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Let’s talk about stress…
Edith Henry Study Day
May 13, 2009
Jeffrey P Schaefer MSc MD FRCPC
Title: Sod-turning ceremony, General Hospital, Calgary, Alberta. Date: September 24, 1954
Dr. L.O. Bradley (hospital administrator); Miss G.M. Hall (director of nursing); Alice Gehman, (associate
director of nursing education); Miss M.M. Street (assistant director of nursing); Mrs. W. Lupypciw
(president alumnae association); Lorraine Digney (president of class of 1955); Eva Austen; Joan
Nicholls (president of class of 56); Jeanne Gammon; Mrs. Edith Henry (association director of nursing
service); Dorothy Cannon (home matron).
website
dr.schaeferville.com
Conflicts of Interest
• none
Objectives
• Session participants will learn that:
– the current paradigm is insufficient
– a psychobiological framework fits observations
– there is more to stress than stress
– we can reduce the effects of stress
Case
• 46 year old health care provider
total body pain and fatigue x 5 years
assessed by GIM, Neurology, Gastroenterology
investigations  normal
Problem List
– daily occipitofrontal headache
– chest pain, episodic, at work
– abdominal pain
– fatigue
– poor concentration & dizziness
– work issues
What’s your diagnosis?
Diagnosis: ______________________
Diagnosis Menu
• What’s your diagnosis / diagnoses?
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Chronic Fatigue Syndrome / Idiopathic Chronic Fatigue
Fibromyalgia
Tension Headache
Irritable Bowel Syndrome
Multiple Chemical Sensitivity Syndrome
Interstitial Cystitis
Hematuria Loin-pain Syndrome
Depression and Anxiety
Conversion Disorder
Somatization
Medically Unexplained Symptoms
• Physical symptoms that prompt the
sufferer to seek health care but remain
unexplained after an appropriate medical
evaluation.
Medically Unexplained Symptoms
Headache
Chest Pain
Irritable Bowel
Infertility
Fibromyalgia
Chronic Fatigue
Dizziness
Are Medically Unexplained
Symptoms Common?
MUS Prevalence
• 30% of primary care visits
• 13.6 visits in the previous year
Psychosomatic Med 2005;67:123-9
Most Frequent
Visitors 5th percentile
GI……………. 54%
Neuro…….. 50%
Rheum……. 33%
ENT………….27%
GIM………… 10%
This is a problem!
This is a big problem!
Unhappiness is…
• Patients Feel Unheard
– physician centered approach
• 69% of MD’s interrupt at 18 sec into the interview
• Ann Int Med 1984:101
– physician patient incongruence
• longer the patient talks  more likely to prescribe
• Psychosomatic Med 2007;69:571-7
– Why reassurance fails?
• PLOS Medicine 2006
P(Disease)
MUS
Depressed
Controls
15%
10%
5%
25
One condition or many?
Chronic Fatigue Syndrome
Fibromyalgia
Irritable Bowel Syndrome
Multiple Chem Sensitivity Syndrome
Sick Building Syndrome
Hypoglycemia
War Syndrome
BodilyGulf
Distress
Disorder
Undocumented Labels
Headache Syndromes
Asthma
Painful Conditions
Various
• Do functional symptoms cluster in a way
that support multiple conditions?
– Cross sectional survey of patients with
functional symptoms
– Screened 2,300 patients  978 were judged
functional
Median Number of Symptoms
Men  4
Women  6
Men & Women  5
“Bodily Distress Disorder”
Fink et al. Psychosom Med 2007
Chest Pain Group
GI Symptoms Group
Musculoskeletal Group
< 3% of patients had symptoms
confined to their predominant group
3 group model explained 36% of the variance
• associated with anxiety
• preoccupied with symptoms
• preoccupied with illness
• low threshold to request consultation
• difficult / impossible to reassure
Multiplicity of diagnostic
labels is an artifact of
medical specialization.
Psychobiology
‘the mind-body connection’
Talk about Stress...
Acute Stress Response
Fight, Fright, Flight, Frolic Response
Hans Selye (1907-1982)
General Adaptation
Response
– Alarm
– Failure to adapt
– Exhaustion
Absolute Stress
Relative Stress
Interpretation of the world
Recipe for Stress
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Novelty
Unpredictability
Threat to ego
Loss of control
stress
Stress Stimuli
Experience the stimuli
Physiological Response
(Body Chemistry Response)
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Hormones
Neurochemistry
Immunochemistry
Energy
Metabolism
Stress Hormones
• Corticosteroids
– Cortisol
• Catecholamines
– Adrenaline (Epinephrine)
– Nor-adrenaline (Nor-epinephrine)
Cortisol
Cortisol Regulation
• Brain
– emotion, pain,
memory
• Hypothalamus
– autonomic function
• Pituitary
– stimulating hormone
• Adrenal Gland
– cortex
Mind Body Connection: neural and hormonal
Left: Areas of the brain that
‘light-up’ during strong emotion.
(happy, sad, disgust)
These correlate to Vagus Nerve
mediated Heart Rate Variability.
Immediate Effects of Cortisol
• Response to Absolute Stress
– increase vigilance
– respond to emotion  don’t think
– raise blood sugar
– increase psychomotor activity
– obtain food
Prolonged Effects of Cortisol
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increase appetite
increase blood sugar
increase fat stores
redistribute fat
salt retention  BP +
reduce acid barrier
menstrual cycle problems
male impotence
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bone calcium loss
muscle wasting
insomnia
irritability
depressed mood
memory loss*
immune dysfunction
Pituitary Tumor & Cushing’s Disease
Disease States
• Moon facies
Catecholamines
• Adrenaline (Epinephrine)
• Nor-adrenaline (Nor-epinephrine)
Effects of Catecholamines
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increase heart rate
increase cardiac force of contraction
narrows blood vessels
increase blood pressure
dilates pupils
dilates airways
reduces flow of blood to GI tract
reduces saliva production
increases platelet adherence ‘stickiness’
increases sweat production
Experience of the
Physiological Response
Acute Stress and MI
• Mortality in Widowers
– 40% increase within 6 mo of spouses death
• Myocardial Infarction Onset Study
– incidence of AMI 14X among recent widows /
widowers
Self-report AMI Trigger
412 reports from 849 AMI
Chronic Stress & Immune Dysfunction
• Influenza Vaccination
• Difference between
stressed and nonstressed group.
– Lancet 1999
Punch Biopsies
• 13 Care Givers vs 13 Controls
• Complete wound healing
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Caregivers 48.7 vs 39.3 days (9 day diff)
Age and income did not effect outcome
Stress & Recovery
Allostatic Load
Psychobiological Framework
So now what?
www.calgaryhealthregion.ca/cmbm/
CMBM Approach
• symptoms are psychobiological
– real & explainable & diagnosable
• management
– cognitive reassurance is insufficient
– uncovering a psychological trauma is insufficient
– psychotropic medications are counterproductive
– success lays in self-regulation
Self-regulation
• Somatic Awareness
– experiential
– link emotional state with body symptoms
– effortless breathing
• Medication Reduction / Elimination
– group therapy
– education
– heartmath
– guided imagery
Don’t forget to breathe…
Dr. Sonia Lupien
• Work on yourself
– improve problem solving
– learn to appreciate others
– learn to appreciate yourself
– practice goodwill
• Work on your Body
– breathe
– move
– power of laughter and smiles
Recognize the Source of Stress
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Novelty
Unpredictability
Threat to Ego
Sense of Loss of
Control
Have a Plan B
Goodwill
• Mother Theresa Effect
– improved self-esteem
• 290 patients 2004 - 2009