1. Stress Jeffrey P Schaefer MSc MD FRCPC February 7, 2007

2. Objectives Medical Aspects of Stress What is stress? Stress Hormones and Actions Allosteric Load Effects of Stress Strategies to Reduce Stress

3. What’s Stress  Popular Definition “Not enough time…”

4. Acute Stress Response The body’s adaptive response to stress. –flight or fright response See Grizzly Bear See Dick Run See Jane Run Run, Run, Run…

5. Hans Selye (1907-1982) General Adaptation Syndrome observed effects of negative events he called ‘Stressors’  Stress Proposed 3 phase to chronic stress: –alarm  prepare for ‘flight / fright’ –adaptation  resistance to stress –exhaustion  inability to cope

6. The ‘un-stressed’ state… Homeostasis: –A balanced and stable internal environment.

7. What is stress? Stress is determined by the balance between perceived demands of the environment and the individual’s resources to meet those demands.

8. Stress – not just psychological Stress  4 components –the stress stimuli –the experience of stress –the physiological stress response –the experience of the stress response

9. Stress Stimuli

10. Experience the stimuli

11. Physiological Response

12. Experience of the Physiological Response

13. Recipe for Stress What makes things Stressful? 1.Novelty 2.Unpredictability 3.Threat to ego 4.Sense of loss of control

14. Categorizing Stress Absolute Stress –threat to life –earthquake, fire, physical attack…

15. Categorizing Stress Relative Stress –implied threat based on interpretation

16. Eustress vs Distress Eustress – good stress Distress – bad stress -Cognitive Interpretation of Events effects our interpretation of events. “Challenge vs Opportunity’

17. Stress Hormones Corticosteroids –Cortisol Catecholamines –Adrenaline (Epinephrine) –Nor-adrenaline (Nor-epinephrine)

18. Cortisol

19. Cortisol Regulation Brain –emotion, pain, memory Hypothalamus –autonomic function Pituitary –stimulating hormone Adrenal Gland –cortex

20. Cortisol Acute Effects Response to Absolute Stress –increase vigilance –respond to emotion  don’t think –raise blood sugar –increase psychomotor activity –obtain food

21. Prolonged Cortisol Effects increase appetite increase blood sugar increase fat stores redistribute fat salt retention  BP + thinning of skin reduce acid barrier interferes with menstrual cycle male impotence bone calcium loss muscle wasting insomnia irritability depressed mood memory loss* immune dysfunction 2006 > Negative fx

22. Pituitary Tumor & Cushing’s Disease

23. Disease States Moon facies

24. Catecholamines Adrenaline (Epinephrine) Nor-adrenaline (Nor-epinephrine)

25. Effects of Catecholamines 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

27. Prolonged Catecholamine Pheochromocytoma –hypertension –cardiac disease –vascular disease

28. Allosteric Load Allostasis (flight or fight response) –‘good stress’  gets us out of trouble Chronic Stress –when we don’t ‘get out of trouble’

31. Allosteric Load Stress Related Disease Disease Related Stress Headache Irritable Bowel Syndrome Obesity  Diabetes  Osteoarthritis Regional Pain Syndromes & Fibromyalgia Chronic Fatigue

32. every disease has a psychological component

34. What does the literature show? Acute Stress & Chronic Stress –studies of people (not test tubes)

35. Acute Stress in Heart Attack Mortality in Widowers –40% increase within 6 mo of spouses death Myocardial Infarction Onset Study –among heart attack victims, there was a 14 times increase in death of significant person last 6-12 mo INTERHEART Study –11,000 first MI vs 13,000 matched controls 52 countries –Stress Events 16.1% vs 13.0 % (OR 1.48; 95% CI 1.33-1.64) marital separation or divorce, loss of job or retirement, loss of crop or business failure, violence, major intrafamily conflict, major personal injury or illness, death or major illness of a close family member, death of a spouse, or other major stress.

36. Triggering an Acute MI

37. Chronic Stress and Disease Cohort of 13,609 mean age 45 yr  measured chronic stress –High 15% Risk of first MI, Stroke, ACS 14% higher men –Mod 6% –Low 80% Social isoation, self-blame, and avoidance higher in a group a 130 MI patients when compared to 102 controls

38. Selected Factors Hostility –Hostility was measured in 1,877 employed men –Observed 10 year incidence of MI / CHD death –Adjusted for age, bp, chol, cig use, etoh Results –42% increase in death from lowest to highest quintiles –Risk of death / MI was 0.68 for low score group

39. Anger in Young Men Medical Students

40. Chronic Stress & Immune Dysfunction Care Giver of Dementia Pts 50 spouses 67 controls Emotional distress higher in care givers Salivary Cortisol levels higher in care givers

41. Chronic Stress & Immune Dysfunction Influenza Vaccination 3 strains –1 strain  difference –2 strains  no difference –Lancet 1999

42. Wound Healing Lancet 1995 Punch Biopsies 13 Care Givers vs 13 Controls Complete wound healing –Caregivers 48.7 vs 39.3 days (9 day diff) –Age and income did not effect outcome

43. So now what? Remember, our body does not understand that’s it’s 2006 AD, not 2006 BC

44. Dr. Sonia Lupien Work on yourself –methods of resolving problems –learn to appreciate others –learn to appreciate yourself –practice goodwill Work on your Body –breathe –move –power of laughter and smiles

45. Solving Problems Avoid Avoidance –may work in short term –negative in the long term

46. Two Basic Responses to Problems Emotional Response –primary instinct  biological factors –danger of incorrect interpretation –predisposes to hostility –risk factor for CV disease Cognitive Response –analyze –problem solve –gain control

47. Goodwill Mother Theresa Effect –improved self-esteem

48. Recognize the Source of Stress Novelty Unpredictability Threat to Ego Sense of Loss of Control Have a Plan B

49. Summary Stress is physiological / psychological Novelty, Unpredictability, Threat, Control Hormones are the stress messengers Allosteric load has negative consequences Strategies to reduce stress are important