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Stress and Heart Disease

The close relationship between stressful emotions and heart disease has been recognized since antiquity. In fact, the ancient Greeks and other early cultures believed that the heart, rather than the brain, was the seat of emotions. We still describe people as being "broken hearted" following some severely stressful event, such as the loss of a loved one. People who are generous have a "heart of gogold", or are "good hearted", while "heart of stone" and "cold hearted" describe opposite temperaments. Being brave is to be "stout hearted", and if you are timid, you are "faint of heart". The heart was viewed as being the essence of life. And, if you want to "get at the heart" of anything from an argument or an apple, you go to its "core", which comes from cor, the Latin word for heart.

One of the problems in studying the relationship between stressful emotions and the heart, is the difficulty scientists have in defining stress, much less being able to measure it accurately. After all, exactly what is stress? Although it had been used in physics for hundreds of years, the term as it is commonly used today, was essentially coined only 60 years ago, by Hans Selye, a brilliant Canadian researcher. He used it to describe a series of responses in laboratory animals subjected to severely disturbing physical or emotional threats, which, if persistent, produced ulcers, heart attacks, hypertension, arthritis, kidney damage, and other diseases. Selye reasoned that if stress could do this in his experimental animals, then perhaps it played a similar role in patients suffering from these disorders, which he referred to as "Diseases of Adaptation". While his research was initially of interest primarily to other basic scientists, Selye's theory and concepts steadily spread into all branches of clinical medicine, and "stress" eventually became a popular buzz word.

A 1983 cover story in Time magazine referred to stress as "The Epidemic of the Eighties", and numerous surveys have shown that the problem has progressively worsened since then. It's difficult to get through the day without reading or hearing something about "stress". Why all the sudden fuss? After all, stress has been around since Adam and Eve were in the Garden of Eden. Is it because there is much more stress today? Is it because the nature of contemporary stress is somehow different, and more dangerous? Or is it because scientific research has increasingly confirmed the important influence of stress in numerous diseases, and uncovered the mechanisms of actions responsible for its diverse effects on physical and mental health? All of these are undoubtedly ingredients. It is estimated that 75-80 percent of all visits to primary care physicians in the U.S. are for stress related complaints, and it is difficult to think of any illness ranging from the common cold to cancer, in which stress could not play a contributory role. The major source of stress for adults stems from workplace pressures. Four out of five American workers describe their jobs as being "very stressful", and the World Health organization declared that job stress has now become a "worldwide epidemic".

However, stress signifies different things to each of us. Some people use it to describe an unpleasant circumstance, like losing your job, while others view stress to refer to the way such challenges make you feel (anger fear, depression), symptoms you experience (angina, palpitations, stomach pain, diarrhea, headache), or even illnesses that seems to result from this (heart attack, stroke, ulcer). Stress is also very different for each of us. Things that are very distressful for one individual may be pleasurable for another, or have little significance either way. That can be readily illustrated by observing passengers on a steep roller coaster ride. Some are hunched down in the back seats with their eyes shut, jaws clenched, and white knuckled as they clutch the retaining bar. They can't wait for the ride in the torture chamber to end so they can get back on solid ground and get away. But up front are the wide-eyed, exhilarated thrill seekers, yelling, and relishing every steep plunge, who actually race to get on the very next ride! And in between, you may find a few with an air of indifference or nonchalance that seems to border on boredom. So, was the roller coaster stressful? Obviously, it's different strokes for different folks.

The roller coaster ride is a useful analogy for several reasons. What distinguished the passengers in the back from those in the front was the sense of control they perceived over the event. While neither group had any more or less control, their perceptions and expectations were quite different. Thus, although you can't define stress objectively, all of our animal and human research confirms that the sense or feeling of being out of control is always distressful. That's what stress is all about. Roller coaster rides, jobs, and people, are not inherently stressful, it's often how we perceive them. As with the roller coaster, we often create our own stress because of faulty perceptions, and that's something you can learn to correct. You can teach people to move from the back of the roller coaster to the front, and nobody can make you feel inferior without your consent.

In The Broken Heart: The Medical Consequences of Loneliness, Dr. James Lynch provides some compelling examples and statistics about the relationship between the stress of bereavement and loneliness with heart disease. The best validated rating scale used to measure the severity of stress places death of a spouse at the top with a value of 100, followed by loss of other important relationships like divorce (73), marital separation (65), and going to jail and death of a family member (63). Getting a traffic ticket (14) is at the bottom of this list of some 43 other stressful events. Stress levels are determined by adding up the total of how many of these have been experienced over the previous 12 months. Thousands of scientific studies have confirmed that the higher the score, the greater the likelihood that you will become sick during the next six to twelve months. Widowed individuals die at rates three to twelve times higher for all the leading causes of death within a year or two following the loss of their mate than married controls. Cardiac deaths are especially high during the first six months of bereavement. A greater risk for heart attacks has also been demonstrated for a variety of other stressful emotions, including depression, anxiety, fright, hostility, and anger, especially when you keep your anger suppressed. We "take things to heart" not only figuratively, but literally. Sudden death, which is the leading cause of death in the world, is very frequently associated with an outpouring of stress related hormones that cause serious disturbances in heart rhythm that can be fatal, even in young, healthy people.

Such "fight or flight" responses to stress have been exquisitely honed over the lengthy course of man's evolution as life saving measures. Under severe stress, heart rate and blood pressure soar, blood sugar rises to furnish fuel for energy, blood is shunted away from the gut where it not immediately needed for purposes of digestion to the large muscles of the arms and legs, to provide more strength in combat, or greater speed in getting away from a scene of potential peril. The blood clots more quickly to prevent loss from hemorrhage, our pupils dilate to improve the range of vision, and a multitude of other reactions over which we have no control are immediately and automatically evoked. All of these would have been useful, if not life saving, in helping primitive man to deal with sudden threats that demanded immediate fight or flight. However, the nature of stress for modern man is not an occasional physical confrontation with a saber-toothed tiger or a hostile warrior , but rather a host of emotional threats, like getting stuck in traffic, fights with customers, co-workers, or family, that can occur several times a day. Unfortunately, our bodies still react with these same, archaic, stereotyped responses, that are now not only not useful, but damaging and deadly. Repeatedly invoked, it is not hard to see how they could cause heart attacks, hypertension, strokes, ulcers, muscle spasms, and other "Diseases of Civilization".

It is important to recognize that stress is not always necessarily bad. Winning a race or election can be just as stressful as losing, or more so. A passionate kiss and anticipating what might follow is stressful, but hardly likely to be accompanied by the same psychophysiologic responses as having root canal surgery. Increased stress also increases productivity - up to a point, after which things deteriorate. It's equally important to emphasize that this level differs for each of us. It's very much like the tension or stress on a violin string. Not enough results in a raspy, grating noise, but too much produces a shrill note that is irritating, or breaks the string. However, just the right amount of stress creates melodic and harmonious tones. Similarly, we all have to find the optimal amount of stress that allows us to make pleasing music in our daily lives, rather than causing us to snap.

Just as stress is different for all of us, no stress reduction strategy works for everyone. Jogging, meditation, yoga, deep breathing or progressive muscular relaxation exercises are great for certain individuals. However, when arbitrarily imposed on others, they can be boring and stressful. Certain types of music have been demonstrated in scientific studies to relieve stress and anxiety in patients about to undergo surgery, in surgeons while they are operating, and to improve immune system function, and reduce pain and post operative complications and duration of hospitalization. Some people find that reading, engaging in hobbies, volunteer work, or aromatherapy, reduces their stress, and you have to find out what works best for you. This is especially important for patients with coronary heart disease. A report in the American Journal of Cardiology showed that men suffering from severe angina improved significantly with meditation. Numerous other studies confirm that walking, regular exercise, music, and other stress reduction activities can also remarkably reduce risk for heart attacks and sudden death.

Stress is an unavoidable consequence of life. There are some stresses you can do something about and others you can't. The trick is in learning how to distinguish between the two. The best way to accomplish this is to take the time to write down all the things that you find stressful in your life. Then separate them into two lists; those you can't possibly hope to avoid or influence, and others that you might be able to control, like changing your work hours to coincide with times of less traffic so your commute takes 15 minutes instead of an hour each way. Try not to become preoccupied with the first list. If a loved one dies, it's obviously stressful, but there is nothing you can do about it. If you can't fight and you can't flee, you have to learn to flow.

Prioritize the items on the second list, so that you can use your time and talents more effectively, rather than being like Don Quixote, tilting at windmills. If one of the items on this list is commuting time/traffic, i.e, what could be a 15 minute commute to work takes you an hour each way because of traffic jams, you could ask your superviser if you can come in and leave one hour earlier. If that's not possible, then instead of fuming and honking your horn, use this time to listen to a tape of a book you haven't had time to read, or to learn a foreign language. This will allow you to achieve a better sense of control over your life, and help you to utilize stress, so that it makes you more productive, rather than self destructive.

Paul J. Rosch, M.D., F.A.C.P.
President, The American Institute of Stress
Clinical Professor of Medicine and Psychiatry
New York Medical College

The American Institute of Stress publishes many more quality articles in their monthly newsletter Health and Stress. Click here for a table of contents of their magazine from 1994-2001. Click here for information on subscribing and ordering back issues (available from 1988) or email stress125@earthlink.net or call 914-963-1200.

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