
low vitamin D, it’s set at a very, very low level. It’s set at the level
that helps you not have sort of skeletal disease
from having too low vitamin D, which is actually the very
lowest level of vitamin D. And when you look at other
medical issues associated with vitamin D, those
levels are higher. So the cutoff for
our lab, I think, is 20 nanograms per milliliter. I hope I’m right on that. But the cutoff of 20 nanograms
per milliliter in your blood means that if you hit 21, that
you are considered normal. But we know that levels below
20 are associated with increased risk for cancer, for instance. So would you want to be
hanging around at 21? I don’t really want to
be hanging around at 21. I had my vitamin D level
measured once and had my level be 21, and I was like,
I don’t like that. But yes? Were you going to– I just missed what you said
there on risk for cancer. You said what level? 20. 20 nanograms per milliliter. Below that, you’re at higher
risk for cancer and skeletal issues with vitamin D.
But levels are higher, if you want to have a
positive effect on mood. So levels closer to
40 is what you’re wanting to target, 35 to 40. And actually, there’s
a recent study. Just a couple days
ago, it came out from UC San Diego
on an increased risk of cancer in people
who had levels below 40. So this is, again,
I think anything on the complementary
and holistic level here is we’re at the beginning
of the research on it. So we’re going to hear,
like, different stories. So don’t just kind of like
stick to whatever the number is I say, and be like, that’s it. I think next week we could hear
a different number coming out. But I try to stay on
top of it, and then I try to look
individually at what’s going on with my patients. So if my patient is at higher
risk for a multiple sclerosis, or if my patient already is
having a lot of depression, then I think about what should
I do with this vitamin D level. Thank you. Yeah. The people that seem to
thrive on stress, that almost are always on, and get off
on high-pressure situations, are they ignoring
their stress levels? Or are they doing any damage
to themselves in the long term? Or are they just
different animals? I don’t think that they’re
necessarily different animals. I mean, I think it depends. It’s hard to answer
that question globally. But I think there are
people– so in psychiatry we talk about hypomania. Right? Hypomania is sort of on
the opposite spectrum of depression. So we’ve got low mood, feeling
lethargic, feeling like you’re sleeping all the time, that
kind of thing on the depression spectrum. And then if you go past
normal mood to the other side, that’s hypomania. And hypomania is where your
ideas are coming super fast, and you’re talking really
fast, and, you know, you’re really excited,
and you’re revved up, and you don’t really
feel like you need sleep, and that kind of thing. And that can actually
be physiologic, right? People who have bipolar
disorder actually go through periods of time
where they have depression, and then they actually,
physiologically, need less sleep for that period
of time, or notice it less. And does that effect them
I’m in the long term? Do they crash in the long term? Yes. And I think there’s a certain
portion, a small portion of people, who really thrive
in those stressful environment, who actually may
be on the spectrum. So I think that that’s one
answer to your question. I think the second answer
is that I think people do thrive on the adrenaline of it. So even outside of that
very small percentage of people who
actually legitimately have like a bipolar II
disorder or something like that, then I think the
rest, the other 98% or 99% of them, are people
who are really thriving on the adrenaline. Right? And so they’re
revved up, they’re excited by what they’re doing. And, you know, I
do think that that has– they’re not exempt from
what we talked about today. Thank you, Dr. Haddad. Absolutely. It’s very inspiring. Oh, good. I had a question about
God-given light, sun. About what? About the sun. The sun? Oh, yeah. That gives you vitamin
D, or how much? I remember when I walk
or jog in the sun, I feel much better
than a cloudy day. I don’t feel it at all, as
I don’t exercise or not. How much? How many hours? Is there a measurement? Yes. Online– and if
you’re not connected, I’m sure that’s something that
we can look up for you here– but it depends on
your latitude, and it depends on the time of year. So what it really depends
on, in terms of the sunlight, is how direct is the sunlight. So is it coming, like, through
many, many, many layers, like at an angle, in which case
you’re probably not getting very much conversion at
your skin of vitamin D. And so there are certain
latitudes where there’s only certain times of the year that
you’re really– even if you’re outside all day long–
that you’re getting much conversion of vitamin D. And then the rest of us are
wearing sunscreen all the time or we’re wearing clothes that
cover of most of our bodies. And it makes sense. We know that there’s an increase
in cancer risk with exposure to the sun. So there’s a reason that we’re
not all out there, sunbathing. But the answer is, it depends. So how much time you
should spend outdoors is going to depend on your
skin cancer risk, and also your latitude, and
the time of year. For darker-skinned
people, maybe more? Yes. That’s a great question. Yes. So darker-skinned
people are going to be more resistant to the sun,
and therefore either need more or need supplementation. Yes. And has to do with sun. When I take more walks in the
sun, I feel less depressed. And I don’t know, I’m a
chronic depressed person. And is there sun therapy,
or light therapy? Yes. I heard something. Yes, there is. So light therapy, it
has been specifically studied primarily for
seasonal affective disorder. And what seasonal
affective disorder is, people who have
depressions primarily during the times of the year
when we have lower light, so fall, winter types
of depression. But there has been
some research on is it helpful outside of
seasonal affective disorder. And that literature is mixed. But I think what’s useful to you
is that you know personally– right, the internal compass
that you just described– is that I know that I
notice when I am outside, the sun seems to help me. Right? Light seems to help me. So I think that
would be something to discuss with your
psychiatrist or your provider or whatever, and see. Because it’s fairly low
risk, to do something like light therapy. And it’s even less risk to
just go outside more often and take a walk. So you know if you can do,
that the physical activity and the light will
be helpful for you. And now that we’re leading
into spring and summer, I think it’s a great time to
really spend more time outdoors and get the physical
activity on the sun. Thank you. Yeah. Thank you so– yes. Sorry. Hold on. Let me get you the mic. I really appreciate
all you coming out. I know it’s like
evening on a Thursday. So thank you. Yeah. First question I have is
a very basic question. Is being depressed
being unhappy? Or is it something different? And second question is, is
it an effective solution to keep oneself distracted? If you’re getting sad or
depressed because of memory– like, if we see
something, then I feel sad– so is it OK to
keep myself distracted, like watching movies
or not feeling at all? Or just internet
and distractions? Good questions, good questions. So is feeling unhappy the
same as being depressed? And the answer is no. So all of us go through periods
of time, probably in every day, right, where we feel
unhappy sometimes. And many of us will
even go through periods of time for a week or more
where we feel unhappy, or for years where we feel
dissatisfied with our job or whatever else. The threshold of
depression– so when we talk about depression
in psychiatry, we’re actually talking about
a combination of symptoms. So it’s not just unhappiness
or sadness or so on. But it actually also includes
some symptoms that actually are happening in your body. So it will include
disruption in your sleep, or disruption in your ability
to enjoy things in your life, or an increased sense of guilt,
or negative thoughts that are happening most of the
day, most days for weeks. It can include decreased energy
level, decreased concentration, changes and your appetite,
suicidal thoughts. So a certain number
of those symptoms, most of the day, most days,
for a couple of weeks, is what marks
depression, not just sort of transient
unhappiness or unhappiness, even in isolation, without
those other symptoms. So that’s the first question. And then the second question. Is it bad to distract
myself if I’m feeling sad? And I would answer
that question no. It obviously depends on what
you’re distracting yourself with. Right? But I think it’s perfectly
normal for you to say, looking at that makes me sad. I don’t want to look at it. Right? Usually that’s the
kind of thing that happens kind in the beginning,
when something bad happens. If you lose a loved one or you
have a break up, or something like that, it’s very
normal to be like, I want to be reminded
of this right now. Right? I need some space from this. So I think you
have to be careful. Use your internal
compass and say, am I just trying to dodge
this feeling entirely and not process and not kind
of experience what I’m feeling? Or am I just kind of
doing what is protective to me right now, which is, I
don’t feel like this is useful. Me just staring at this
photograph of somebody is making me sad. So I think it’s a balance. So distraction, if
you’re watching a movie or you’re listening to music,
or you’re taking a walk, or you’re doing
something like that, I think that that can be
perfectly functional, depending on the context. I notice you mention
about meditation. You mentioned it several times. And I was kind of curious
exactly which type you recommend, and how
many different types are there of meditation? Yeah. So the question was that
I mentioned meditation on multiple occasions. And is there a type I recommend? I’m sorry. What was the last
part of your question? Yeah. The type you recommended. And how many different types
of meditation is there? I don’t know how
many different types, but it’s a lot of different
types of meditation. And I think the one
that I recommend is really the one that
works best for you. And I think it depends
on the time in your life, the time in the day,
and that kind of thing. I think the best place
to start is to put aside 5 or 10 minutes in your day. And I think most people start
with meditation very basic. So that can just be something
like counting your breath. So it would be
counting your breath, and focusing on your breath,
up to the count of four. So four breaths, and then
just starting over again, and counting your
breath again up to four, and starting over again. So that is a form of
mindfulness meditation. So that is a way of becoming
just present to your breath. So you can do that
with many things. So you can do that by
sitting in your chair and looking at a
particular point in space. So you can look at this
particular part of the podium, for instance. It can be anywhere. Right? And then you just
examine, and you say, oh, look, I can
see the color here. I’m looking at the
brown here, and it’s sort of a reddish brown. And then I’m looking at
the lighter reddish brown that’s right around it. And I’m sort of noticing
the texture of it. I’m noticing the
sheen of the light as it comes off
of it, and so on. And you do that
for five minutes. And I know a lot of
people who actually set their timer on
their phone so they don’t have to think about it. And they just set the
timer for five minutes. Start mild. Three minutes, even. OK? Because it can be hard. Your mind is going to be
like, blah, blah, blah. What are you doing? I don’t want to
sit here right now. Blah, blah, blah, blah. Right? And you’re going to be like, OK. And you’re going to
get annoyed, and be like, why can’t I meditate? I can’t meditate. But this is the
process of meditation. Meditation is not like
a state you get to. The process of meditation
is noticing, oh, wait, I just got back into my
chattering mind again. Oh, let me go back and
focus on the podium again. And then, oh, OK. Nah, nah, nah, nah, nah. Focus back on the podium again. Right? So it’s the process
of doing that. So you just set yourself a
little goals, three minutes, four minutes, five minutes,
whatever you can tolerate. And really, whatever
you’re attracted to. So you could listen
to the sounds that are happening around you. It can be visual. It can touch. You could be touching a penny. Right? That’s a classic one. Or touching something. So you know, that’s a
form of mindfulness. And that’s usually where
I tell people to start. But there are many
types of meditation. Yoga has meditation embedded
in it, and so on and so forth. [INAUDIBLE] Thank you. I think that’s our last
question for tonight, because we’ve run out of time. Before we close, I wanted to let
you know, if you’re interested, I printed out and some of
those morningness-eveningness questionnaires, which are
about kind of helping you figure out what your circadian
rhythm is, if want to. If you already know, no worries. But the last time I gave
this, a lot of people were interested in that. So I wanted to offer
that to you, if you want. And there’s sort of
a way to calculate your score at the end. And maybe it gives you some
useful information, maybe not. But it’ll probably take you,
like, three minutes to do, if you’re interested. Any online also? Yes. You can find it online. You can Google it. You can also find it– I
actually put it on my website, so you could find it easily. If you want, my website
is And it’s actually at
the Discover link. It’s the first one
on the Discover link. Thank you, Dr. Haddad. Yes. I printed them out. Oh, beautiful. Thank you very much. Absolutely. Thank you for coming, everyone. I really appreciate it.

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