by Frank Sabatino, D.C., Ph.D.
Stress is an unavoidable and natural part of life. Some stress and tension are necessary to motivate and fuel our personal ambition, success, and creative expression. Yet, if we define stress as the variety of enervating life situations and tensions that challenge our ability to cope, and potentially damage physical and mental health, I think we can agree that the degree of stress in our “sophisticated” modern society has become excessive and deleterious. In fact, I contend that every case of health or disease is caused, and/or modified, by the ways that we evaluate, respond and react to the routine events of our lives. So that the reduction of debilitating stress, and the protection and cultivation of life energy, is an extremely important, and vastly overlooked, part of healthcare.
The relationship between the cognitive processing of life events, feelings, reactive emotional responses, and the subsequent expression and/or dysfunction in physical systems (nervous, muscular, immune and endocrine) has been conveniently described as the mind-body connection. Over the past half-century, the concept of mind-body interaction has become firmly enmeshed in the domain of science.
In discussing cardiovascular disease (CVD), the role of stress is equivocal, challenging, and potentially very important and exciting. Almost 13 million Americans suffer from coronary artery disease, and over 12 million Americans have a history of heart attack, angina (chest pain), or both. Coronary artery disease usually results from atherosclerosis, when arteries become narrowed or hardened due to cholesterol plaque build-up. Atherosclerosis can occur from a variety of factors including high blood pressure (hypertension), high cholesterol, or endothelial dysfunction, an impairment of the inner lining of the blood vessel wall. In a study to evaluate the link between mental stress and impaired function of blood vessels, Dr. George Noll, of the University Hospital in Zurich, Switzerland, used ultrasound techniques to examine the blood vessels of healthy patients in their 20s and 30s before and after mental stress tests. 1 Blood vessels were impaired by mental stress. The opening of blood vessels decreased, while heart rate and blood pressure increased. In addition, the chemical endothelin-A was identified as a cause of atherosclerosis and blood vessel impairment, and was in-creased in response to mental stress, also suggesting a potential mechanism for the stress-induced blood vessel impairment.
Mental stress can elicit myocardial ischemia (reduced blood flow to the heart) in both lab studies and daily life. Negative emotions like anger can have similar effects. The ischemia induced by mental stress is associated with an increased risk for future cardiac events, including unstable angina, repeat heart attacks, and the need for coronary revascularization (heart bypass and/or angioplasty), in people with a history of heart or coronary artery disease. In a large study at the Duke University Medical Center, Dr. Blumenthal and colleagues examined 107 high- risk heart disease patients with a previous history of coronary artery disease and ischemia. 2 They evaluated the extent to which ischemia induced by mental stress can be modified by exercise or stress management techniques. The group that performed routine stress management techniques (e.g. meditation, yoga, etc.) over a 4-month period experienced more than a 70 percent reduction in the risk of another cardiac event compared to the control group, and was also significantly better than the exercise management group. The stress management group experienced a lower rate of recurrent heart attacks, need for revascularization, and death during the ensuing three years. Consistent with these data, a report from Dr. Hiroyaso Iso from the University in Ibaraki-ken, Japan, examined the relationship than 73,000 people aged 40-79 over a period of eight years. 3 Japanese women reporting a higher level of mental stress were more than twice as likely to die from heart disease and stroke than women reporting low stress levels. Men who were more stressed out were more likely to die of a heart attack, but there was no significant correlation in men between stress and stroke or coronary artery disease. The women in this study who were more stressed out were also less active, smoked more and were more likely to have a history of high blood pressure and diabetes. Therefore, it is difficult to separate the real contribution of stress from other negative lifestyle factors to the outcome of CVD and the death in these women.
Stress may also have a significant direct effect on vascular blockage disease. Drs. Castillo-Richmond and Schneider at the College of Maharishi Vedic Medicine in Fairfield, Iowa, investigated the impact of Transcendental Meditation (TM) on 60 African-American men and women with high blood pressure. 4 Men and women were randomly assigned to either a TM group that meditated 20 minutes twice a day, or a health education group that spent a similar amount of time performing a leisure activity of their choice. Participants were monitored for 6-9 months to evaluate risk factors for heart disease prior to and after the experimental protocol. Ultrasound sonograms of the meditating group showed a significant reduction in the fatty deposits and thickness of their carotid artery walls, while the health education group continued to experience thickening of their blood vessel walls. The TM group also experienced significant decreases in blood pressure and heart rate. The observed changes represented an 11 percent decrease in the risk of CVD and a 15 percent decrease in the risk of stroke.
However, a recent study from Scotland has challenged the link between stress and heart disease. Dr. John Macleod and his coworkers measured stress among 8,000 middle-aged Scottish men and then followed them for more than 20 years to see whether they developed heart disease. 5 Men who thought they were most stressed were the most likely to report symptoms of ill health, including angina. Hospital diagnosis of heart disease and death from heart disease were lower among men reporting high stress. However, these researchers found that the men reporting more stress tended to be more socially and economically advantaged. These men reported more symptoms of heart disease more often, had better access to medical care, and sought out help and support more often. This led the researchers to conclude that the protective benefits of affluence may have helped to offset unhealthy lifestyle choices.
Stress can also affect the efficient function of the immune system. Animal models have provided evidence to support the link between stress and infectious disease. Social disruption of mice causes reactivation of latent herpes simplex virus. 6 Stress has also been shown to enhance reactivation of latent viruses like the Epstein-Barr virus in humans. 7 Chronically stressed populations, such as spousal caregivers of patients with Alzheimer Disease, have shown poorer immune responses to vaccines, and delayed wound healing. 8 In addition, supportive social environment can reduce stress and improve resistance to infection. Researchers at Carnegie Mellon University infected 276 healthy volunteers with nasal drops containing rhinoviruses and evaluated the impact of a diversity of supportive social ties on the development of a common cold. 9 People with more diverse social ties were significantly less susceptible to common colds, produced less mucus, were more effective in ciliary clearance of their nasal passages, and shed less virus, suggesting less viral replication and a greater resistance to upper respiratory infection. So our mental well-being and stress responses can affect a variety of health issues from the simplest colds to advanced forms of debilitating chronic disease.
However, it is not stress per say that seems to be the problem. What seems to be a more major concern is the “changing nature of stress,” and the way our brains and nervous systems deal with it.
Whenever we encounter a threat in our environment, the perception of danger triggers an automatic state of arousal called the “fight or flight” response. That means, whether it’s a primitive encounter with a threatening tribe or animal in the past, or an encounter with perceived danger today, we basically have two choices. We can fight that experience head on, or the better part of valor may be to turn around and run away from it. However, there is also a third pattern of response that Dr. Phillip Nuernberger has described as passive withdrawal or the possum response. 10 If we encounter a level of stress or trauma that fills us with a sense of desperation and hopelessness, we can lay down and play dead. This response is rooted in fear, and the sense that some stressful situations can be so overwhelming that we really believe there’s nothing we can do to make a difference. Conditions like chronic depression and asthma may be products of the fear and trepidation of the possum response. For example, imagine how big, overwhelming and desperate various emotional experiences can seem to a small child. This feeling of desperation will trigger an inhibitory possum response that causes the respiratory airway to constrict. If the child is then fed a typical American diet loaded with meat, dairy products, and refined sugar, this devastating diet can provoke inflammation, swelling, and mucous discharge in the restricted airway. This combination of restricted airway, and inflammation, mucous, and swelling, is the definition of asthma! How many asthmatic children are suffering the abuses of inhalers, antibiotics, and dangerous steroid medications instead of addressing the true causes of poor nutrition and emotional stress?
As pointed out by Dr. Nuernberger, a more comprehensive view is that stress is a state of internal imbalance reflecting the unrelieved dominance of either arousal or inhibition leading to impaired physiological or mental function. 11 In other words, stress occurs when we are out of balance.
Typically, the sympathetic “fight or flight” response is more prevalently discussed and associated with arousal, protection, and survival. The only way we can carry out either of these options, fighting or running away, is through the response of our nervous and muscular systems. In fact, no matter what you and I experience on a physical, emotional, or spiritual level, the only way we can act on this information is through our neuromuscular responses. Therefore, the perception of some kind of danger triggers a variety of internal changes designed to focus our attention and direct more oxygen and blood into our muscles in the shortest period of time so we can more effectively fight or run away.
Some of these internal changes include:
• Increased muscle tension to prepare the body for action.
• Increased heart rate and blood pressure to get more oxygen for energy into the muscles in the shortest period of time.
• Activation of blood clotting mechanisms to protect against injury.
• Increased respiratory rate and a shallowness of breathing to increase oxygen supply in the blood. If you’re concerned with a threatening tribe or animal, how concerned do you think you would be to take long, slow deep breaths? Not very, because by the time you took one breath, you could be dead.
• Decreased digestive function, including a decrease in the peristaltic muscular movement of the digestive tract, and a decrease in the release of digestive enzymes. This is designed to divert more blood to muscles and the brain.
Therefore, we are not designed to eat or process food during arousal stress. But when do many of us eat the most? during stress. When do we look for the greatest comfort and distraction in some of the most difficult foods to eat, high saturated fat and refined sugar? in fight or flight stress. Many of us are eating the most indigestible large quantities of food at a time when we are least able to handle it. Is it any wonder why we have the bloating, distension, heartburn, and reflux that are so common in our culture? Sometimes the best meal you can have is the last one you missed!
If you look at the internal changes of the fight or flight response, they are the very actions that the body has established over eons of time and evolution for the purpose of survival. However, they are also the very actions that drive people to doctors’ offices on a daily basis: musculo-skeletal pain and tension, high blood pressure, cardiovascular disease, lung and breathing problems, and the litany of bowel-related pathologies, including irritable bowel syndrome and reflux. Many people are running to doctors’ offices trying to medicate out of existence the very actions that the body has learned to create for our protection. We couldn’t completely get rid of these actions short of removing our entire brain and nervous systems. What we need to address is why the body has found it necessary to relentlessly maintain these actions and changes.
That brings us to the changing nature of stress. When our primitive ancestors encountered threatening tribes and animals, they experienced the actions of the arousal response, dealt with the stress in present time, and moved on with their lives to their next survival challenge. In modern times, we are no longer dealing with concrete tribes and animals. We are dealing with paper tigers. Many of our stresses have become more of the chronic, gnawing, nagging kinds of stress associated with modern job and family pressures, suppressed emotions, unresolved needs, and abstract, confusing interpersonal relationships and communications. We are no longer effectively in the precious present, we tend to get lost in the sorrows of the past, or we become painfully apprehensive about our insecure future. As a result, we have a hard time discharging the tension and actions of the fight or flight response. So, for example, suppose you were arguing with someone. Your blood pressure would go up temporarily. It was designed to go up for your benefit and survival. But if you do not discharge that tension in the present, you can begin to maintain the elevated blood pressure long after the original argument or hassle. If episodes of tension, rage, anger, worry and upset are internalized and repeated over time, and not discharged effectively in the present, you can begin to weave a pattern of elevated blood pressure into the tapestry of the nervous system and carry it into your insecure future. As a result, the very action that was created for your benefit can then become a condition of chronic disease. So, as serious as hypertension can be, elevated blood pressure is not the basic problem. Why the body has found it necessary to relentlessly maintain it in an elevated state is the problem. It is essential to be able to encounter and embrace the precious present to release the tensions of the moment. The past was the present at one time, but it is not now. The future will be the present at some time, but it is not now. The present is the only moment we really have.
It is important to understand that the internal changes of the arousal response occur as a result of a more involved general adaptation response that has been described in the work of Dr. Hans Selye. 12
In the ALARM phase of the adaptation response, when we first perceive a threat, the adrenal glands, our glands of stress, release hormones and transmitters that trigger the changes of the fight-or-flight response. In the RESISTANCE phase, the body attempts to regain balance by adjusting to the changes of the alarm phase, using its energy reserves to resist any ongoing conditions of stress. If the stress continues beyond our ability to handle it any longer, our reserves are depleted and we enter the third phase, EXHAUSTION. Physiological systems of the body begin to break down.
I think you can appreciate that these phases of the stress response occur automatically, via our autonomic nervous system, out of our conscious control. We don’t usually sit around consciously thinking about alarm, resistance, and exhaustion. Unfortunately, this can give you the idea that when it comes to the management of stress there isn’t much you can do about it. Because of the automatic features of the stress response, the impression is that we are slaves to our own nervous systems. Yet, while it is true that there are automatic features of the stress response, there are many things we can consciously do to proactively reshape the pattern of our own mind-body connection.
Every second of every day we are swimming in a sea of information. An endless array of bits and bytes of data are constantly coming into the incredible computer we have under our bony skull, the cerebral cortex. However, we do not process this information equally. Every person has a unique life history that has fashioned a unique frame of reference, that selectively filters the data of experience into the thoughts, feelings, and language unique to each of us. This information moves from higher brain areas through more primitive brain areas near the base of the brain. These limbic and hypothalamic areas of the brain are the sites of pathways associated with a variety of reactive emotions, feelings, and ancient survival instincts. These primitive areas also release a variety of hormones and neurotransmitters that directly influence and regulate the nervous, muscular, immune, and endocrine systems. There is never even one moment when you can have a thought that is not connected to responses in every one of these physiological systems. This is the mind-body connection. In this connection, mental function can directly affect physical outcomes in the body, while physical responses in the body can feedback, influence and reinforce patterns of thought and emotion.
As a result of this connection, repetitive choices and actions, both positive and negative, are woven into the tapestry of our behavioral repertoire. However, with some patience, practice, and consistency, healthy choices can establish new patterns of response in the nervous system and become a routine part of your life as they replace negative behaviors and addictions. It is important to realize the power we have to change our lives and behavior. This realization is critical for successful stress management. Simple because, while it is true that the lower primitive parts of the brain tend to foster automatic, reactive survival responses consistent with Dr. Selye’s model of adaptation, much of what occurs at the level of the cortex is remarkably proactive and willful. In the discussions about the role of nature (genetics) vs. nurture (early environment) on the outcome of behavior, the component of free will is often overlooked. We are all empowered at any time to make proactive, willful choices that can reshape the pattern of our own mind-body connection, thereby creating healthier options of response, reducing the negative impact of stress, and strongly reinforcing the realization that we do not have to be slaves to our own nervous systems.
These choices come with each moment of focused awareness. Many of us labor under the illusion that because we are frantically running around with our eyes open, we are actually conscious and awake. Many times, because of all the distractions and chatter in our lives, we need to step back, close our eyes, go inside and become aware of what is true and authentic for us. This sense of self-truth and authenticity is also critical to the process of stress management. There are tools and techniques that can help us focus our awareness and reduce the negative aspects of stress.
In addition to the fight-or-flight response, we are all capable of creating a relaxation response. As we relax, the brain begins to slow down and shift into an alpha level of response. There is nothing strange or mystical about this at all. We typically go in and out of this level of function at different times throughout the day. When you first wake up in the morning, and you’re half-asleep and half-awake, you’re moving in and out of the alpha level. How many times have you been driving your car, and suddenly you realize that you’ve drifted off momentarily as you’re jolted back into an awareness of your car and the road? By actively creating the relaxation response, we are able to create a condition of pure present time. The relaxation response creates a state of being that is divorced from the normal ego concerns that are constantly demanding our attention, and distracting us from a better awareness of who and what we really are. This allows us an opportunity to more effectively embrace the precious present, and more effectively evaluate our own mind-body connection to take more responsible action and change its outcome in a healthier direction. Quiet sitting, meditation, using a word mantra or progressively relaxing the major muscle groups of the body, yoga, tai-chi, and chi gung are all very valuable approaches for cultivating life energy and balancing mind-body function. Take some time each day to slow things down. Take some time each day to step back from the chatter of your life and replenish your energy reserves.
The way we breathe can also affect mental and physical health, and our level of stress and anxiety. When we inhale, the diaphragm, a muscle that basically separates the chest from the abdomen is designed to drop. This expands the space of the lungs so that air can rush in to fill the space, while all the abdominal contents below the diaphragm are pushed down as our bellies expand outward. Shallow chest breathing, with tight shoulders and tight flat stomachs, is the breathing pattern of fight-or-flight stress. This is the breathing
pattern of tension, stress, and anxiety. Remember this. Because of the reciprocal influences of the mind-body connection, if you consistently breathe in the breathing pattern of anxiety, you can create anxiety whether you have anything to be anxious about or not.
The following short exercise can help you improve your breathing pattern. It is a combination of quiet sitting, biofeedback, and relaxed breathing. Sit or stand with eyes open or closed, with your hands resting comfortably one on top of the other on your lower belly below your naval. Imagine that your hands are embracing the skin of a balloon. As you take a slow breath in through your nose, slowly count number one, and imagine your breath taking an elevator ride down to your hands expanding the skin of the balloon. Your hands should slowly move away from your body. If they are not moving, you need to practice bringing your attention to this detail until they do. This is the biofeedback portion of this exercise. Then, slowly exhale as your belly collapses back. Repeat, slowly inhaling as you count the number two and continue this exercise up to a count of ten. This will dramatically improve your diaphragmatic breathing, and by the time you get between five and ten most anxieties of the moment will be remarkably reduced. For the few minutes that this exercise takes, it is a very useful tool to help us delay our reactive responses in stressful situations that occur day to day in the home or workplace.
Moderate consistent exercise can also be a valuable stress management tool. Walking 30-60 minutes 4-5 times a week can produce chemical changes in the body and brain that remarkably reduce stress, tension, anxiety, and depression. In addition, regular physical movement can also improve our sleeping pattern, and sleep disturbances and deficiency will also increase stress and physical and mental breakdown.
Poor nutritional habits can also exacerbate stress, fatigue, tension and depression. The typical American diet loaded with fat, refined sugar, dangerous chemical additives — like Nutrasweet, preservatives and dyes — and dangerous stimulant drugs like caffeine in coffee, sodas, and chocolate, can cause wide swinging fluctuations of blood sugar and energy. This will cause increased sympathetic discharge (arousal), leading to autonomic imbalance (stress), tension, anxiety, and the reactive crash of chronic fatigue and depression.
We can all make a list and inventory of the stressful events in our lives. Some of these stresses can be changed fairly quickly by small consistent changes in our own choices and behavior. Often, however, they can’t be changed short of eliminating the environment and people around you, which can not usually be done. So, very often, we have to change the ways that we respond and react to the events of our lives. Our goal should not be to merely relieve the symptoms of stress, but to alter, and gradually eliminate the habits and choices that led to them in the first place. Stress management is not just a set of techniques; it is an entire gestalt. It is a function of how we move, breathe, eat, sleep, process the information of our experience, express our emotions, and resolve deep- rooted issues of our personal relationships. However, various lifestyle choices and techniques of stress management can be useful tools to focus our attention on the details of our own mind-body connection. Stress never takes a vacation from our lives, so make these supportive activities and choices a major priority in your life and realize that you do not need to be a slave to your own nervous system. Realize how empowered you really are to make proactive choices, any time you choose, that can improve mental and physical balance, and help you truly embrace your legacy of health and freedom.
References
1. Noll, George et al. Mental stress induces prolonged endothelial dysfunction via endothelin-A receptors, rapid access issue; Circulation May 20, 2002.
2. Blumenthal J, Jiang W, et al. Stress management and exercise training in cardiac patients with myocardial ischemia; effects on prognosis and evaluation mechanisms. Arch Int Med 1997, Oct 27; 157: 2213-2223.
3. Iso H, et al. Effects of mental stress on heart disease risk in Japanese men and women. Circulation 2002. Aug 13: 106.
4. Castillo-Richmond A, Schneider RH, et al. Effects of stress reduction on carotid artery atherosclerosis in hypertensive African Americans. Stroke 2000; 31:568-573.
5. Macleod J, Smith GD, et al. Psychological stress and cardiovascular disease: empirical demonstration of bias in a prospective observational study of Scottish men. Brit med J 2002 May 25;324:1247 (Abs).
6. Padgett DA, Sheridan JF, et al. Social stress and the reactivation of latent herpes simplex virus-type 1. Proc Natl Acad Sci USA. 1998;9:7231-7235.
7. Glaser R, Kiecolt-Glaser JK. Stress-associated immune modulation and its implication for reactivation of latent herpes virus. In: Glaser R, Jones J eds. Human Herpes Virus Infections, New York, NY: Marcel Dekker Inc; 1994:245-270.
8. Kiecolt-Glaser JK, Marucha PT, et al. Slowing of wound healing by psychological stress. Lancet 1995;346:1194-1196.
9. Cohen S, Doyle WJ, Skoner DP, et al. Social ties and susceptibility to the common cold. JAMA 2004 Feb 15;277(24):1940.
10. Nuernberger P. Freedom From Stress. Honesdale, PA: The Himalayan International Institute of Yoga Science, 1981.
11. Nuernberger P, op cit.
12. Selye, H. The Stress of Life. New York: McGraw-Hill, 1976.
©Copyright 2004. All Rights Reserved. Health Science is the publication of the National Health Association. This article reprinted from the Spring 2004 issue.