Stress Management

Understanding Stress


  • Stress is a term that most people are familiar with
  • Stress can feel unpleasant and frightening at times.
  • While stress is not always bad, it can cause long term effects on our body and health if we are unable to cope
  • Pain and stress are very closely related.
  • Persistent pain can contribute to life stressors, and chronic stress can worsen the pain experience.
  • The good news is that anything that helps you manage stress can also help your pain, and anything to help with pain can also help you cope with stress.

  • By going through common sources of stress and warning signs, you will begin to identify your own personal stress and knowing more about what can be done to improve your stress and its impact on pain.

In this module you will learn:

  • What stress is and why people experience stress.
  • How stress and pain are related.
  • How to identify your stress triggers and warning signs.
  • How to cope with stress in healthy ways.

About Stress

  • Stress is a natural response within our bodies when we feel in danger, under threat, or our brain feels that we do not have the resources to cope.
  • When you think of a situation or event as being overwhelming, beyond your abilities to cope, and threatening to your well-being, then it is considered “stressful”.
  • Stress can motivate us to action and protect us when faced with danger.
  • The stress response is adaptive in that it can help us protect ourselves, for example a car coming toward you at an intersection or a bear chasing you in the woods.
  • The stress reactions allow our bodies to have the energy to get to safety and drives us to action.

A stress response....

Stress is related to a primitive system in our body called the “Fight-Flight-Freeze” response. This evolved from our need to survive, enabling people and other mammals to react quickly to life-threatening situations. To understand the fight-flight-freeze response you have to understand how the nervous system and the parasympathetic nervous system work together to deal with the threats we face and help us recover. Both of these systems control the same group of body functions, but they have opposite effects on the functions that they regulate.

All of these body changes are designed to maintain long-term heath, conserve energy and maintain a healthy balance in our body. Stress reactions and relaxation responses cannot happen at the same time.

Key Concepts:

  • The Stress Response (Fight-Flight-Freeze) protects you from threat by preparing your body for action.
  • The Relaxation Response (“Rest and Digest”) allows the body to relax and repair after a threat has passed.
  • The stress and relaxation responses balance each other, offering opposite, but complementary effects.

Not all stress is bad. Some stress is considered healthy. 

Some people may think that “stress” is always bad, but as you now know stress can help protect us from danger. Stress can also be the result of positive events in our lives (e.g., the birth of a child, a promotion at work, physical activity). Some events such as deadlines and competitions, may produce feelings of eagerness and excitement that motivate us and help us perform, especially when we think that we have a chance of succeeding.

Types of Stress

  • Our bodies react the same way to physical danger as we do to emotional stressors, therefore it is important to recognize the sources of our stress.
  • Stress is typically broken down into two types: acute stress and chronic stress.
  • Acute stress is any stress that you experience for a short period of time and chronic stress is long-term stress often caused by being faced with the stressor or multiple stressors on an ongoing basis.
  • Acute Stress

    • Being chased by a bear
    • Being in the path of an on-coming car
    • Having an argument with a friend
    • Being late for an interview
    • New baby 
  • Chronic Stress

    Chronic stress

    While the stress response is helpful when we are faced with an acute danger, problems arise when we experience stress for a long period of time or when it is triggered when it isn’t necessary. In times of stress, the body’s short term survival systems get energy and the body’s long term survival systems do not, for this reason chronic levels of high stress can have a negative effect on our overall health can well-being. Chronic elevate stress can result in:

    • Increased risk for heart disease, diabetes, high blood pressure, obesity, stomach ulcers, reproductive disorders.
    • Weaker immune system
    • Increased cortisol and other stress hormones can disrupt almost all of your body's systems such as immunity, digestion and reproduction.
    • Increased fatigue
    • Digestive problems
    • Muscle tension
    • Difficulty sleeping
    • Poor memory
    • Burnout
    • Negative moods (depression, anxiety, irritability, anger)
    • Decreased work performance
    • Strained relationships


    Examples of Chronic Stress include: 

    • Living in a high crime neighborhood
    • Having a demanding job
    • Living with financial problems
    • Living with chronic pain/ illness


Stress and Trauma

  • Chronic stressors, particularly when they occur in early childhood, have the potential to change how the nervous system responds (Vinalli, 2016, Goldstein, 2019).
    • Up to 40% of people presenting for pain treatment also have PTSD (Goldstein, 2019)
    • Up to 75% of people presenting for PTSD treatment also have chronic pain (Goldstein, 2019).
    • People with both PTSD and pain report more pain sensitivity, functional interference and disability.
    • Past adverse experiences, threats of death, serious injury or violence may contribute to the development of chronic pain and mental health disorders.
  • Adverse Childhood Experiences (ACE)

    • Physical violence from parents or caregivers
    • Sexual abuse
    • Neglect
    • Being separated from parents or caregivers frequently or for a long time
    • To check your AE score, you can visit
  • Traumatic Experiences

    • Sexual or physical assault
    • Highly stressful medical interaction
    • Historical trauma, intergenerational transmission of trauma, race-based trauma

Key concepts:

  • Chronic stress that occurs in early childhood has the potential to change our nervous system. 
  • Knowing your ACE (adverse childhood events) score can be a helpful tool to identify whether chronic stress from early childhood may be affecting your current stress and pain.

Identify your sources of stress  

Finding effective ways to cope with stress begins with knowing what causes you stress.

  • Stress triggers (often called stressors) can be internal or external
  • Internal stress comes from inside of us (e.g., your personal goals, expectations, attitudes, beliefs)
  • External stress are factors from our environment or from others that cause us stress.

Below are a list of common stressors, Identify which apply to you and start to think about what strategies you may implement to decrease the impact of these stressors on your overall wellbeing.


Internal stressors

  • Lifestyle choices

    • Caffeine
    • Lack of sleep
    • Overloaded schedule
    • Unhealthy diet
  • Unhelpful self-talk

    • Pessimistic thinking
    • Unrealistic expectations
    • Taking things personally
    • Self-criticism
    • Black and white thinking
    • Overanalyzing
    • Worrying about problems instead of problem-solving
  • Expectations and beliefs

    • Needing to please others
    • Reluctance to ask for help
    • Difficulty saying no
  • Physical Symptoms

    • Chronic pain
    • Headaches
    • Illness
    • Fatigue


  • Difficult emotions

    • Anger
    • Sadness
    • Anxiety
    • Guilt
    • Lack of motivation

External Stressors

  • Physical environment

    • Noise
    • Crowds
    • Bright lights
    • Temperature
    • Tight spaces
  • Social factors

    • Arguments
    • Rudeness
    • Aggressiveness
    • Being told “no”
    • Stigma or discrimination
    • Asking for help
  • Major Life Events

    • Death of a friend, relative, or pet
    • Losing a job
    • A promotion
    • Marriage
    • New baby
    • Retirement
  • Daily hassles

    • Waiting
    • Commuting
    • Misplacing keys
    • Mechanical breakdowns
  • Social and cultural stressors

    • Racism 
    • Homophobia
    • Lack of social or financial supports
    • Inaccessible spaces

Key concepts:

  • Stressors can be both internal or external
  • Identifying the source of our ongoing stressors can serve as a starting point for implementing stress managing strategies

Learn your own warning signs:

Everyone experiences stress in different ways. What are the thoughts, (e.g., “I can’t cope”), moods (e.g., anxiety), physical symptoms (e.g., headaches), and behaviors (e.g., becoming short with others) that are “yellow flags” that you are building up to stress? The following is a list of common warning signs that you might be experiencing increased stress see which apply to you, or you can download the checklist here: 

  • Physical Symptoms

    • Muscle tension
    • Fatigue
    • Chest Pain
    • Indigestion
    • Headaches
    • Sleep problems
    • Tics
    • Low sex drive
    • Tremors
    • Muscle Spasms
    • Sweating
    • Hot/cold flashes
    • Feeling Faint
    • Constipation/Diarrhea
    • Heart palpitations
    • Rapid breathing
  • Emotions

    • Anxiety
    • Irritability
    • Anger
    • Sadness
    • Depression
    • Overwhelmed
    • Helpless
    • Hopeless
    • Confused


  • Thoughts

    Thoughts related to themes of overestimation of bad events occurring, our inability to cope with stressors or low-self-esteem. For example:

    • “I can’t cope”
    • “I should be able to do this”
    • “I can’t do anything right”
    • “I should not ask for help”
    • “I can’t do this”
    • “It’s going to be a disaster”
    • “I’m going to be blamed”
  • Behaviours

    • Procrastinating/overcompensating
    • Avoidance (behavioral or cognitive)
    • Angry outbursts
    • Crying
    • Impulsivity
    • Overeating/reduced eating
    • Tobacco/alcohol/drug abuse
    • Misusing medication
    • Social withdrawal
    • Reduced exercise
    • Excessive shopping/TV watching etc.
    • Pacing/fidgeting/biting nails
    • Having problems making decisions
    • Being clingy

Managing Stress

We can think about the experience of stress like a forest fire.

  • Imagine a small campfire. How difficult would it be to put this fire out? Probably not too difficult. It might take a  little energy, some water, and a little time.
  • Now, imagine a roaring forest fire. What would it take to put this fire out? A lot more resources! It might take a long time and require a lot of people to help. 
  • This is like stress. When stress is low, like a small campfire, it takes a lot less personal resources to deal with it. 
  • When we allow stress to build by not implementing strategies to reduce our stressors early, it becomes harder to manage.

Stress Log

  • It may be helpful to reflect on your day and think about a stressful situation that you were faced with, can you identify any thoughts or emotions that popped into your head?
  • What did you do at the time to manage that stressor? Was that coping strategy helpful? This may serve as a good starting point to determine some stress management strategies you may want to explore or implement.

Here is a worksheet to help you identify your personal stress warning signs (.pdf)

Top Strategies for Managing Stress

Here are several different kinds of changes you can make to help you manage stress. Review these lists and note which ones you want to try. If you reflect on the boxes above think of what your biggest stressors are and how to modify. 

  • Breathing

    • o It only takes 3 minutes to turn off the stress reaction and turn on the relaxation reaction with deep breathing!
      o Deep breathing sends a powerful safety signal through the nervous system.
      o Breathe into your belly and lower ribs, allowing the lungs to fill up completely
      o Breathe out slowly, feeling the body relax

    Free On-Line Recordings:

    Cara Kircher – Chronic Pain Service at Toronto Rehab, Rumsey Centre

    Chronic Pain Program, Alberta Heath Services


  • Exercise

    • Improves mood and decreases the stress response for up to a day after the exercise session
    • Exercise allows the body to have an outlet to release the extra energy and sugar that it has built up through the stress reaction (increase in oxygen to the muscles, increase in blood sugar, increase in heart rate etc).
    • Exercise’s effect on stress only lasts for approx. 24 hours to it is important to practice exercise regularly
    • Exercise is only effective for stress if it is an activity that you enjoy doing, if you feel “forced” to do it it may have a stress inducing effect. For example someone may enjoy dancing as a means of exercise, if you hate music or don’t enjoy exercising in a group it may be stress provoking.
  • Meditation

  • Relaxation

    • Can be informal, like taking a bath, journaling, or listening to music
    • Can be formal, like progressive muscle relaxation or visual imagery

    Cara Kircher – Chronic Pain Service at Toronto Rehab, Rumsey Centre

    CPS Progressive Muscle Relaxation

  • Social Support

    Research shows that when people experience a stressor/stressful situation with a stranger, the reaction is larger. When people are around friends or people who are supportive, the reaction is decreased. When people have social support during a stressful event, the cardiovascular stress response and resting cortisol (stress hormone) levels are lower.

    • Spend time talking with people you trust and who support you
    • Give support to others- kindness to others is a positive way to feel a sense of control as well as social support and connectedness.
  • Create predictability in routine

    • Create schedules and routines so the mental load of activities is lowered
    • Learn ways to budget
    • Seek support for stability in housing, finances and work
  • Figure out where it is helpful for you to have control

    Just knowing or feeling like you are in control can help lower stress. Think back to the definition of stress earlier in the module: stress occurs when there is a mismatch between the demands of a situation and perception of coping skills. When there is high demand and low sense of control, stress can increase. Be aware of trying to have control over events in the past (where things may have already happened and are beyond our control).

    • Create realistic SMART goals
    • Learn ways to be aware of our emotions, thoughts and behaviours

Step by Step guide to managing stress

To learn to manage stress you can download this worksheet 

  • Key concepts:

  • Practicing these strategies can help you to learn when a particular strategy will be useful, and to choose the right stress management strategy at the right time.

  • Being flexible about your stress management strategies can help you have more options. 


  • There are many healthy ways to manage stress.
  • Top strategies for stress management include:
    • Adopting healthy lifestyle habits
    • Finding ways to relax and enjoy life
    • Cultivating more healthy and balanced ways of thinking
    • Adopting positive attitudes towards yourself, others, life
    • Changing how you feel when experiencing strong, negative emotions


  • Managing stress works best when you use a variety of strategies.



  • Insight Timer
  • Calm
    • Website:
    • Has both free guided meditations and paid subscription options
    • Available on Google Play or Apple Store
  • Smiling Mind
    • Website:
    • Free meditation resources for children, teens, and adults
    • Available on Google Play or Apple Store
  • Meditation Oasis
    • Website: – Click on “Podcast”.
    • There are many free guided meditation tracks that you can stream online, as well as some tracks and apps that are for sale.
  • Headspace

YouTube Videos

Channel Name: Cara Kircher

Video names:

  • Gentle Tai Chi and Qi Gong LEAP Service
  • Gentle chair yoga 10 min
  • CPS Progressive muscle relaxation
  • CPS Breathing space

Channel Name: DocMikeEvans 23 and 1/2 hours

Video names:

  • What is the single best thing we can do for our health?

Channel Name: Aboutkidshealth Stress and Thinking

Video names:

  • The Mind/Body Connection



  • The Relaxation and Stress Reduction Workbook. By M. Davis, E. Robbins Eschelman, & M. McKay (2008).
  • Get Out of Your Mind and Into Your Life: The New Acceptance and Commitment Therapy. By Steve C. Hayes (2005).
  • The Happiness Trap: How to Stop Struggling and Start Living: A Guide to ACT. By R. Harris (2008).
  • The Client’s Guide to Cognitive-Behavioural Therapy. By Aldo Pucci (2006).
  • The Anger Control Workbook. By M. McKay and P. Rogers (2000).
  • The 10 Best-Ever Anxiety Management Techniques Workbook. By M. Wehrenberg (2010).
  • The Mindfulness Solution to Pain. By J. Gardner-Nix (2009).
  • The Mindful Way Workbook. By Williams, Teasdale, & Segal (2014).
  • Full Catastrophe Living – Revised Edition. By Jon Kabat-Zinn (2013).



  1. Abdallah, Chadi, & Geha, Paul. (2017). Chronic Pain and Chronic Stress: Two Sides of the Same Coin? Chronic Stress, 1, 1-10, DOI: 10.1177/2470547017704763
  2. Borsook, D., Maleki, N., Becerra, L., McEwen, B., 2012. Understanding migraine through the lens of maladaptive stress responses: a model disease of allostatic load. Neuron 73, 219–234.
  3. Otis, J. D., (2007). Managing Chronic Pain: A Cognitive-Behavioral Therapy Approach. New York: Oxford University Press, Inc.
  4. Sapolsky, R. (2004). Why Zebras don’t get Ulcers, 3rd Edition. New York: St. Martin’s Press.
  5. Staal, M. (2004). Stress, Cognition, and Human Performance: A Literature Review and Conceptual Framework. California: NASA Ames Research Center.
  6. Vachon-Presseau, E. (2017). Effects of stress on the corticolimbic system: implications for chronic pain. Progress in Neuropsychopharmacology & Biological Psychiatry,
  7. Yerkes-Dodson Law. Wikipedia. Retrieved on Dec. 5, 2017 from:

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