1. Medical Effects of Chronic Stress Jeffrey P Schaefer MSc MD FRCPC November 17, 2015

2. http:// dr.schaeferville. com

3. Conflicts of Interest none

4. Objectives Participants will... –define stress and learn its ingredients –gain an understanding of stress physiology –consider clinical implications –consider remedies

5. Case 42 year old female –weight loss (20 kg / 9 months) –poor appetite, nausea, insomnia –no medication, no tobacco, no alcohol, married exam normal labs all normal imaging including pan CT, GI, normal colonoscopy endoscopy normal Diagnostic Procedure?

6. Case Resolution Q: “What happened in your life around the time you became unwell?” A: “My sister was diagnosed with lymphoma and my mother got deported from Canada.” Q: “Is it possible that these events caused you to lose your appetite? A: “I’ve never thought about that before... is that possible?”

7. Objectives Participants will... –define stress and learn its ingredients –gain an understanding of stress physiology –consider clinical implications –consider remedies

8. Stress...

9. Acute Stress Response Fight, Fright, Flight, Frolic

10. Hans Selye (1907-1982) Stress “Non-specific response of the body to any demand for change”

11. decons truct acute stress

12. Stress Stimuli

13. Experience the Stimuli

14. Physiological Response Hormones Neurochemistry Immunochemistry Metabolism

15. Experience of the Physiological Response

16. Good Stress (absolute stress)

17. Eustress Gap between have and want is just beyond... Motivating!

18. Relative Stress Interpretation of the world

20. Hans Selye (1907-1982) General Adaptation Response –Alarm –Failure to adapt –Exhaustion

21. Stress & Recovery

22. Allostatic Load

23. Recipe for Stress Novelty Unpredictability Threat to ego Loss of control

24. Objectives Participants will... –define stress and learn its ingredients –gain an understanding of stress physiology –consider clinical implications –consider remedies

25. Stress Hormones Corticosteroids –Cortisol Catecholamines –Adrenaline –Nor-adrenaline

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

27. Happy Sad Disgust Mind Body Connection: neural and hormonal

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

29. Prolonged Effects of Cortisol increase appetite increase blood sugar increase fat stores redistribute fat salt retention  BP + reduce acid barrier menstrual cycle problems male impotence bone calcium loss muscle wasting insomnia irritability depressed mood memory loss* immune dysfunction

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

31. 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

32. Stress also... stimulates –Vasopressin release  ACTH –Growth Hormone release (depletes in chronic) suppresses –insulin production –gonadotropins –suppresses TSH

33. Objectives Participants will... –define stress and learn its ingredients –gain an understanding of stress physiology –consider clinical implications –consider remedies

35. 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

36. Self-report AMI Trigger 412 reports from 849 AMI

39. Cardiovascular Disease: 3.1 (1.1-8.6) Coronary Heart Disease: 3.5 (1.1-11.8) Myocardial Infarction: 6.4 (1.8 – 22.3)

42. Psychobiological Framework

43. Non-Stressed Mice: 32 tumours Stressed Mice: 84 tumours Non-Stressed Mice: 32 tumours Stressed Mice: 84 tumours

44. RR Persistent Positive Depression = 1.34 (1.01 – 1.76)

45. Mice  8 months of stress

46. Sperm Concentration: – 38% Sperm Count:– 32% Semen Volume: – 15% Nov 2015 Sperm Concentration: – 38% Sperm Count:– 32% Semen Volume: – 15% Nov 2015

47. Chronic Stress & Immune Dysfunction Influenza Vaccination Difference between stressed and non- stressed group. –Lancet 1999

48. Wound Healing

49. 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

50. Medically Unexplained Symptoms Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.

51. MUS Prevalence 30% of primary care visits 13.6 visits in the previous year Psychosomatic Med 2005;67:123-9

52. Highest Frequency Clinics GI 54% Neuro50% Rheum33% ENT27% GIM10%

53. Medically Unexplained Conditions Non-CardiacChest Pain Headache Syndromes Fibromyalgia Irritable BowelChronic Fatigue Infertility Dizziness

54. 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

55. Median Number of Symptoms Men  4 Women  6 Men & Women  5

56. “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

57. Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Multiple Chem Sensitivity Syndrome Sick Building Syndrome Hypoglycemia Gulf War Syndrome Undocumented Labels Headache Syndromes Asthma Painful Conditions Various Bodily Distress Disorder

58. So now what?

59. Objectives Participants will... –define stress and learn its ingredients –gain an understanding of stress physiology –consider clinical implications –consider remedies

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

62. n=109 Chronic Pain Clinic Patients randomized: Mindfulness Meditation (8 weeks) Wait List 33 completed / 54 meditation 40 completed / 55 wait list

63. http://dr.schaeferville.com

64. 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

65. MUSDepressedControls P(Disease)15%10%5% 25

66. Goodwill Mother Theresa Effect –improved self-esteem

67. www.calgaryhealthregion.ca/cmbm/

68. 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

70. 290 patients 2004 - 2009

71. Objectives Participants will... –define stress and learn its ingredients –gain an understanding of stress physiology –consider clinical implications –consider remedies