STRESS AND DISEASE: PSYCHOSOMATIC MEDICINE 101

1. STRESS AND DISEASE: PSYCHOSOMATIC MEDICINE 101 Leonard L. Magnani, M.D., Ph.D. Medical Consultant and Staff Physician Alta California Regional Center

2. Proverbs • “Good tidings strengthens bones”--16:24 • “A depressed spirit will make bones wither” --17:22

3. Mind→ Body→ Mind→ Body→ “I have learned this: It is not what one does that is wrong, but what one becomes as a consequence of it.” Oscar Wilde • In advanced biological systems, “software” slowly changes “hardware” (e.g., repressed anger hardens arteries); and hardware helps rewrite software (e.g., a fit, healthy and relaxed body promotes serene and joyful contemplation).

4. Definitions: Stress and Psychosomatic Disease • Stress—a reaction to a situation, not the situation itself; not necessarily “bad”(Example: Sky diving on an 80th Birthday vs. bailing out of a burning airplane→PTSD) • Our focus: Bad stress, the kind of reactions “we wish would go away”

5. Bad Stress is Dis-Ease, and Responds to Treatment • Inability to cope with environmental demands in a healthy (“wholeness”) way causes the fragmentation and disruption of our soma (body) and our thinking (psyche). • This stressful situation makes many people who experience it, physically ill. • By definition this reaction of “stress” has the potential to cause physical harm.

6. So it’s all in my mind? (“Mind?”) • Mind is an “activity” and the stress reaction is not “all in your mind,” in your thinking. (We term that “hysteria,” and it’s a mental illness.) • Stress is a physical (physiological) response to undesirable situations or intrusive thoughts. • If the “thinking” about a situation or event continues afterwards, stress becomes “chronic.” • Chronic stress reactions may disrupt and control both a person’s work and home life.

7. Psychosomatic Diseases are Physical Diseases Caused by Chronic Stress Reactions We can assert that, “All human diseases have a psychosomatic component, one often overlooked.”

8. Mind-body duality is really a mind-body blend. • Thoughts impact physiology; body sensations impact our thinking. We are conscious of only a very tiny fraction of our thoughts. All circuits must be replayed by the unconscious mind(the good, bad and ugly) or they are lost forever. • Verbal and non-verbal representations of the past can promote or exacerbate harmful physiology. • Automatic or conditioned responses to situations w/o any thoughtful reflection (mind) can promote illness. • Noisy environments, rush hour traffic  tight neck muscles and chronic headaches

9. Normal Human Physiology:The General Adaptation Syndrome(GAS) Stress reactions, and the diseases they are capable of creating, are a large part of what it means to be a human primate. (It’s in our nature to get stressed out!)

10. The Autonomic Nervous System Protects Us From Danger • 1. Sympathetic—regulates arousal;the physiologic “preparation” to go into battle or to run and escape (fight or flight). • 2. Parasympathetic—regulates relaxation, recuperation, body temperature and waste management; it prevents “exhaustion.”

11. Neuroendocrinology: The Brain Squeezes Those Glands • Hypothalamic-pituitary-adrenal (HPA) axis: Hypothalamus sends corticotropin releasing hormone (CRH) to pituitary gland  releases adrenocorticotropin hormone (ACTH) and beta-endorphins into blood stream; ACTH stimulates adrenal cortex, which then releases cortisol, the “king of steroids.”

12. Cortisol is what runs amok: • Cortisol, in low or healthy levels— • improves memory, learning & reasoning speed,relaxes gut, helps utilize glucose for bursts of energy. • Chronic high-level cortisol release produces disease: • Hypertension, cardiomyopathy and heart failure, digestive and ulcer disease, brain (hippocampal) impairment and cognitive/emotional problems; it can cause diabetes and greatly accelerate atherosclerosis. • “Alpha” baboons always die young—Newer research: “Smart” beta baboons live the longest.

13. Hypothalamic-Adrenal-Medullary System • Hypothalamus stimulates arousal; it causes adrenal gland to release adrenalin (epinephrine) and the other catecholamines. • Epinephrine and norepinephrine  heart rate, open lung’s airways,  blood supply of glucose and the sugar’s utilization, produces muscle toning, strength, and speed of movement. • Excessive, chronic release of catecholamines  blood vessel wall (musculares) thickens and high blood pressure and cardiac arrhythmias occur, with eventual depletion, exhaustion and collapse.

14. A Few Examples of Psychosomatic (Stress Exacerbated) Diseases

15. The Cardiovascular System • Anger (especially suppressed hostility)increases renin and heart enlargement. • More left ventricular hypertrophy (LVH) in NYC, as well as more mitral valve prolapse (MVP). • Arteriosclerosis, hardening of arteries, is accelerated by tension and stress; relaxation slows it down. • Suppressed anger and personality (type A or B) effect blood clotting and the risk for stroke or heart attack. • Emotional stress can induce arrhythmias.

16. Mental Stress Can Induce Cardiac Instability Mental stress such as anger recall and frustration can induce deadly EKG changes in patients with arrhythmic vulnerability. This can occur at much lower heart rates than with exercise, according to the results of several studies.

17. American Heart Association on Stress and Serious Heart Disease: • Individuals who’s blood pressure spikes during stressful situations are six times more likely to have a heart attack (pulse may not change or might even slow down during mental stress). • Even if “mental stress-free” for some time, this increased risk persists for 5-6 years. • “Hot responders” or “hyper-reactors” are “completely unable to judge their physical response to mental stress.”

18. Immunological Diseases:The Stress response diminishes immunity and increases histamine release. • Asthma increases—along with resistance to asthmatic therapy—as the stress response progresses (i.e., becomes “chronic”). • Herpes simplex II occurs six times more in “stressed populations;” recurrences correlate highly with an active “stress life.”

19. More on the Immunological Impact • Production of IGG and other beneficial immunoglobulins are reduced by chronic stress responses; feeling “distress” from life situations triples the chance of “catching a cold” or even a Strep throat infection. • Autoimmune disease antibodies and rheumatoid factor (IGM fraction) are increased by chronic stress.

20. Neuroimmunoendocrinology • Lymphocytes have receptors for endocrine complexes and for neurotransmitters. • Increased cancer rates and increased rates of mononucleosis and chronic fatigue syndrome are found in the chronically stressed. • Stress reduction augments chemotherapy.

21. Gastrointestinal Diseases:The “Brain” in the Gut Responds to the Blood’s Chemical Messengers and the Vagal Nerve signals.

22. Trouble in the Tunnel: • The chronic stress response disrupts the multi-wave transmission called “peristalsis.” • Mildest problems: constipation and sometimes “irritable bowel syndrome”; some more serious problems from chronic stress are diverticulitis and very painful ulcerative colitis. • Stomach acid production increase, combined with the inhibition of base secretion, is a result of chronic stress reactions→ ulcers.

23. The Gut and Stress Continued: • Gastroesophageal sphincter integrity is compromised by the stress response (GERD) • Liver and pancreas are sensitive to many hormones and neurotransmitters; insulin secretion, “resistance,” and body weight (fat storage, metabolism, and diabetes) are all influenced by the chronic stress response.

24. Mental Illness May Be Induced Or Exacerbated By Chronic Stress Responses

25. Anxiety and Panic Attacks: • Anxiety is worsened by stress responses. • Worries impact physiology; body chemistry engenders worry. • Panic attacks are sometimes caused by subconscious, stressful ideation, and sometimes by loss of control of normal physiology (inhibitory mechanisms) because of prior (conditioned from past experiences) chronic stress responses.

26. PTSD • Post traumatic stress disorder (PTSD) is worsened by patterns of chronic stress responses, which makes the individual more vulnerable to intrusive thoughts, to chronicpoor sleep/bad dreams, to hypervigilance, and a detachment from meaningful participation. • There is a belief in the “hopelessness” of any future reality.

27. Depression and Loss of Interest • Depression is worsened by brain serotonin depletion caused by chronic stress responses. • A very vicious cycle since low brain serotonin increases likelihood of a stress response • Burn-out is a form of depression: • Very common among health care & social workers • Chronic stress response consumes fuel & promotes: • Emotional exhaustion (loss of sense of accomplishment) • Depersonalization, cynicism, “rule rigidity,” interpersonal conflicts, lost or frustrated ideals

28. Some Other Diseases Influenced By Psychosomatic Physiology

29. Every Part of the Body is “Hurt” • Seizures are inhibited by relaxation and stimulated by stress reactions. • Fibromyalgia is very rare in those low in stress responses; in the stressless ones, almost no micro-muscle trauma is found. • Prostaglandins are increased and endorphins decreased by the biochemistry of chronic stress, which causes amplification (not attenuation) of chronic pain signals. Poor sleep hygiene plays an important part in this.

30. Back pain is more often promoted by stress responses than by morphological pathology, that is, MRI visualized spinal disease. • Stress responses increase muscle spasm (“armoring”), they decrease spinal blood flow, and they cause “CNS disassociation.” • Headaches of all kinds, vascular and muscle traction type, are stress response associated; frequently, most vulnerable time is mid-exhaustion phase, long after the planes have all safely landed on the ground.

31. Even Tissue Malignancies… Some forms of cancer have been related to personality type: • Increase in these malignancies is found in the“type C personality,” someone who represses all outward signs of emotion, all evidence of stress. • Type A personality, while heart attack prone, does better with chemotherapy and cancer survival.

32. How Stressed-Out Are We Now? Are We On Fire Or In End-Stage Burn-Out? How Much Conflict Is There In Our Lives? Is There Someone Who’s “On Our Case” or “Out to get us”?

33. Take A “Stress Test” On These Tests, Chronic High Scores Correlate With a Higher Incidence of Physical Diseases

34. Some Stress Tests That are Used: • Assess the degree of stress due to frustration and inhibition • Assess our vulnerability to “overload” • Assess our degree of perfectionism and/or self-righteousness • Measure our compulsive, time-urgent, and aggressive behavioral traits • Assess whether we are fixated on outcomes or are more process oriented

35. Stress Management:Various Strategies and Therapies That Treat Or Prevent Psychosomatic Diseases

36. There’s a Long List of Successful Strategies and Therapies to Lessen Chronic Stress Responses: • Bio-feedback or progressive muscle exercises to relieve residual tension • Depression and anxiety medicines • Aerobic exercise programs • Proven methods to improve sleep patterns • Techniques that let cognitive therapy change the way we think and react • Meditation methods to help us become mindful and relax • Nutritional practices to physically replenish us • Spiritual practices that “feed” our inner spirit

37. Cognitive Therapy Works!(Alone, With a Therapist, or in a Self-Help Group)

38. Be Your Own Therapist Journal and log daily; write down what works and what doesn’t; what provokes the stress response, or, most importantly, how a different interpretation of events might have produced a less stressful response. Record in writing all of the antecedents & step-by-step events that produced the stress chemistry.

39. Say It Aloud & Say It Often! • Affirmations, repeated very frequently,really can change biochemistry. • Our erroneous beliefs and maladaptive behaviors are often invisible to ourselves; they must be shared. • Sessions with a therapist or support group often lead to a life-long freedom from our narrow, tunnel vision. • All situations can be placed in more than one “frame”. • But always, there’s a first and most important question: “What part do I play in all this?” • STOP BLAMING OR SHOULDING ON YOURSELF

40. Relaxation Techniques Are A Vital Part Of Stress Management

41. Relaxation Techniques Work! • Progressive visualization has three steps: • Relaxing with peaceful imagery • Engendering peaceful images and the images of the stressful situation at the same time • Thinking about peaceful and relaxing images while immersed in a real life stress response situation • Progressive muscle traction followed by progressive muscle relaxation exercises produce lasting reductions in intensity/frequency of stress responses. Yoga has 5000 years of proven benefits.

42. It’s the Breathing: • Deep breathing is a powerful tool. The most conscious act is forced exhalation; focus on inhalation and let the diaphragm be stretched by the outward pull of the abdominal wall muscles. Inhale very deeply; exhale slowly. This drastically alters sympathetic tone. • Conscious control of heart rate (pulse) and fingertip temperatures can be mastered by everyone; it just takes some practice.

43. Meditation: Journey vs. Destination • Meditation is enhanced by deep breathing; listen to our “chattering monkey brain,”just listen. Focus on breathing, a mantra, a candle flame, flower, favorite photograph, etc. “Don’t fight the river.” • No matter what relaxation technique is used, even sitting in a hot tub, assume a body or hand position that’s easy to duplicate when in situations producing stress responses; it returns us to the warmth even then.

44. Nutrition And Body Weight Can Amplify Or Attenuate The Stress Response

45. High Glycemic Diet=More Stress • Sugar is the primordial “drug.” Unfortunately, chemical “highs” have hidden costs. • Insulin homeostasis promotes relaxation;insulin excess (resistance) increases stress response. • Vitamins are coenzymes (they are not food); they require good nutrition or they are worthless. • We need to eat more (often); low fat protein in the morning is beneficial; simple carbohydrates (white & tan food, desserts, etc.) are a bane of good nutrition.

46. Gentle Exercise (Like Walking) Modifies The Stress Response And Lessens Psychosomatic Illness

47. No Pain, Still Much to Gain! • A progressive build-up of muscle mass changes our metabolism. All the organs benefit. • Taking control and accomplishing bodily changes increases self-assertiveness and self-esteem. Just take a few steps a day. • Physical conditioning changes stress arousal triggers, diminishes volatility, lengthens lives.

48. Sleep Deprivation, Even If At Low Levels, Enhances The Stress Response. Good Sleep Hygiene Helps Combat Against Psychosomatic Illness.Good Sleep = Good Health

49. How To Improve Each Night’s Sleep • Stop or cut in half use of alcohol, nicotine, and caffeine; none after 5 pm. • Discuss all your medications with your doctor, including non-prescription (herbal) products. • No napping. Keep bedtimes and wake up times the same, seven days a week. • Never go to bed hungry, or on full stomach. • Institute pre-bedtime, 30-minute relaxation periods, away from the physical bedroom.

50. More on good sleep….. • Exercise is a great benefit to help with sleep: aerobic, but at least 4 hours before bedtime. • Bedroom is for sleep only. • No TV, no music, no lying in bed worrying or making plans. • Get out of bed, write worry or “to do” list in the kitchen, then leave it there for a morning look. • Never allow yourself to see the clock dial while in bed.