Stress & The Effects on the Skin

Integrative Dermatology Blog Image

stress

It has been established in recent years that the skin is a direct target of psychological stress via a cascade of hormones, neuropeptides, and neurogenic signals (causing nerve hypersensitivity and inflammation). The skin has been shown to be capable of launching its own local response to stress as well by producing many of the same substances that the brain produces, further enhancing the local effect at the skin level when someone is under acute or prolonged stress. It is no surprise that the skin can perceive and respond to stress similar to the brain and nervous system, since the two systems have evolved from the same germ layer during embryonic development.

The main skin cells (keratinocytes), mast cells (involved in allergy type reactions and inflammation), immune cells, and peripheral nerve endings all will have an effect on various cell behaviour and processes within the skin under stress that can lead to skin disruption, premature ageing and disease development.

The skin is rich in nerve endings, so when an individual is stressed the peripheral nerve endings secrete numerous substances such as Substance P and Nerve growth factor that contribute to hypersensitivity, inflammation, and allergic reactions.

Due to the impact of stress related hormones and peptides, and growth factors on the skin, stress can play a role in the development and exacerbation of skin disorders such as Eczema, Acne, Psoriasis, and Rosacea.

Psychological stress activates the autonomic nervous system to trigger release of catecholamines [e.g. epinephrine and norepinephrine] from the adrenal glands, and in situations of chronic stress corticotrophin releasing hormone [CRH] and ACTH (adrenocorticotropic hormone), mediate a release of glucocorticoids (Cortisol) from the adrenal cortex.

Here is a brief outline of some key stress mediators and the effect that they have on the skin:

Glucocorticoids:

Excess levels can cause atrophy and impaired wound healing by interfering with keratinocyte and fibroblast function. Keratinocytes are the primary skin cells that form the epidermis of the skin, and fibroblasts are responsible for collagen and elastin formation.

This manifests as atrophy and thinning of the skin, increased trans-epidermal water loss related to disruption to the skin permeability barrier, and easy bruising with impaired wound healing.

The skin barrier is also negatively impacted by excess cortisol as this effects the lamellar bodies in the skin cells which are responsible for lipid synthesis; the lack of essential lipids weakens the barrier resulting in dry skin, allergies and sensitivity, delayed healing and infections.

Insulin:

Excess glucocorticoids stimulate Insulin production and lead to insulin excess and Insulin resistance. Elevated Insulin stimulates IGF2 (Insulin growth factor) which increases growth of keratinocytes, and stimulates abnormal keratinocyte growth, (exacerbates Psoriasis and Acne) and increases androgens and testosterone release.

Substance P:

This is neuropeptide released in times of stress. Substance P stimulates sebaceous germinative cells and proliferation of sebaceous glands which results in excess oil production and blockage of the oil ducts and the development of acne. Substance P also activates mast cells, increasing histamine release and itch sensation. Substance P induces vascular permeability and inflammation, which aggravates conditions like Eczema and Rosacea.

Corticotropin Releasing Hormone (CRH):

CRH stimulates release of MSH (melanocyte stimulating hormone) causing hyperpigmentation and blotchy skin.

Catecholamines (Adrenaline, Noradrenaline)

Decrease blood perfusion to skin reducing availability of oxygen and nutrients resulting in poor texture and sallow / pallor. Catecholamines have also been shown to cause immune suppression, interfere with DNA repair and contribute to ageing.

Managing stress

While the effects of stress on the skin are only briefly outlined above, it illustrates the significant impact this can have on individuals predisposed to skin conditions. It is therefore imperative to minimise stress where possible in order to avoid any exacerbation of skin disorders.

There are some straight forward tips to reduce stress such as getting a good night’s sleep, exercising and following some simple dietary guidelines (listed below).

stress_2

Reduce salt intake

Avoid alcohol

Avoid caffeine

Avoid skipping meals

Avoid refined, processed foods.

Avoid high fat foods

Do eat high fibre, low glycaemic index diet

In the following blogs we will present some relaxation techniques that are easy to implement and will have a direct effect in reducing the side effects of stress.

 

References

  1. Dunn, Jeffrey HKoo, John; Psychological Stress and skin aging: A review of possible mechanisms and potential therapies; Dermatology Online Journal 19 (6): 1 University of Colorado, School of
  2. Medicine, 2 University of California, San Francisco, Department of Dermatology 2013 Permalink: http://escholarship.org/uc/item/3j0766hs
  3. Jessica M. F. Hall, desAnges Cruser, Alan Podawiltz, Diana I. Mummert, Harlan Jones, Mark E. Mummert; Psychological Stress and the Cutaneous Immune Response: Roles of the HPA Axis and the Sympathetic Nervous System in Atopic Dermatitis and Psoriasis; Dermatology Research and Practice Volume 2012, Article ID 403908, doi:10.1155/2012/403908
  4. Ying Chen, John Lyga; Brain – Skin Connection: Stress, Inflammation and Skin Aging; Inflammation & Allergy – Drug Targets, 2014, 13, 177-190
  5. Theoharis C. Theoharides, Jill M. Donelan, Nikoletta Papadopoulou, Jing Cao, Duraisamy Kempuraj, Pio Conti; Mast cells as targets of corticotropin releasing factor and related peptides; TRENDS in Pharmacological Sciences Vol.25 No.11 November 2004

Stress, Anxiety, Depression – Atopic Eczema (AE)/Atopic Dermatitis (AD) and associated Itch

researchblogcategoryimage

Atopic dermatitis may be caused by genetic predisposition and environmental conditions, including hereditary factors, allergens, and neurogenous (arising from the nervous system, or from some lesion of the nervous system) and immunological factors. However, the major contributing cause remains unknown. AD may cause psychosocial problems such as anxiety, depression, sleep disorders, emotional excitability, stigmatization, social isolation, and discrimination and on the other hand, all of these factors may also contribute to and exacerbate the symptoms of AD. Of the many factors related to atopic dermatitis, psychological stress is considered to be among the most important.1

 The psychological, physical and social impact of AD is complex and varies among different ages. The relationship of stress, anxiety, depression, not to mention feelings of stigma, shame, embarrassment, and low self-esteem all impact upon a person who is suffering from a skin condition such as AD. Research has confirmed that adults with AD exhibit high levels of anxiety, depression, and emotional excitability. Children with AD also have higher levels of emotional distress and more behavioral problems than healthy children or children with minor skin problems. Psychosocial factors contributed in the form of exacerbating factors in as high as 94% of AD hospitalized patients. Clinically, it has long been appreciated that both acute stress (stressful life events) and chronic psycho-emotional stress can trigger or enhance pruritus.2, 3, 4,5

Pruritus, or itching, is a main symptom of AD and is often one of the first presenting symptoms.

Itching leads to scratching, which leads to and exacerbates the skin lesions.

  • AD has been referred to as the “itch that rashes.”
  • The cycle of itching and scratching is considered an important factor in the maintenance of AD symptoms and is believed to be one of the first symptoms of an impending AD flare.
  • Scratching tends to cause further itching, leading to the so-called “itch-scratch cycle.” 6

Results of one study found that in patients with AD the itching intensity played an important role in determining the patient psychosocial well-being and that a relationship between pruritus and depression was also found.6

 Scratching often begins automatically in association with stress and emotions, and becomes habitual, being performed many times every day. In addition to the psychological factors, such as anger, irritation, impatience, relief, anxiety, etc., many patients say that they somehow find themselves scratching even when they do not feel itchy. Research has identified that habitual scratching is involved in the formation of the lesions of AD. The scratching is patterned, with the rash exhibiting a bilaterally symmetrical distribution over the back and normal skin remaining in the middle where the hands cannot reach, producing a “butterfly” sign. The prominent red face can also be explained by this scratching behavior.4

 This vicious cycle can cause sleeplessness in over 65% of AD sufferers leading to sleep deprivation which leads to tiredness, mood changes and impaired psychosocial functioning of the sufferer and their family, particularly at school and work. Embarrassment, comments, teasing and bullying frequently cause social isolation and may lead to depression or school/work avoidance. The sufferer’s lifestyle is often limited, particularly in respect to clothing, holidays, staying with friends, owning pets, swimming or the ability to play or do sports. For parents caring for a child with eczema, restriction of normal family life, difficulties with complicated treatment regimens causing an increased work load together with disturbed sleep can lead to parental exhaustion and feelings of hopelessness, guilt, anger and depression. And so the whole family is impacted by the condition.5,6,7

Research has suggested that some AD patients might benefit from certain psychological interventions: patients showing psychological characteristics that comprises high depression, low agreeableness and high public self-consciousness would probably benefit from psychological interventions, such as cognitive restructuring, anger management and self-assertiveness training, because these interventions might be able to modulate the extent of the personality characteristics that are associated with induced itch.8

Recent emerging research indicates that mindfulness meditation training may have beneficial effects across a spectrum of health conditions, but the mechanisms linking mindfulness meditation training with health are unknown. One striking feature of the mindfulness training literature to-date is that mindfulness training effects on disease outcomes have been observed in diseases where stress is known to trigger the onset or exacerbation of disease symptoms and pathogenesis (e.g., HIV, psoriasis, depression, pain, chronic inflammation).9   Research has indicated that relaxation techniques appear to be helpful in the treatment of patients suffering from chronic itch in patients that are open to it. And it is becoming a standard recommendation by many Practitioners and hospitals that relaxation training be considered clinically in patients who report that their itch increases during periods of heightened stress.10

The challenge for sufferers of AD is, with the aim of improving their quality of life, to help themselves to find, together with their practitioner, the best personal treatment plan and then sticking to it. The main challenges in the effective management of AD, comes down to patient adherence to the treatment plan and their emotional resilience.

 

References

  • Kwon1 J.A. et al.; Does Stress Increase the Risk of Atopic Dermatitis in Adolescents? Results of the Korea Youth Risk Behavior Web-Based Survey (KYRBWS-VI); PLOS ONE, www.plosone.org; August 2013, Volume 8, Issue 8, e67890
  • Han-Ting Wei et al.; Risk of developing major depression and bipolar disorder among adolescents with atopic diseases: A nationwide longitudinal study in Taiwan; Journal of Affective Disorders 203 (2016) 221–226
  • Buske KIrschbaum Hellhammer et al.,; Endocrine and immune responses to stress in chronic inflammatory skin disorders; 992. 231-240 (2003)
  • Sang Ho Oh et al.; Association of Stress with Symptoms of Atopic Dermatitis; Acta Derm Venereol 2010; 90: 582–588. The Journal of Clinical Investigation; http://www.jci.org; Volume 116, Number 5, May 2006
  • Kamide R.; Atopic Dermatitis: Psychological Care; Journal of the Japan Medical Association (Vol. 126, No. 1, 2001, pages 59–62).
  • Brown T.M. et al.; Assessing Pruritus Among Patients With Atopic Dermatitis: Targeted Literature and Instrument Review; https://www.rtihs.org/sites/default/files/Brown_isporposter_May2012.pdf
  • Lewis-Jones S. Quality of life and childhood atopic dermatitis: the misery of living with childhood eczema. Int J Clin Pract. 2006;60(8):984-992.
  • Schut C. et al.; Personality Traits, Depression and Itch in Patients with Atopic Dermatitis in an Experimental Setting: A Regression Analysis; Acta Derm Venereol 2014; 94: 20–25
  • Creswell J.D. et al.; Brief mindfulness meditation training alters psychological and neuroendocrine responses to social evaluative stress; Psychoneuroendocrinology (2014) 44, 1—12
  • Schut C. et al.; Psychological Interventions in the Treatment of Chronic Itch; Acta Derm Venereol 2015 Preview

Simple Mental/Mind Relaxation Techniques Part 1

lifestyleblogcategoryimage

As we indicated in the Simple Physical Relaxation Techniques blog, it is important that you take control and find some relaxation techniques that best assist you to relax and to control your stress levels and increase your emotional resilience. Once you have mastered the 4 exercises that you found or will find in our Physical Relaxation Techniques blog it is time to combine any one of these with some simple Mental/Mind Relaxation Exercises and find the one that works for you:-

RELEASING YOUR TROUBLES AND WORRIES

 Create a Picture in Your Mind

Think of a view or a place or an object that you find simple, quiet and inspiring or use one of the following.

simple_mental_part1_2simple_mental_part1_1simple_mental_part1_3simple_mental_part1_4

Study every minute detail in your mind.

If you are sitting on the sand on the beach, feel the aetting sun warming your face, feel the breeze on your skin, smell the ocean air, taste the salty tang on the breeze, hear the waves washing right up to you and as you hear each and every wave, release all of your stress and throw it onto the waves to wash out into the ocean …… take a bad feeling and do the same with this feeling and just release it to the waves, repeat with a troubled thought, or a person who riles you or who has upset you … do it with everything that has angered, troubled, annoyed, worried or upset you until you are totally relaxed and free from all troubles and worries.

When using the sunset …. Do the same as you imaging the colour changing and fading until you are free from all troubles and worries and looking at a beautiful starry night.

When using the rainbow … do the same as you climb higher onto the rainbow ……. with each step leave another thing behind you. Climb right to the top of the rainbow and view the world free from all troubles and worries and as you begin to make your way down the rainbow know that you remain free from all of you troubles and worries as you step into a field of beautiful flowers and lush grass.

When using the garden …. Smell the flowers, hear the bees, watch the sun glint on dragon fly wings, and as you go through the gate leave all of your troubles behind you and imagine yourself walking along a golden path into beautiful warm, fern forest. Wind the path back to the garden but notice that when you walk back into the garden your troubles and worries have all gone and you a free to enjoy the garden with a feeling of peace and serenity.

RELEASING PAIN AND DISCOMFORT

Body Scan Meditation

To practice the Body Scan Meditation, get into a comfortable position, by lying on a yoga mat on the floor or on a bed. You can use a pillow under your head. You can also sit in a chair on in the Yoga position. Use the Controlled Breathing or the Progressive Relaxation exercise from our Simple Physical Relaxation Technique blog and gently bring your awareness to the present.

1. Concentrate on a specific body part, e.g. your right arm. As you breathe deeply, scan that part of your body for sensations – heat, pain or burning. Notice the sensations but try not to get lost in thought and feel the heat, pain or burning. Repeat in your mind – “ALL HEAT, PAIN, or BURNING IS GONE”…………. Repeat three times

Gradually let your focus move to different body parts—each leg, your hips, stomach, chest, hands, arms, and head. And do the same.

simple_mental_part1_5

2. Practice the Body Scan Meditation and do not worry if you become aware of your mind’s tendency to drift to other thoughts. When you notice this happening, just let the thought go and gently bring your attention back to your body. If you have any pain or discomfort, just notice it, accept it, and release it using the mantra and continue scanning

The more you do this exercise the greater control you will achieve over your pain or discomfort.

Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Physical Relaxation Techniques for Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients, Simple Mental/Mind Relaxation

 

 

REFERENCES

  •  National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  • Relaxation Techniques for Health: What You Need To Know; National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf
  • Progressive Muscle Relaxation; http://www.cci.health.wa.gov.au/docs/ACF3944.pdf
  • Manzoni G.M. et al.; Relaxation training for anxiety: a ten-years systematic review with meta-analysis ; BMC Psychiatry 2008, 8:41 doi:10.1186/1471-244X-8-41
  • Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf

Simple Physical Relaxation Techniques

lifestyleblogcategoryimage

It is important that you and you alone take control – find the solution that best helps you and ensure that you keep doing it – remember it comes down to your adherence to not only your treatment plan but also in your efforts to control your stress and increase your emotional resilience.

The next step is to test some simple Physical Relaxation Techniques and find the one that works for you:-

Use the following to help you release muscle tension.

YOGA STRETCH

 1.         Stand relaxed with your arms hanging at your sides and place your feet comfortably apart.

simple_physical

2.       Tilt your head back and count slowly to five.

3.       Roll your head forward and count slowly to five.

4.       Exhale as you curl your body forward and bend at the waist; arms dangling down and slowly count to five.

5.       Inhale slowly through your mouth as you slowly straighten up whilst raising your arms overhead – stretching as far as you can. Then            drop your arms slowly to sides as you exhale though your mouth.

Repeat several times.

CONTROLLED BREATHING

1.        Use a yoga mat or a folded blanket – lie down with your back flat on the floor and place a book or large magazine on your                          stomach.

2.        Bend your knees (you can close your eyes if this makes your more relaxed).

3.        Inhales and push your stomach upwards (but not you upper chest) as far as you can and slowly count to five, then exhale slowly.                You may also use the affirmative “I am relaxed” as you exhale.

Repeat several times.

Use the following after a physical reaction to a stressful situation to allow the physical changes of your stress reaction to subside and return to a non-stress state.

RELAXATION RESPONSE

simple_physical_2

1.        Sit (or lie) in a comfortable position in a quiet environment with eyes closed.

2.        Start with your feet and mentally relax each muscle group moving up to the head—calf, thigh, waist, stomach, arms, chest, neck,              face, and forehead.

3.        Breathe in through your nose gently pushing your stomach out (but not your upper chest).

4.        Breathe out through your mouth and let your stomach relax.

Repeat this exercise for 10-20 minutes.

When finished, open your eyes but remain seated or lying for several more minutes.

PROGRESSIVE RELAXATION

1.        Lie flat on a yoga mat or a folded blanket – with your eyes closed and knees bent.

2.        Beginning with your right foot, press foot firmly to the floor and count slowly to five, then relax for the count of five; repeat with the              left foot.

3.        Straighten legs out and press back of lower right leg firmly to the floor and count slowly to five, then relax for the count of five;                    repeat with left leg.

4.        Press each of the following areas firmly to the floor and count slowly to five, and then relax for the count of five. (one at a time):

             a.      Back of thighs and buttocks

             b.       Lower back and shoulder blades

             c.       Arms

             d.      Back of head

REMEMBER: – to breathe normally as you press and relax. Repeat several times.

There are many other forms of Relaxations Techniques including, exercise, meditation, yoga, Tai Chi etc. On the internet there are many sites that offer other tips for relaxation exercises and meditation techniques…

Walking is an excellent form of exercise that will cost you nothing.

And of course other activities e.g. gyms and swimming pools will require membership fees to be paid.

Also read our blog “Stress, Anxiety, Depression and Psoriasis, Stressed about Psoriasis – Identify Your Stressors and Yours Stress Responses, Simple Mental/Mind Relaxation Techniques Part1, and Simple Mental/Mind Relaxation – Part 2

 

REFERENCES

 

  • National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  • Relaxation Techniques for Health: What You Need To Know; National Institutes of Health; U.S. Department of Health and Human Services; https://nccih.nih.gov/sites/nccam.nih.gov/files/Get_The_Facts_Relaxation_Techniques_02-06-2015.pdf
  • Progressive Muscle Relaxation; http://www.cci.health.wa.gov.au/docs/ACF3944.pdf
  • Manzoni G.M. et al.; Relaxation training for anxiety: a ten-years systematic review with meta-analysis ; BMC Psychiatry 2008, 8:41 doi:10.1186/1471-244X-8-41
  • Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf

 

Stressed about Your Skin Condition – Identify Your Stressors and Your Stress Responses

blog-20

Whether you suffer from Psoriasis, Eczema / Dermatitis etc. stress is a recognized trigger that initiates and exacerbates fale ups. Being able to recognize what your Stress Triggers (Stressors) may assist you in modifying your responses and be part of the learning curve in managing your condition.

Identifying your Stressors

Use the list below to identify your stressors. For each item on the list, note whether or not it is important to you and whether or not you have control over it.

Changing Jobs/Promotion      Family Conflicts                      General Health   

Lack of Confidence                  Isolation                                     Money Worries

Pain/Fatigue                              Planning for Retirement         Public Speaking

Traffic to/from Work               Travel/Vacation/Holidays       Upcoming Wedding

Social Events                           World Events: War, Natural Disasters, Economy

Other:_______________        Other:_______________

 

 IMPORTANTNOT IMPORTANT
 

 

 

You are in Control

 

 

 

    
 

 

 

You do not have Control

 

 

 

  

 

 How Does Your Body Respond to Your Stressor?

Take note of what your body is telling you. Your body may constantly show a set pattern of response to stress and, as such, if you become aware of these responses you can then take the next step in trying to control these responses. These are classified as the following:

1) Physical

2) Behavioral

3) Emotional

4) Cognitive and

5) Spiritual

 

Physical symptoms include:- Shallow or rapid breathing, rapid heat beat, headaches, nausea or indigestion, hot flushes or sweaty palms, back pain, tight shoulders and/or neck or other unusual random aches and pains, insomnia and/or excessive fatigue, Psoriasis flare up.

tiredness-sets-in-1482054-640x480 backache-1620045-639x442

Behavioral symptoms include:- Excessive smoking, abuse of alcohol and/or compulsive eating.  Compulsive chewing of gum or inner cheek or grinding one’s teeth, especially at night. Aggressiveness, bossiness and/or being over critical of others;

smoker-1457305-639x497 bad-guy-1623961-640x960have-a-drink-1-1510449-640x480

 

Emotional symptoms include:- Excessive impulse to laugh or cry, unhappiness for no reason and being easily upset. General boredom or nervousness and edginess. Extreme loneliness and/or overwhelming feelings of being powerless to change things. Over reacting and/or intense anger.

crying-1440466-640x480frustrated-1439244-640x480

Cognitive symptoms include:- Mental confusion/concentration – trouble thinking clearly or being able to do simple mental tasks e.g. adding numbers up or simply being able to read a book, forgetfulness, memory loss and loss of sense of humor.

Spiritual symptoms might include:- Loss of faith – doubt, martyrdom and just a general loss of direction in one’s life, being vulnerable to cult groups.

 

Identify Your Stressor Responses

When you know how your body responds to stressors, you can focus your attention on finding the best stress management technique for each one. Tick the box corresponding to your Body Responses as to when you feel stressed and identify what the stressor was.

SYMPTOMSSTRESSORSYMPTOMSSTRESSOR
Chest Pain

 

 Fatigue 
Chest Tightness

 

 Lack of Energy 
Heart Palpitations

 

 Difficulty Sleeping 
Headache/Migraines

 

 Depression/Anxiety 
Neck & Shoulder Pain

 

 Sadness 
Teeth Grinding

 

 Crying 
Backache

 

 Irritability/Anger 
Muscle Crams/Spasms

 

 Frustration 
General Muscle Tension Forgetfulness

 

 
Pain

 

 Worrying 
Upset Stomach/Nausea

 

 Restlessness 
Diarrhea / Constipation

 

 Lack of Motivation 
Increased Smoking

 

 Blaming Others 
Increased Alcohol Consumption Loneliness 
Excessive eating for the sake of eating, not when hungry Skin Flare-up (State the Condition) ________________

e.g. psoriasis

 

 

Now Rate the Severity of Your Stress Response

 

0       1        2        3       4        5       6       7        8        9       10

l____l____l____l____l____l____l____l____l____l____l

 

Not                        A little                   Somewhat                Very                        Extremely

troubled                troubled                 troubled                 troubled                    troubled

Date/TimeStress Level

(0-10)

What Did I Do?What Did I Think?
E.G.   9.30pm10Argument with Partner Yelled and stormed outI hated myself, I hated him/her, I hated life, I hated the way I felt
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   
 

 

 

   

 

Also read our blog “Stress, Anxiety, Depression and Psoriasis”, Simple Physical Relaxation Techniques for Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 1 – For Psoriasis Patients, Simple Mental/Mind Relaxation Techniques Part 2 – For Psoriasis Patients”

 

 

 

References

 

  1. Bamber, Petrina Nicole, “Quality of life for patients with psoriasis : more than skin deep” (2009). Master’s and Doctoral Projects. Paper 272. http://utdr.utoledo.edu/graduate-projects/272
  2. National Center for Health Promotion and Disease Prevention (NCP); Manage Stress Workbook; http://www.prevention.va.gov/mpt/2013/docs/managestressworkbook_dec2013.pdf
  3. Franklin C.L. et al.: Relaxation Enhancement Therapist Manual; http://www.mirecc.va.gov/visn16/docs/Franklin_Relaxation_Therapist_Manual.pdf