Ultimate Stressors: Public Drama, Private Pain

charlie-sheenRecently televised interviews with Mr. Charlie Sheen appear to have focused attention on the symptoms and manifestations of the manic phase of bipolar disorder. A public display of inflated self-esteem or grandiosity, profuse talkativeness, increase in goal-directed activity, psychomotor agitation, and the excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish investments) are the textbook criteria for a manic episode. More privately, the individual in the grip of mania also experiences a decreased need for sleep, flight of ideas or racing thoughts, and distractibility. When this disturbance is sufficiently severe, it can cause marked or total impairment in occupational functioning, usual social activities and relationships with others and may necessitate hospitalization to prevent self-harm or harm to others. Episodes of mania, whose symptoms are the opposite of those denoting depression, are rarely seen alone. Usually, the manic state is preceded and followed by depressive periods in an alternating fashion, with each state lasting from many months to a few weeks, the latter being described as ‘‘rapid cycling.’’

This constellation of symptoms was known, until a few years ago, as manic-depressive disorder. Nowadays, it goes by the somewhat more cryptic label of bipolar disorder. The neurochemical basis of bipolar disorder is not exactly known. One of the most valid hypotheses regarding the neurochemical mechanisms of bipolar disorder is the synergy between two neurotransmitters that determine mood states, whereby a lower than normal release of norepinephrine produces a disordered mood (significantly higher or lower than the normal range), while the levels of serotonin determine the direction the symptoms will take, i.e. downward toward depression or upward toward mania.

What Bipolar Disorder Feels Like

The subjective experience of these intense mood swings ranges from abject despair and hopelessness to not entirely distressing and almost pleasurable. Depression produces a pervasive
and relentless sense of gloom, inadequacy, rumination, guilt, and worthlessness. No logic, willful effort or remembrance of wellness seems capable of dispelling these cognitive and emotional experiences, often for prolonged periods.

Mania reverses and accelerates upward from the disappearance of depression, through a state of well-being that can be considered a normal mood state. Normality soon becomes exuberance, enters into a state of unexplained euphoria, and finally culminates into a chaotic state of racing, incomprehensible, disconnected thoughts, and bizarre behaviors. Given a choice, the individuals so affected report that they much prefer the state of mania, in which they experience a release from inhibitions, a hedonistic focus, and a pursuit of pleasure and gratification that can be nearly devoid of accountability or restraint. Self-medication with alcohol and illegal drugs is often present in the manic phase, which sets up a circular relationship that exacerbates its symptoms and impedes treatment and recovery.

An individual in a state of mania can be frightening, annoying, or amusing to the casual observer. It is perhaps easy to overlook the nature of the behavior, especially when there is an assumption of intent. In most cases, however, the individual has virtually no control over thoughts, words and behaviors and little if any insight into their bizarre, provocative, and sometimes dangerous presentation. The loss of reality testing, judgment and moral restraint of bipolar disorder is sure to cause psychological pain to the people who experience it and to the people who love them. Mr. Charlie Sheen has been variously portrayed as victim and perpetrator, and variously diagnosed by experts and entertainment reporters.

Bipolar Disorder: A Brief History

The first connection between a manic state and depression as belonging to the same neurochemical disorder was established in 1686 by the French physician Theophile Bonet, who observed individuals who appeared to cycle between high and low moods, and described their presentation as ‘‘manico-melancolicus.’’ In the middle of the 19th century, two other French researchers, Falret and Baillarger, who had independently observed the same cycling of moods in their patients, arrived at the same conclusion that the symptoms must be two different presentations of the same illness. Falret described the disorder as ‘‘circular insanity’’  and hypothesized a hereditary component to the disorder. In the late 1800s to early 1900s, German psychiatrist Emil Kraepelin elaborated the description and classification for manic–depressive illness that is considered the standard presentation that we see today.

It was John F. J. Cade, a doctor in the Mental Hygiene Department of Victoria, Australia, who introduced and promoted the belief that manic–depression was a biological disorder of the brain. On the basis of his research on neurochemistry, Cade administered a lithium salt preparation to several highly agitated manic patients and observed a remarkable reduction in symptoms, with a near return to a normal mood state. Lithium is currently the standard of care for the pharmacological treatment of bipolar disorder, and still the most effective in the management of its symptoms.

Marijuana Linked to Earlier Onset of Psychosis

Manifesti_LotteriaTripoli_194_mMarijuana (cannabis), thanks to the powerful depressing action of its active ingredient tetrahydrocannabinol (THC), is one of the oldest and most widely used means of self-medication against acute and chronic stress. THC users report experiencing a pleasurable state of relaxation, with heightened sensory experiences of taste, sound and color. In addition to its psychological effects, THC produces alterations in motor behavior, perception, cognition, memory, learning, endocrine function, food intake, and regulation of body temperature. The common perception is that, of all illegal drugs, marijuana may be the safest and least addictive—despite significant evidence that it causes side effects of fatigue, paranoia, memory problems, depersonalization, mood alterations, urinary retention, constipation, decreased motor coordination, lethargy, slurred speech, and dizziness, in addition to increased tolerance and addiction.

Impaired health including lung damage, behavioral changes, and reproductive, cardiovascular and immunological effects have been associated with regular marijuana use. Regular and chronic marijuana smokers may have many of the same respiratory problems that tobacco smokers have (daily cough and phlegm, symptoms of chronic bronchitis), as the amount of tar inhaled and the level of carbon monoxide absorbed by marijuana smokers is 3 to 5 times greater than among tobacco smokers. Smoking marijuana while shooting up cocaine has the potential to cause severe increases in heart rate and blood pressure. – NHTSA Fact Sheet

New research suggests that marijuana use may play a direct causal role in the development of psychotic disorders, including schizophrenia. An extensive meta-analysis of more than 443 studies comparing the age at onset of schizophrenia in individuals who used marijuana with the age at onset of schizophrenia in non–users yielded most sobering results.

Investigators at Prince Wales Hospital and the School of Psychiatry at the University of New South Wales in Sydney, Australia, found that the mean age at illness onset was more than 2.7 years earlier for cannabis users compared with nonusers. The age of onset did not significantly differ between alcohol users and nonusers. These results were published in the February 2011 issue of the Archives of General Psychiatry.

The results support the hypothesis that cannabis use plays a causal role in the development of psychosis… (and) suggest the need for renewed warnings about the potentially harmful effects of cannabis. – Matthew Large

In presenting the findings, lead study author Matthew Large, MBBS, Department of Mental Health Services concluded that the meta-analysis provides strong evidence for a relationship between marijuana use and earlier onset of psychotic illness and of a direct causal role in the development of psychosis in some more vulnerable individuals.

The Ineffable Madness of War

guernica-picasso
Over 2.2 million American service members have served in Iraq or Afghanistan since September 11, 2001.

Detailed statistics have been recently released that reveal the enormous cost in lives and health of these two ongoing American wars:

  • The US Veteran’s Administration (VA) has diagnosed 167,000 new cases of post-traumatic stress disorder (PTSD), 195,000 cases of depressive conditions and affective psychoses, and 103,000 cases of anxiety disorders among these troops.
  • The suicide rate in the Army and Marine Corps has, for the first time, equaled that of the US civilian population.
  • An estimated 18 US veterans are dying by suicide each day, according to the VA.
  • In 2009 throughout the Army, 160 soldiers died by suicide, at the same time as 160 soldiers died while serving in Iraq, i.e. one suicide for each combat casualty.
  • In 2009 worldwide another 146 Army soldiers died from unintentional drug overdoses, murders, or from other causes that the Army labels as risky behaviors.
  • The Army reported over 1700 known suicide attempts in 2009.
  • The suicide rate in 2009 for the US Marines was 24 suicides per 100,000 marines, which was even higher than the 22 suicides per 100,000 rate of the US Army.

Abuse in Childhood May Mean Shorter Life

aavanGogh_1885_AutumnLandscapeAccording to an analysis by the Centers for Disease Control and Prevention (CDC), the experience of verbal, physical, sexual abuse, or severe family dysfunction, such as an incarcerated, mentally ill, or substance-abusing family member, domestic violence, or absence of a parent because of divorce or separation, is directly linked to serious problems in adulthood, which may include substance abuse, depression, cardiovascular disease, diabetes, cancer, and premature death.

The combination of risky behaviors such as substance abuse, the effects of severe depression on variables such as suicide, and the incidence of deadly diseases such as diabetes and cancer contribute to an elevated risk of early death in adults who experienced abuse and dysfunctional family environments. More specific studies have confirmed that individuals with six or more adverse childhood experiences were almost twice as likely (1.7  times) to die before age 75 and 2.4 times more likely to die before age 65 years, i.e. below to well below normal life expectancies.

The CDC analyzed information from 26,229 adults in five US states (Arkansas, Louisiana, New Mexico, Tennessee, and Washington) using the 2009 ACE (Adverse Childhood Experience) module of the Behavioral Risk Factor Surveillance System (BRFSS), which is operated by state health departments in cooperation with the CDC. The results of the analysis show that 59.4% of the interviewed reported having at least one adverse childhood experience, and 8.7% reported five or more.

The prevalence of each adverse childhood experience ranged from a high of 29.1% for household substance abuse to a low of 7.2% for having an incarcerated family member. Over one quarter (25.9%) of respondents reported having experienced verbal abuse, 14.8% reported physical abuse, and 12.2% reported sexual abuse. In measures of severe family dysfunction, 26.6% reported separated or divorced parents, 19.4% reported that they had lived with someone who was depressed, mentally ill, or suicidal, and 16.3% reported witnessing domestic violence.

The analysis reiterates the risk for long-term impact on health and mortality of childhood abuse, stress and trauma. Numerous studies (Sansone & Poole, Ozer, Best, et al., Heim, Newport, et al., Bremner et al., to cite only a few of the most recent) have confirmed the positive and significant correlations between childhood physical abuse, emotional abuse, and witnessing violence and the number of psychophysiological and pain disorders in adulthood.

Growing Interest in Pastor Stress and Burnout

The issue of the biopsychosocial consequences of acute and chronic stress on church ministers has attracted nationwide attention over the last few years, and the level of attention appears to be on the increase. Our post Stress and Burnout Endanger Clergy Health published on August 4, 2010 rapidly rose to second all-time most-read among Stresshacker readers. Clearly, the issue stirs interest among all of us, and especially pastors, church leaders and judicatories, not only for its health implications, but also for the consequences of chronic stress on interpersonal relationships, productivity, job satisfaction, the danger of burnout and of increasingly rapid turnover among church leaders of all denominations.

{tab=Research}
Obesity 18, 1867-1870 (September 2010) published the research High Rates of Obesity and Chronic Disease Among United Methodist Clergy by Rae Jean Proeschold-Bell and Sara H. LeGrand.

Researchers used self-reported data from United Methodist clergy to assess the prevalence of obesity and having ever been told certain chronic disease diagnoses.

Of all actively serving United Methodist clergy in North Carolina (NC), over 95% (n = 1726) completed self-report height and weight items and diagnosis questions from the Behavioral Risk Factor Surveillance Survey (BRFSS).

The questionnaires were used to calculate BMI categories and diagnosis prevalence rates for the clergy and to compare them to the NC population using BRFSS data. The obesity rate among clergy aged 35–64 years was 39.7%, or 10.3% higher than their NC counterparts in the general population.

Clergy also reported significantly higher rates of having ever been given diagnoses of diabetes, arthritis, high blood pressure, angina, and asthma compared to their NC peers.

This research is the most recent, most completed and empirically validated. Clearly it does not address but a few of consequences of stress and burnout. Its results cannot be extrapolated to other organizations, other locales and other manifestations of stress. Nonetheless, it is valuable as a snapshot that identifies an area of investigation that is worth exploring.

{tab=Broadcasts}

Clergy Members Suffer From Burnout, Poor Health was broadcast by National Public Radio on Talk of the Nation (August 3, 2010) with guests: Paul Vitello, religion reporter, New York Times; Robin Swift, director of health programs at the Clergy Health Initiative, Duke University Divinity School.

The broadcast discusses how priests, ministers, rabbis and imams are generally driven by a sense of duty to answer calls for help. The guests touch on research, which shows that in many cases, pastors rarely find time for themselves. The hypothesis of the broadcast is that members of the clergy suffer from higher rates of depression, obesity and high blood pressure, and many are burning out. Listen to Talk of the Nation: Clergy Burnout [30 min 18 sec]

{tab=Articles}

Taking a Break From the Lord’s Work, written by Paul Vitello and published in The New York Times (August 1, 2010)

“Members of the clergy now suffer from obesity, hypertension and depression at rates higher than most Americans. In the last decade, their use of antidepressants has risen, while their life expectancy has fallen. Many would change jobs if they could.”

Also published in the New York Times, Congregations Gone Wild, written by G. Jeffrey MacDonald (August 7, 2010)

“But churchgoers increasingly want pastors to soothe and entertain them. It’s apparent in the theater-style seating and giant projection screens in churches and in mission trips that involve more sightseeing than listening to the local people. As a result, pastors are constantly forced to choose, as they work through congregants’ daily wish lists in their e-mail and voice mail, between paths of personal integrity and those that portend greater job security. As religion becomes a consumer experience, the clergy become more unhappy and unhealthy.”


Peter Drucker, the late leadership guru, has been widely quoted to have said:

The four hardest jobs in America (and not necessarily in this order) are the president of the United States, a university president, a CEO of a hospital and a pastor.

The setting in which this quote was uttered is unknown, but it continues to be reported as factual. A recent retelling of this quote can be found here.


Episcopal clergy ‘very stressed,’ but ‘very happy’, written by Herb Gunn and published in the official web site of the Episcopal Church USA (August 12, 2010)

“Through analysis articulated in the Clergy Wellness Report (2006) and the initial findings of the Emotional Health of Clergy Report (2010), we have observed that there is more to the challenge of clergy stress than fickleness of congregations and the cultural pressures of increased consumerism among churchgoers.

This research points to interesting conclusions that differ slightly from the research Vitello noted, as well. CREDO’ s research found that the only major health factor for which Episcopal clergy are at greater risk than the larger population is stress. Yet, remarkably, work-related stress, which frequently leads the general population to employment dissatisfaction, job loss or job change, exists alongside notably lower “turnover intent” for Episcopal clergy. Compared to the general population, Episcopal clergy report significant levels of well-being, self-efficacy and meaning in their work.”


What Pastors Want, written by Rich Frazer of Focus On the Family (2009).

“We in the United States lose a pastor a day because he seeks an immoral path instead of God’s, seeking intimacy where it must not be found.

Focus On the Family statistics state that 70% of pastors do not have close personal friends, and no one in whom to confide. They also said about 35% of pastors personally deal with sexual sin. In addition, that 25% of pastors are divorced.”


On the cost and grace of parish ministry – Part III, written by Jason Goroncy and published on the Christian-themed blog Cruciality (August, 2010)

Mistaken attitudes to the issue surrounding clergy burnout are not helped by the frequent interchangeability of the terms ‘burnout’ and ‘stress’. While related phenomena, burnout and stress describe different realities. In his wee booklet Ministry Burnout (Grove Books, 2009), Geoff Read makes the point that ‘stress is essentially the physiological or psychological response to many different sorts of situations and demands … Burnout is one response to sustained exposure to certain sorts of stressors. A person reaches a state of burnout when the three factors of emotional exhaustion, detachment and sense of lack of achievement have reached a level of such severity that the person’s ability to function is significantly impaired’ (p. 6).”

{tab=Statistics}

This is a list of sources that have published statistics, from various sources, on the state of physical, relational, managerial and financial health of church ministers across a wide spectrum of US denominations. Some of the statistics are second- or third-hand reports of data published elsewhere, and the original source is not always identifiable. Thus, readers are cautioned about drawing specific conclusions from these data.

Pastor Burnout Statistics by Daniel Sherman. Many of Mr. Sherman’s numbers below come from H. B. London’s book, Pastors at Greater Risk:

  • 13% of active pastors are divorced
  • Those in ministry are equally likely to have their marriage end in divorce as general church members
  • The clergy has the second highest divorce rate among all professions
  • 23% have been fired or pressured to resign at least once in their careers
  • 25% don’t know where to turn when they have a family or personal conflict or issue
  • 25% of pastors’ wives see their husband’s work schedule as a source of conflict
  • 33% felt burned out within their first five years of ministry
  • 33% say that being in ministry is an outright hazard to their family
  • 40% of pastors and 47% of spouses are suffering from burnout, frantic schedules, and/or unrealistic expectations
  • 45% of pastors’ wives say the greatest danger to them and their family is physical, emotional, mental, and spiritual burnout
  • 45% of pastors say that they’ve experienced depression or burnout to the extent that they needed to take a leave of absence from ministry
  • 50% feel unable to meet the needs of the job
  • 52% of pastors say they and their spouses believe that being in pastoral ministry is hazardous to their family’s well-being and health
  • 56% of pastors’ wives say that they have no close friends
  • 57% would leave the pastorate if they had somewhere else to go or some other vocation they could do
  • 70% don’t have any close friends
  • 75% report severe stress causing anguish, worry, bewilderment, anger, depression, fear, and alienation
  • 80% of pastors say they have insufficient time with their spouse
  • 80% believe that pastoral ministry affects their families negatively
  • 90% feel unqualified or poorly prepared for ministry
  • 90% work more than 50 hours a week
  • 94% feel under pressure to have a perfect family
  • 1,500 pastors leave their ministries each month due to burnout, conflict, or moral failure
  • Doctors, lawyers and clergy have the most problems with drug abuse, alcoholism and suicide.

The following pastor demographic and church statistics compiled by Mr. Sherman come from George Barna’s book, Today’s Pastors: A Revealing Look at What Pastors Are Saying About Themselves, Their Peers and the Pressures They Face:

  • 97% of pastors are male
  • The median age is 44
  • 96% are married
  • 80% have a bachelors degree and half have a master’s degree placing the pastorate among the most educated professions – but among the lowest paid as well
  • The average length of a pastorate is about four years
  • The median pastor salary is about $32,000 a year including housing allowance and other benefits, while the national average among married couples (1991) was nearly $40,000
  • 24% of the American population is 50 or older but 51% of church attenders are at least 50 years old
  • 40% of church attenders read the bible during the week
  • 30% of congregation members would seek help from their pastor during a difficult time in their lives
  • 53% of pastors believe that the church is showing little positive impact on the world around them
  • 60% of pastors believe that church ministry has negatively impacted their passion for church work
  • 51% of pastors expect that the average attendance at their church will increase by at least 10% in the coming year
  • 4% of senior pastors (say they) have a clear vision for their church

The following list of pastor statistics (and the comments that accompany them) was compiled by Jim Rose of Year of Jubilee. In some instances, the primary or secondary source of the data is provided.

  • More than 70% of pastors do not have a close friend with whom they can openly share their struggles. The dominant cause for pastors to leave the pastoral ministry is burnout. Number two is moral failure. These are alarming statistics.
  • 80% of pastors believe the pastoral ministry has negatively affected their families (Life Enrichment Ministries – 1998)
  • Only 50% of pastors felt that the education they received adequately prepared them for ministry. Most pastors rely on books and conferences as their primary source of continuing education. (George Barna – 2002)
  • 25% of all pastors don’t know where to go for help if they have a personal or family conflict or concern. 33 percent have no established means for resolving conflict. (George Barna – 2002)
  • 40% have no opportunity for outside renewal like a family vacation or continuing education. There is a very clear relationship between the amount of time a pastor takes for personal renewal and his satisfaction in his job. (George Barna – 2002)
  • At any given time, 75% of pastors in America want to quit. (Church Resource Ministries – 1998)
  • More than 2000 pastors are leaving the ministry each month (Marble Retreat Center 2001)

Several web sites cite research done in the 1991 Survey of Pastors by The Fuller Institute of Church Growth. This institute, connected with Fuller Theological Seminary in Pasadena, California, does not have a web site and may no longer be in activity.  The original research could not be located for this post. The numbers refer to the situation as it may have existed among pastors over twenty years ago. It may indicate that what pastors are experiencing now is not new.

  • 90% of US pastors work more than 46 hours a week
  • 80% believed pastoral ministry affected their families negatively
  • 33% believed ministry was a hazard to their family
  • 75% reported a significant stress related crisis at least once in their ministry
  • 50% felt themselves unable to meet the needs of the job
  • 90% felt inadequately trained to cope with ministry demands
  • 70% say they have a lower self esteem now compared to when they started in ministry
  • 40% reported serious conflict with a parishioner at least once a month
  • 37% confessed to having been involved in inappropriate sexual behavior with someone in the church
  • 70% do not have someone they consider a close friend

Alan Fadling  published the following ministry burnout statistics in 2009, unfortunately without referencing the source of his data.

  • Churchgoers expect their pastor to juggle an average of 16 major tasks
  • Pastors who work fewer than 50 hours a week are 35 percent more likely to be terminated.
  • 87 percent of Protestant churches have full-time paid pastors.
  • 50 percent of all congregations in the United States are either plateauing or declining
  • Two-thirds of pastors reported that their congregation experienced a conflict during the past two years; more than 20 percent of those were significant enough that members left the congregation
  • The typical pastor has his/her greatest ministry impact at a church in years 5 through 14 of his pastorate; unfortunately, the average pastor lasts only five years at a church.
  • 90 percent of pastors work more than 46 hours a week.
  • 80 percent believe that pastoral ministry affects their families negatively.
  • 75 percent report they’ve had a significant stress-related crisis at least once in their ministry.
  • 50 percent feel unable to meet the needs of the job.
  • 40 percent report a serious conflict with a parishioner at least once a month.
  • 40 percent of pastors say they have considered leaving their pastorates in the last three months.
  • 19 percent of pastors indicate that they’d been forced out of ministry at least once during their ministry; another 6 percent said they’d been fired from a ministry position

The Francis Schaeffer Institute Statistics on Pastors was compiled by Dr. Richard J. Krejcir. The numbers and his comments are published here verbatim.

“Here are some startling statistics on pastors; FASICLD (Francis A. Schaeffer Institute of Church Leadership Development). This quest started in 1989 as a Fuller Institute project that was picked up by FASICLD in 1998.

From our recent research we did to retest our data, 1050 pastors were surveyed from two pastor’s conferences held in Orange County and Pasadena, CA—416 in 2005, and 634 in 2006 (I conducted a similar study for the Fuller Institute in the late 80s with a much greater sampling).

Of the one thousand fifty (1,050 or 100%) pastors we surveyed, every one of them had a close associate or seminary buddy who had left the ministry because of burnout, conflict in their church, or from a moral failure.
Nine hundred forty-eight (948 or 90%) of pastors stated they are frequently fatigued, and worn out on a weekly and even daily basis (did not say burned out).

Nine hundred thirty-five, (935 or 89%) of the pastors we surveyed also considered leaving the ministry at one time. Five hundred ninety, (590 or 57%) said they would leave if they had a better place to go—including secular work.
Eighty- one percent (81%) of the pastors said there was no regular discipleship program or effective effort of mentoring their people or teaching them to deepen their Christian formation at their church (remember these are the Reformed and Evangelical—not the mainline pastors!). (This is Key)

Eight hundred eight (808 or 77%) of the pastors we surveyed felt they did not have a good marriage!
Seven hundred ninety (790 or 75%) of the pastors we surveyed felt they were unqualified and/or poorly trained by their seminaries to lead and manage the church or to counsel others. This left them disheartened in their ability to pastor.

Seven hundred fifty-six (756 or 72%) of the pastors we surveyed stated that they only studied the Bible when they were preparing for sermons or lessons. This left only 38% who read the Bible for devotions and personal study.
Eight hundred two (802 or 71%) of pastors stated they were burned out, and they battle depression beyond fatigue on a weekly and even a daily basis.

Three hundred ninety-nine (399 or 38%) of pastors said they were divorced or currently in a divorce process.
Three hundred fifteen (315 or 30%) said they had either been in an ongoing affair or a one-time sexual encounter with a parishioner.

Two hundred seventy (270 or 26%) of pastors said they regularly had personal devotions and felt they were adequately fed spirituality. (This is Key).

Two hundred forty-one (241 or 23%) of the pastors we surveyed said they felt happy and content on a regular basis with who they are in Christ, in their church, and in their home!

Of the pastors surveyed, they stated that a mean (average) of only 25% of their church’s membership attended a Bible Study or small group at least twice a month. The range was 11% to a max of 40%, a median (the center figure of the table) of 18% and a mode (most frequent number) of 20%. This means over 75% of the people who are at a “good” evangelical church do not go to a Bible Study or small group (that is not just a book or curriculum study, but where the Bible is opened and read, as well as studied), (This is Key). (I suspect these numbers are actually lower in most evangelical and Reformed churches because the pastors that come to conferences tend to be more interested in the teaching and care of their flock than those who usually do not attend.)”

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The Cardiopsychology of Stress

Happy2011What effect does psychological stress have on cardiovascular physiology? Does psychological stress contribute to cardiovascular disease? These important questions are the domain of cardiopsychology, the discipline that studies how psychosocial stressors impact the onset, course, rehabilitation and the illness processing (coping) of cardiac diseases. In this post, we look at the effects of stress on the normal heart in healthy condition, and the effects of acute or chronic stress on individuals with cardiovascular disease.

{tab=Overview}
Tuvalu_EN-US163122471The body responds to stress primarily through the mobilization of resources initiated by the autonomic nervous system and endocrine activity. Endocrine activity consists of sympathetic adrenomedullary, pituitary-adrenocortical, and thyroid responses. The most important stress hormones released by sympathetic adrenomedullary response are epinephrine and norepinephrine. The stress hormones released in the pituitary-adrenocortical response are adrenocorticotrophic hormone (ACTH) and cortisol.

Psychological conditions shown to have an effect on cardiovascular disease include anxiety disorders, panic disorders, and depressive disorders. There is compelling evidence that acute psychological stress triggers major autonomic cardiovascular responses and cardiac events. Nonetheless, the evidence that chronic stress causes cardiovascular disease is highly controversial. Although the most prevalent opinion among cardiologists, psychiatrists, physiologists, and psychologists is that psychological stress has an effect on cardiovascular disease, these effects are not easily quantifiable or attributable with any degree of precision. What we do know is that acute stress is often accompanied by cardiovascular changes, some of which can be dangerous to certain individuals.

Data on whether chronic stress may, over time, cause cardiovascular disease are less convincing. For example, there is little validated evidence that people with anxiety-related disorders have a higher prevalence of cardiovascular disease than their less anxious counterparts. Moreover, except for postmyocardial infarction depression, there is insufficient evidence that individuals with cardiovascular disease have a higher prevalence of psychological disorders than those who have no cardiovascular disease.

{tab=Normal Heart}
MaldiveAtolls_EN-US1893647453Acute mental stress alters baseline parameters on the normal heart and vascular system in good health condition. Under acute stress, it is quite normal for blood pressure to rise, due to the action of neural mechanisms that regulate stress-induced blood pressure changes as a stress reaction to a dangerous situation that requires an increase in cardiac activity.

Structures of the central nervous system involved in this rapid arousal include the medulla oblongata, the medial geniculate body, the limbic system (amygdala and hypothalamus), and the brainstem. Psychological stress-induced changes in blood pressure are usually predictable and can vary depending on many variables, including duration of stress, time of measurement, expectations, psychological preparedness, and individual background.

Specific effects of psychological stress on the cardiovascular system are increased cardiac output, higher stroke volume, stronger forearm blood flow, increased left ventricular ejection fraction, higher peripheral vascular resistance, and increased cardiac microcirculation. These effects are not dangerous on the normal heart and vessels in good health condition, and they generally subside and return to normal levels after the stressor has passed.

{tab=Acute Stress}
SnowyChristmas_EN-US2022031457As in the healthy heart, acute stress increases blood pressure (generally by 10–20% and sometimes to hypertensive levels) in individuals with cardiovascular disease. Acute stress also increases the heart rate of individuals with cardiovascular disease, and angina pectoris and ischemia may result from this increase in heart rate. In some cases, the stress-induced increase in heart rate also alters cardiac electrical stability and may cause life-threatening arrhythmias.

Acute stress may also cause coronary artery vasoconstriction, reduce left ventricular ejection fraction, and induce or exacerbate left ventricular wall motion abnormalities in individuals with cardiovascular disease. In this respect, studies have shown that frequent anger among individuals with cardiovascular disease may increase their vulnerability to cardiac complications.

Psychological stress produces strong limbic-hypothalamic activity, which may contribute to the yet unclear etiology of essential hypertension, i.e. high blood pressure that does not appear to have specific organic causes. Conversely, the presence of hypertension, borderline hypertension, and genetic risk for hypertension may have an impact on blood pressure reactivity to psychological stress, thus setting up an apparent circular causality between stress-hypertension-higher reactivity to stress.

Individuals with high blood pressure are characterized by a greater arterial wall-to-lumen ratios compared with healthy individuals. Thus, the same quantity of norepinephrine causes a greater increase in peripheral vascular resistance compared to healthy individuals who have a smaller arterial wall-to-lumen ratio. Also, individuals who are already suffering from angina pectoris react to stress with a greater elevation of blood pressure.

{tab=Chronic Stress}
KugaCanyon_EN-US1699950676Chronic stress and prolonged bereavement have been shown to increase the risk of cardiac death. A large-scale study showed that stress due to the death of the wife caused a 40% increase in the death rate of the surviving husbands during the first 6 months of loss, with two-thirds of those deaths attributable to cardiovascular disease. A similar increases did not occur among widows following the death of their husbands.

Studies conducted on individuals who exhibit type A and type B personality patterns have tested the hypothesis that personality may affect the inset, course, and outcome of cardiovascular disease. Type A personalities are those characterized by time-urgency, high competitiveness, ambitiousness, and frequent hostility. Type B personalities are unhurried, more relaxed, and less competitive. The results of these studies show that if there is a correlation between personality patterns and cardiovascular disease, this correlation is very weak. Thus, type A or type B personalities appear to have similar outcomes in the convergence of stress and cardiovascular disease.

Anxiety is a significant factor in producing chest pain even when coronary arteriography is normal, and anxiety disorders have been confirmed as a debilitating factor. Major depressive disorder is the second significant factor, and this disorder appears to predict future cardiac events among patients with coronary artery disease. Chronic anxiety, helplessness, and depression have been specifically linked to angina pectoris and sudden death by cardiac arrest. More than 300,000 Americans experience sudden (within minutes) death each year. Excluding acute myocardial infarction-induced ventricular arrhythmias, about one in ten sudden deaths are due to cardiac arrhythmias (particularly ventricular arrhythmias).

Research by Rahe and others on the health impact of significant life changes discovered that individuals who suffer a myocardial infarction are more likely to have had a major life change during the 6 months preceding the heart attack. In another study, Rahe and Lind provided evidence that life change occurs more frequently among victims of sudden cardiac death compared with survivors of myocardial infarction.

The relationship between chronic psychological stress and hypertension remains controversial. Psychological stress-induced increases in heart rate and blood pressure reactivity do have an immediate effect on blood pressure readings. Nonetheless, this clearly demonstrable increase in blood pressure following a sudden and significant stressor does not appear to carry on to produce long-term effects on blood pressure.

In summary, the extent of coronary artery disease, the degree of left ventricular dysfunction, and the presence of arrhythmias appear to determine individual vulnerability to stress-induced sudden cardiac death. When individuals are already suffering from advanced cardiovascular disease, stress-related precipitants of sudden cardiac death are ubiquitous and may be impossible to avoid. Acute stressors often contributing to sudden cardiac death include bereavement, unemployment, financial distress, dislocation, lower education levels, individual responses to psychological stress, and social isolation. Research results are somewhat contradictory in establishing a clear association between cardiovascular disease and such factors as gender, personality patterns, anxiety, panic disorder, PTSD, bereavement, depression, and occupation.

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REFERENCES
1. Dimsdale JE. Psychological stress and cardiovascular disease. J Am Coll Cardiol 2008;51:1237– 46.
2. Culic V, Eterovic D, Miric D. Meta-analysis of possible external triggers of acute myocardial infarction. Int J Cardiol 2005;99:1– 8.
3. Kloner RA. Natural and unnatural triggers of myocardial infarction. Prog Cardiovasc Dis 2006;48:285–300.
4. Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. J Am Coll Cardiol 2007;49:1230 –50.
5. Smith SC Jr., Allen J, Blair SN, et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic vascular disease: 2006 update: endorsed by the National Heart, Lung, and Blood Institute. J Am Coll Cardiol 2006;47:2130 –9.
6. Bhattacharyya MR, Steptoe A. Emotional triggers of acute coronary syndromes: strength of evidence, biological processes, and clinical implications. Prog Cardiovasc Dis 2007;49:353– 65.
7. Davidson KW. Emotional predictors and behavioral triggers of acute coronary syndrome. Cleve Clin J Med 2008;75 Suppl 2:S15–9.
8. Rozanski A, Blumenthal JA, Davidson KW, Saab PG, Kubzansky L. The epidemiology, pathophysiology, and management of psychosocial risk factors in cardiac practice: the emerging field of behavioral cardiology. J Am Coll Cardiol 2005;45:637–51.
9. Strike PC, Steptoe A. Behavioral and emotional triggers of acute coronary syndromes: a systematic review and critique. Psychosom Med 2005;67:179–86.
10. Strike PC, Magid K, Whitehead DL, Brydon L, Bhattachatyya MR, Steptoe A. Pathophysiological processes underlying emotional triggering of acute cardiac events. Proc Natl Acad Sci U S A 2006;103:4322–7.
11. Thrall G, Lane D, Carroll D, Lip GY. A systematic review of the effects of acute psychological stress and physical activity on haemorheology, coagulation, fibrinolysis and platelet reactivity: implications for the pathogenesis of acute coronary syndromes. Thromb Res 2007;120:819–47.
12. Tofler GH, Muller JE. Triggering of acute cardiovascular disease and potential preventive strategies. Circulation 2006;114:1863–72.
13. Rahe, R., & Lind, E. (1971). Psychosocial factors and sudden cardiac death: a pilot study. Journal of Psychosomatic Research, 15(1), 19.

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PTSD Takes a Heavy Toll on Mind and Behavior

aaRenoir_NiniAuJardinPosttraumatic Stress Disorder (PTSD), regardless of its cause, takes a heavier toll than it is widely known on the mind and behavior of its victims. PTSD sufferers feel, think and behave as in a state of prolonged, and for some even unending, stress reaction. This disorder of the mind strikes after a traumatic event has disrupted a person’s life. Immediately following an experience such as combat, rape, assault, physical abuse or violence, a natural disaster or a terrorist act, most people react with acute stress. They may persistently re-experience the trauma in recurring images, thoughts, dreams, illusions, flashbacks, some form of dissociation or derealization, and in the inability to recall details of the event. Significant anxiety is also felt, with poor concentration, difficulty sleeping, irritability, hypervigilance, startle response and restlessness. For a minimum of two days and up to four weeks after the event, Acute Stress Disorder is the natural and expected reaction to the magnitude and seriousness of the psychological impact of the trauma. Even though the disturbance can cause impairment of functioning and significant distress during this time, many of these symptoms generally subside and even disappear within three to four weeks of the event. Except when they don’t.

The Many Forms of PTSD

In PTSD, all these symptoms, often in more severe form, persist well beyond the 4-week span of acute stress. In many cases, as in Acute PTSD, the symptoms last up to three months. In Chronic PTSD, they can continue indefinitely, especially if the disorder remains unacknowledged or is inadequately treated. In some cases, after the acute stress phase is over and life seemingly has returned to normal, PTSD can suddenly appear six months or longer after the trauma has occurred (PTSD with Delayed Onset).

This disorder causes great anxiety and a disruption of life’s activities that can have serious financial and social consequences. It also takes a heavy toll on the mind of its victims and affects their behavior in multiple ways, by inhibiting certain actions, modifying others, and removing barriers to self-injurious acts, including suicide.

The Heavy Toll on the Mind

Many survivors of severe trauma who suffer from PTSD develop self-focused beliefs that have a victim theme. They may see themselves as being continually and particularly vulnerable to physical danger. In the wake of the 9/11 terrorist attacks on New York City and Washington D.C., many people continue to experience pain, fear, threat and a heightened sense of vulnerability. They may also perceive themselves as being mentally defeated.

"Ball four… take your base."  Those were the sympathetic words of the umpire during my little league baseball pitching debut – after I had walked the 11th batter in a row, thus… run number seven.  My coach finally started to come out to relieve me, and I was glad to be taken out of the game.  Feeling mentally defeated and miserable, as he approached the mound, I desperately needed a little comfort and compassion from the adult leader of the team. Unfortunately, I was met with criticism and a few choice words that confirmed my perceived inadequacy as a baseball player. –-Dwayne K. Smith

It is not unusual for PTSD sufferers to continuously dwell on the negative implications of their traumatic experiences. Although they may protest that their trauma safely belongs in the past and no longer bothers them, they remain preoccupied with their own view of themselves and with others’ views of their behavior under fire, their inability to fend off their attacker, their shattered self-esteem. Lastly, a persistent imagining and a continuous ruminating about what might have happened (a “wishing the past could have been different”) blocks progress toward real healing and forgiveness. The experience continues to rerun on the horror channel, and is seldom if ever safely archived in the history channel.

Depressed-Soldier-02Alongside with bothersome thoughts and negative self-assessments, the constellation of symptoms also induces the development of negative beliefs about the world and the future. Most common are the belief that the trauma consequences are permanent and unchangeable; that the world has become unsafe, unpredictable, untrustworthy; that the future will be negative; and that life has lost its meaning. In the most severe cases of PTSD, these beliefs can lead to deep feelings of hopelessness and despair and culminate in suicide. According to recent US Army data, there are an average of 950 suicide attempts each month by veterans who are receiving some type of treatment from the Veterans Affairs Department. Seven percent of the attempts are successful, i.e. 18 veterans commit suicide each day, and 11 percent of those who don’t succeed on the first attempt try again within nine months.

How PTSD Negatively Affects Behavior

PTSD wreaks havoc on the individual’s behavior patterns, by inhibiting certain protective actions and inducing others that can be harmful or at the very least do not promote recovery. Among the actions that are most often induced by PTSD are behaviors associated with a continuous state of hypervigilance, such as barricading doors and windows, sleeping with a weapon nearby, frequently checking behind one’s back and scanning the environment for threats. In the same vein, the individual may also intentionally avoid any reminders of the traumatic events, dissociate, engage in “undoing” behaviors that more properly belong to compulsive disorders, withdraw from social contact, abandon normal and previously pleasurable routines, and engage in unsafe behaviors such as gambling or drug and alcohol abuse.

Among the behaviors that PTSD may inhibit are change behaviors that could help treat the disorder, such as psychotherapy, counseling or medication; communication behaviors that could help share one’s trauma story with others, including openly acknowledging the symptoms that are being experienced. The individual may also dismiss the notion that anything positive could result from trauma experience, and not read, watch or listen to information that would disconfirm their negative beliefs. Perhaps most harmful, PTSD also inhibits the seeking of social support from close relatives and friends, and the utilization of available means of coping (such as faith and religious practices).

Treatment Options for PTSD

Empirically-validated treatment options for PTSD that have been proven as effective include:

  • Cognitive-behavioral psychotherapy. This type of talk therapy is effective in desensitizing the individual by a gradual and guided exposure to negative and irrational thoughts, images, situations and feelings that are reminders of the traumatic event, in a safe environment. The treatment may last for a minimum of three months and up to one year of weekly session.
  • Family counseling. Family therapy is especially effective in treating not only the individual who is directly affected by PTSD, but also spouses, children and extended family that may also be affected by the symptoms. Family therapy promotes understanding, facilitates communication and helps address the relationship problems that almost always accompany a case of PTSD.
  • Medication. Psychotropic medication, most often fluoxetine (Prozac) or sertraline (Zoloft), is prescribed in PTSD to relieve severe symptoms of depression or anxiety. These medications have an effect on the symptoms, but they do not treat the causes of PTSD.
  • EMDR (Eye Movement Desensitization and Reprocessing). This treatment consists of cognitive-behavioral therapy combined with guided eye movements, hand taps or sounds. In EMDR, the bilateral stimulation of the brain works by reprocessing highly charged fragments of memory and emotion and integrates them into safer and less emotion-laden memories.

Can Psychological Stress Increase Cancer Risk?

FaggioBurcinaThe continuous circulation of white immune cells throughout the body is our defense against disease caused by bacteria, viruses, harmful chemicals, as well as our built-in, 24×7 surveillance system against the development of cancer. A healthy body sees between 4,000 and 11,000 white cells per microliter of circulating blood, but this concentration increases in response to a threat. Psychological stress has an immuno-suppressive effect by reducing the white cell count and thus the body’s ability to fight diseases ranging from the common cold to cancer.

How Stress Affects the Immune System

The direct communication between the sympathetic nervous system (SNS) and the immune system consists of adrenergic projections and sympathetic nerve terminals that are found in many organs of the body, such as the spleen. An acute SNS activation by a stressor causes the immediate release of catecholamines from nerve endings, initiating the automatic arousal that takes place during the stress reaction. This neuroendocrine response to stressors also increases the levels of glucocorticoids (primarily cortisol) in circulation, which are steroid hormones that in addition to rapidly mobilizing the body against the threat also have an effect on the immune system.

Acute vs. Chronic Stress

Stressors, depending on their nature and duration, modulate the functions of the immune system by influencing the number of white cells circulating in the bloodstream. The effects of a brief, acute stressor (e.g., a sudden noise) on white cell circulation are short-lived and subside when the stressor passes. There are longer lasting effects on white cell circulation when the stressor is prolonged and severe (e.g., a relationship problem), as in chronic stress.

Regardless of its origin, psychological stress always leads to a change in white cell count at varying degrees depending on the type and duration of the stressor. Current research shows that longer-lasting stressors cause a reduction of immune function and increase our vulnerability to disease. Numerous studies document the immune system suppression caused by severe stressors such as marital strife, bereavement, long-term caregiving, living in unfavorable conditions, and by the psychological reaction to environmental disasters such as floods, earthquakes, fires, and hurricanes.

Stress, Immune System and Cancer

According to the National Cancer Institute’s current information on the possible association between stress and cancer, at least three areas of investigation are being explored: stress effects on virus-related cancer, stress effects on cell processes, and stress effects on tumor growth and spread.

Virus-related Tumors. An indirect relationship between certain types of virus-related tumors (Kaposi sarcoma, Burkitt lymphoma, cancer of the liver) and stress has been established. The indirectness results from the fact that some cancers are triggered by a process that involves certain precursor infections (such as herpes and hepatitis) that are known to be exacerbated by stress and a weakened immune system.

Cell Processes. The body’s natural neuroendocrine response has been shown to alter important cell processes that protect against the formation of cancer, such as DNA repair and the regulation of cell growth. Age-related deficits in protein synthesis and the responsiveness of cells to stress, decreased cell-cell communication, and inefficient signal transduction may render old cells less able to withstand stress (genotoxic stress).

Tumor Growth and Spread. The precise biological mechanisms underlying the influence of stress on the growth and spread of cancer are not yet well understood, but a link between the effects of stress on the immune system and the growth of some tumors has been documented. A recent study at the University of Texas Anderson Cancer Center in Houston indicates that stress hormones, especially norepinephrine and epinephrine, can contribute to tumor progression in patients with ovarian cancer.

Other Factors in the Effects of Stress on the Immune System

There are many factors that can exacerbate the negative influence of stress on the immune system. Age, nutrition, gender, ethnicity, and psychosocial characteristics of the individual can affect white cell circulation in response to stressors. Depression, lack of social support, or a hostile personality can cause altered immune cell responses to acute stress. Among the protective factors, physical fitness appears to be a very important positive mediator of white cell activity in the presence of psychological stressors.

Mental Health USA: An Inconvenient Truth

aaWyeth_1946_WinterIn 2009, almost 20% of the adult population in the United States (19.9% or 45.1 million people) had a mental illness of some kind during the prior twelve months. Those with a serious mental illness were 4.8% of the adult population, or 11 million people.

These are the sobering results of the latest National Survey on Drug Use and Health (NSDUH), a report presenting estimates on the prevalence of mental disorders and mental health services utilization among adult Americans.

The results showed that adult women were more likely than men to have a mental illness of any kind (23.8 vs. 15.6%) or a serious mental illness (6.4 vs. 3.2%). An estimated 8.4 million adults, or 3.7%, had serious thoughts of suicide, 2.2 million (1%) had made suicide plans, and 1 million (0.5%) had attempted suicide within the past year.

The survey results estimate that among the over 45 million adults with any mental illness in the past year, almost 9 million had substance dependence or abuse. Among the 11 million adults with a serious mental illness, almost 26% also had substance dependence or abuse.

Only 17 million people with any mental illness received mental health services, whereas 28 million neither sought or received any treatment. Six in ten adults with a serious mental illness received mental health services, while almost 4.5 million received no treatment at all.

aaWyeth_1948_ChristinasWorldThe survey is conducted each year by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration of the U.S. Department of Health and Human Services using computerized interviewing. The 2009 results were extrapolated from screening completed at 143,565 addresses, and 68,700 completed interviews. In this survey, the category any mental illness includes the presence of a diagnosable mental, behavioral, or emotional disorder in the past year (excluding developmental and substance use disorders) of sufficient duration to meet diagnostic criteria specified within the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The category serious mental illness includes a diagnosable mental, behavioral, or emotional disorder resulting in substantial impairment in carrying out major life activities.

You can see the complete results of the 2009 survey, published a few days ago, on the OAS-SAMHSA web site by following this link.

All the Skinny On Skin-Deep Stress

DSC_3019Sometimes the stress reaction causes unwanted problems that are only skin-deep. Good thing, you might say. Keeps issues just on the surface. Well, not quite. It turns out that skin inflammation can be one of the most bothersome (and not so rare) consequences of stress and emotion. In 1978, Harvard psychiatrist and dermatologist Robert D. Griesemer authored a comprehensive index of the effect of emotions on various skin disorders that has become a classic in the field. The Griesemer index lists 27 interactions of stress and emotion on the skin and skin disorders that are mediated by the nervous system including the autonomic nervous system, the immune system, and the hormonal system (see the index after the jump). Stress can induce or worsen skin conditions in just a few seconds after the stressor (for neurotic excoriations and pruritus, for example) or up to two to three weeks later, as in the case of nail dystrophy, cysts and vitiligo.

That a direct relationship exists between skin problems and stress is easily demonstrated by the fact that taking medications which reduce anxiety or depression, such as benzodiazepines or selective serotonin reuptake inhibitors (SSRIs) usually results in a complete clearing up of the skin condition, whereas applying topical ointments or creams can have little to no effect. Moreover, nonpharmacologic treatments such as heart rate variability biofeedback, cognitive-behavioral therapy, hypnosis, meditation, relaxation or yoga that counteract the effects of stress and emotion also have a significant beneficial effect on stress-related skin problems.

What are the most important psychological disorders that have a direct effect on the skin? Anxiety tops the charts, followed by delusions, depression, and obsessive-compulsive disorder. Let’s take a look at each one.

Psychological Disorders Affecting the Skin

Acute or chronic anxiety induces or significantly worsens most skin conditions. When anxiety is left untreated, the skin problems it can cause stubbornly refuse to clear up and can become resistant to even the most aggressive dermatological treatment. It is only when anxiety subsides that the skin has a chance to heal.

ZebraStressSpecific monomaniacal delusions of parasitosis, bromhidrosis, or fibers (Morgellons) are particularly resistant to treatment. If the individual believes that his or her skin is affected by one of these conditions, even though from a clinical point of view it isn’t, the only effective treatments have proven to be antipsychotic medications.

One of the most frequent consequences of severe depression is the involuntary (and sometimes unstoppable) scratching, picking, digging, burning, cutting, pulling, or tearing of the skin, hair, or nails. Recent studies have shown that up to 1/3 of patients receiving treatment in a dermatology clinic actually suffer from depression. Once again, treating the psychological condition with antidepressants results in a definitive improvement of the skin condition and puts a stop to the self-harming behavior.

Psychogenic physical symptoms that have no identifiable organic cause are common in dermatology. Similar in etiology to irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome, and interstitial cystitis, stress-related dermatological diseases include pruritus, urticaria or angioedema, self-induced dermatoses such as dermatitis artifacta and trichotillomania associated with dissociative states. A somewhat more psychological psychosomatic condition is body dysmorphic disorder, which is an excessive and often unfounded preoccupation with one’s skin or hair. Not unlike other stress-related disorders, these psychosomatic manifestations respond well to exercise and psychotherapy and not so well to medical procedures and injections.

Stress-related problems with the management of impulse can prevent individuals from being able to avoid or stop picking at their skin or twisting and pulling on their hair, thus causing acne excoriée, neurodermatitis, and trichotillomania. Cognitive behavioral psychotherapy, hypnosis and self-hypnosis appear to work well in resolving skin conditions by focusing the treatment on the underlying psychological problem of impulse control.

Finally, obsessive-compulsive disorder is often the aggravating factor of many skin diseases such as acne, atopic dermatitis, and psoriasis. For skin complications aggravated by OCD, the combination of cognitive behavioral therapy and the prescription of SSRI antidepressants appear to produce the most long-lasting results.

And you thought that skin-deep stress was just a superficial problem.

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When Stress Hurts: The Credibility Gap

StMarksSquare_EN-US761640507How the brain processes and maintains psychogenic pain is the subject of this, the fifth post in the series on the close association between psychological stress and psychogenic pain. Hope is hard to come by for swift and lasting relief of chronic back pain, muscle pain, headaches, migraines, stomach pain, and other stress-related conditions. Medication can help but carries the dangers of addiction or dependency. Non-medical remedies do exist and can work well, but may not be as well known or easy to apply. So the pain continues without relief in sight. And then there is the credibility gap.

Unbelievable Pain That Is Hard To Believe

Even though there is no diagnosable medical condition in the body, and even though
the physical injury that may have originated the pain is now healed, the pain is real. Unexplained. Mysterious. Intense. This is hard to accept by the sufferer, by family and friends, by physicians and pharmacists. There is no “proof” of its existence or intensity that anyone can see. This apparent credibility gap, in itself, creates additional stress to the pain sufferer, which (you guessed it) creates even more pain.

The best illustration, and the best indirect proof that psychogenic pain is real, is offered by “phantom limb” pain, a well-known condition not uncommon among amputees. Significant pain is felt in an arm or a leg that has been amputated. Clearly, there can not be anything wrong with a limb that is no longer there—yet this pain can be excruciatingly intense. What’s going on? What we know about phantom limb pain is that it is created by overly sensitized nerve endings that stop at the point of amputation, but continue to transmit previously learned and now outdated pain information along “stuck” pathways to the brain, as if the arm or the leg was still there. These pathways produce a continuing cycle of pain that can last for months, years, or even decades.

A similar phenomenon of “stuck” pathways takes place in psychogenic pain. Let’s see how it works.

How the Brain Processes Psychogenic Pain

Psychogenic pain is produced when overly sensitized nerve pathways are established between the brain and certain parts of the body, which may be initially provoked and later maintained by a continuing psychological stressor.  The nervous system learns to process psychological distress along these neural pathways (exactly why this happens we aren’t quite sure) and the longer the stress goes unattended, the more sensitized and overactive these peripheral nerves become, producing significant amounts of pain to the muscles, the head and other parts of the body.

The brain interprets these nerve signals and transforms them into the experience of pain. The event that started this learning process in the nerves may have been an injury or a stressful event earlier in life, or the pain may just appear without any directly verifiable reason. Only a careful and detailed look at our current situation and life history can reveal the stressors that may have originated and continue to maintain psychogenic pain.

The Case for Fibromyalgia

Musculoskeletal pain localized in the lower back, shoulders, and arms appears frequently to be unrelated to physiological disease. Fibromyalgia has reportedly become one of the most frequent reasons for patient referrals to rheumatology clinics. It is a disorder that affects many musculoskeletal structures and is characterized by persistent pain, sleep and mood disturbances.

Fibromyalgia origins have been traced to stuck pain pathways in the central nervous system, which cause decreased levels of pain-reducing serotonin and increased levels of substance P in the cerebrospinal fluid. These pathways are further reinforced over time by a stress reaction to the pain. Just about everyone who has chronic fibromyalgia pain reacts to it with fear, anger, anxiety, frustration, and other negative thoughts and emotions. Anger and sadness specifically have been recently linked to an increase in fibromyalgia pain.

Psychological stressors, negative thoughts and emotions, conscious or subconscious,  thus appear to be major causative factors in psychogenic pain and its related syndromes, such as fibromyalgia. The decreased activity, diminished income, difficult relationships that are byproducts of constant fibromyalgia pain do nothing but add to the misery of it all, making the pain-producing nerve pathways even stronger.

In our next and final post on this series we will take a look at the medical and non-medical remedies that have been devised to cure psychogenic pain.

Previously in this series:

Next:

  • Medical and Non-Medical Treatments for Psychogenic Pain

When Stress Hurts: The Psychology of Pain

SerraDosOegaos_EN-US952673641Psychological factors that play a role in the onset of physical pain are the subject of this, the fourth post in the series on the close association between psychological stress and psychogenic pain.

Likely Causes of Psychogenic Pain

Negative interaction with one’s spouse has been correlated with the sudden appearance of pain symptoms in otherwise healthy individuals (Campbell, 2002; Hughes, Medley, Turner, & Bond, 1987). Numerous studies show that the appearance of pain is often closely associated with the onset of psychological stress, financial problems, job dissatisfaction (Melin et al., 1997), unemployment, and with other less severe but long-lasting life stressors (Bennett et al., 1998). Covington (2000) speaks of a continuum of suffering of pain and stress and suggests the terms “psychologically augmented pain” (p. 292) to describe physical suffering that appears to be at least partially caused by psychological factors.

Chronic stress in adults, especially over many years and of particular severity, often results in alterations in the allostatic control system, which in the case of gastrointestinal disorders can lead to an exacerbation of symptoms (Bennett et al., 1998). Earlier in life, significant stressors in an infant’s life have been shown to produce a permanent upward modification in the levels of Corticotrophin Release Factor secretion and in the overactivation of the locus ceruleus (Ladd, Huot, Thrivikraman, & al., 2000). Moreover, prolonged abuse or neglect at any stage of life has been linked to a permanent alteration of the HPA axis response to stressors (Heim, Newport, & Heit, 1999).

Certain life stressors have been positively linked with the onset and persistence of gastrointestinal disorders, including inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), functional gastrointestinal disorder (FGD), and gastro-esophageal reflux disease (GERD). Research has also established a correlation between acute stress in adults (such as rape or combat situations) or early life stressors (such as child abuse) and the later onset of these gastrointestinal disorders (Mayer, 2000).

Stress-related Muscle and Bone Pain

Pain in the muscles and joints is often associated with stress. Musculoskeletal pain localized in the lower back, shoulders, and arms appears frequently to be unrelated to any disease and thus bear all indications of having psychological causes (Harkness, Macfarlane, Silman, & McBeth, 2005). Researchers postulate that an increase in this type of pain observed in data collected by the Arthritis Research Campaign over a 40-year span may be due to “an increase in the proportion of the population who are psychologically distressed”  (Harkness et al., 2005, p. 893).

Other research suggests that musculoskeletal pain may be caused by multiple factors such as psychosocial environment, individual personality, specific behaviors, and mental stress. A study by Melin and colleagues (1997) on several hundred factory workers, assembly line workers, and supermarket cashiers suffering from musculoskeletal pain showed that the telltale signs of strong HPA axis activation, i.e. urinary catecholamines and cortisol, salivary cortisol, blood pressure and heart rate, and norepinephrine output all increased due to psychological stress.

Stress, Mental Health and Pain

Physiological pain and psychological disorders such as depression often coexist. Blackburn-Munro & Blackburn-Munro (2001) reported that while approximately 30 percent of individuals who report pain are diagnosed with clinical depression, 75 percent of patients diagnosed with depression also suffer from physical symptoms, including pain. Drossman (1982) provided evidence that individuals who seek medical help for irritable bowel syndrome are significantly more likely to present with psychiatric disorders, abnormal personality patterns and greater life stress.

Katon et al. (2001) in their extensive review of large epidemiological studies found that headache and other variously localized pain are associated with approximately 50% of visits to primary care physicians, and that most of the time, no clear medical explanation of the pain symptom is found. Stressful life events, anxiety and depressive disorders, childhood and adult trauma, and specific personality traits have all been found to be associated with multiple physical symptoms. Kroenke & Mangelsdorff (1989) reviewed over 1,000 patient records and noted 567 new complaints of chest pain, fatigue, dizziness, headache, edema, back pain, dyspnea, insomnia, abdominal pain, numbness, impotence, weight loss, cough, and constipation, and that an organic etiology was demonstrated in only 16% of these cases.

Finally, data from the World Health Organization’s study of psychological problems in general health care was used by Gureje and colleagues (2001) to examine the course of persistent pain syndromes among 3197 randomly selected primary care patients in 14 countries, which evidenced a strong and symmetrical relationship between persistent pain and psychological disorders.

Previously in this series:

Next:

  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain

Heart Attack or Stress?

Warsaw_EN-US2451207088Emergency room or a chill pill? What is that sudden stabbing pain that lasts only a few seconds? Or that pressure on the chest that won’t go away and feels like it’s getting worse? A heart attack, heartburn or something else? Dramatic questions like these bring people to emergency rooms or doctors’ offices by the thousands every year. The stress caused by chest pains and severe discomfort in the area around the heart can be acute, and fear of the worst in fact augments the symptoms and brings on additional ones, such as sweating, dizziness, racing heart beat, and more.

But how can we tell when to seek emergency treatment and when to simply lay down and relax? Pain or severe discomfort centered around the heart can be caused by literally dozens of conditions, from pancreatitis, to pneumonia, to an anxiety attack. Given the variety of causes, some of which carry a lethal risk, it is not surprising that most people choose to consult a doctor. In fact, it may be the wisest thing to do, unless pain and discomfort subside in just a few minutes.

The most accurate (but slow) way to determine whether a person has experienced a heart attack is a blood test that identifies creatine kinase and cardiac troponin, chemical markers that appear in the blood stream when the heart muscle has sustained some damage. A faster (but less accurate) method is an electrocardiogram (ECG). The third method (the most immediately available but least accurate) is the person’s own description of the chest pain and any other symptoms to an emergency room physician.

The Harvard Medical Letter describes the following symptoms as generally indicating a condition other than a heart attack, including anxiety or stress:

  • sharp or knifelike pain brought on by breathing or coughing
  • sudden stabbing pain that lasts only a few seconds
  • pain clearly on one side or another
  • pain confined to one small spot
  • pain that lasts for many hours or days without any other symptoms
  • pain produced by pressing on the chest or with body movements.

These symptoms may not require a visit to the emergency room, especially if they resolve within a few minutes. When they persist longer, a doctor’s visit would be necessary to identify their exact cause and take the appropriate remedies.

On the other hand, the following symptoms may indicate a stronger likelihood that a heart attack is in progress and should be taken much more seriously:

  • sensation of pain, or of pressure, tightness, squeezing, or burning
  • the gradual onset of pain over the course of a few minutes over a diffuse area, including the middle of the chest, and its persistence
  • pain that extends to the left arm, neck, jaw, or back
  • pain or pressure accompanied by other signs, such as difficulty breathing, a cold sweat, or sudden nausea
  • pain or pressure that appears during or after physical exertion, or emotional stress, or while at rest.

The appearance of these symptoms would more clearly warrant a 911 call.

When Stress Hurts: Neurochemistry Cognates

In this third post in the series on the close association between psychological stress and psychogenic pain, we take a look at neurochemical substances that are involved in the process of psychogenic pain generation and reaction to psychological stress.

The Neurochemistry of Pain: Substance P

aaGiotto_DeposizioneSubstance P, discovered in the 1950s, is the quintessential pain neurochemical, which is activated in response to physiological pain as well as to psychological stress (DeVane, 2001). It is a prototypic neuropeptide of the tachykinin family that has been linked to the production of over 50 neuroactive chemical substances (Brain & Cox, 2006). Its best documented role is as the modulator of signals to nociceptive neurons that communicate the intensity of noxious or adverse stimuli, not only those caused by pain but also those produced by psychological stress (DeVane, 2001; Shaikh, Steinberg, & Siegel, 1993). Substance P receptors are found throughout the CNS but especially in the substantia gelatinosa of the dorsal horn, which is the first point of arrival of afferent pain signals to primary nociceptive fibers.

It is not coincidental that Substance P is also present in the limbic system of the CNS, in the hypothalamus and in the amygdala, all structures that are closely associated with the perception and processing of emotions (Bannon et al., 1983; Culman & Unger, 1995; DeVane, 2001; Stahl, 1999).

Some purely psychological and psychogenic reactions of the organism also see the involvement of substance P, such as the vomiting reflex, anger and defensive behaviors (Krase, Koch, & Schnitzler, 1994), changes in cardiovascular tone (Black & Garbutt, 2002), stimulation of salivary secretions, and other physiological responses that are associated with the general adaptation of the body (Selye & Fortier, 1950) to stressful stimulation.

Kohlmann and colleagues (1997) reported the discovery of substance P in blood pressure regulation in individuals with essential hypertension, a condition that has been related to maladaptive responses to stress (Palomo et al., 2003) and has been shown to respond to psychotherapeutic interventions (Amigo, Buceta, Becona, & Bueno, 1991). Other evidence of the concurrent role of substance P in signaling pain and in the stress reaction comes from animal studies that show an array of defensive behavioral and cardiovascular changes in animals subjected to stressful stimulation (Krase et al., 1994), as well as the detection of substance P in the amygdala of laboratory animals upon neonatal separation (Kramer et al., 1998).

The Neurochemistry of Stress

The neuroendocrine response to a real or perceived stressor consists of the near simultaneous release by the sympathetic nervous system (SNS) of the catecholamines norepinephrine (NE) and epinephrine, the release by the hypothalamus of corticotrophin releasing hormone (CRH), the inhibition by the hypothalamus of gonadotropin releasing hormone (GnRH) and pituitary gonadotropins, the release by the pituitary gland of prolactin (PRL), and the release by the pancreas of glucagon (Sapolsky et al., 2000).

Upon release of NE into the synaptic cleft, approximately 10% of it enters the plasma, thus making plasma NE levels one of the most reliable measures of SNS activity and the magnitude of the body’s response to stressors. Peroutka (2004) has proposed that a migraine attack may be triggered by a significant decrease of NE due to the excessive or prolonged release of adenosine, dopamine and prostaglandin by the over-stimulated SNS. Since sympathetic activation is the primary component of the stress response, stress is thus unequivocally linked to the onset and maintenance of migraine headaches.

The Closest Association: Stress-Induced Analgesia

Livingstone_LionRThe body’s reactivity to real or perceived stressors provokes measurable changes in the autonomic nervous system (ANS) and in the structures controlled by the hypothalamic-pituitary-adrenal (HPA) axis. These changes include blood pressure elevation, pupil dilation, and secretion of cortisol. In the presence of a significant stressor, the stress response also includes a “stress induced analgesia,” or a decreased sensitivity to further pain (as writer-explorer David Livingstone so eloquently reported). This antinociceptive action of the ANS translates into an inverse relationship between blood pressure and pain sensitivity in animals and humans, and is designed to maintain the integrity of the body’s defense systems. Additionally, the release of CRF by the hypothalamus has known analgesic effects (Okifuji & Turk, 2002).

The ANS was recognized by Cannon (1914; Cannon, 1933) as the originator and enabler of the “fight or flight” response to stress. Stress-related releases of adrenaline stimulate the feedback provided by the afferent and efferent vagal fibers. Once again, these same fibers are involved in the activation of endogenous pain modulation centers (Bielefeldt, Christianson, & Davis, 2005). Pain and stress just seem to go together.

Previously in this series:

Next:

  • Psychological Stressors and the Sudden Appearance of Psychogenic Pain
  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain

When Stress Hurts: Central Nervous System

In establishing the connection between the onset of psychogenic pain and stress, it is important to notice that pain and stress share the same central nervous system (CNS) pathways and structures. In this second post in the series on the close association between psychological stress and psychogenic pain, we’ll take a look at these shared structures.

CNS Structures Mobilized by Pain and Stress

PendulumThe body’s response to pain engages a large number of CNS structures that are often the same as the ones activated by the stress reaction. The afferent pathways that carry pain signals connect to the thalamic nuclei and from there to the somatosensory, insular and anterior cingulate (ACC) portions of the brain cortex. A recent functional MRI (fMRI) study (Keltner et al., 2006) on the effects of pain expectation on pain transmission provides the best evidence for the activation of the rostral ACC (rACC), periaqueductal gray (PAG), and medial prefrontal cortex. This and other imaging studies provide evidence of a bidirectional pain pathway receiving input from the limbic system and the amygdala, converging on the PAG, traveling through the pontomedullar nuclei, and controlling spinal pain transmission neurons (Fields, 2000; Fields & Martin, 2001). As the authors of this study point out, “expectation for a higher intensity noxious stimulus increases subjectively experienced pain intensity in part through the action of a descending pathway that facilitates nociceptive transmission at and/or caudal to the region of the contralateral nucleus cuneiformis (nCF)” (p. 4442). The nCF, in humans and other primates, has a composition similar to the PAG and its neurons project directly into the rostroventral medulla, the hypothalamus and the amygdala, all structures directly involved in modulation of the stress reaction.

PMR_muscle-crampsLikewise, the body’s stress response engages a large number of the same CNS structures, specifically certain subregions of the hypothalamus such as the paraventricular nucleus (PVN), the amygdala, and the periaqueductal grey; and certain cortical brain structures, such as the medial prefrontal cortex and subregions of the anterior cingulate and insular cortices (Maier, 2003). These structures provide output to the pituitary and pontomedullar nuclei, which in their turn stimulate the body’s neuroendocrine secretions, as well as to the hypothalamic-pituitary-adrenal (HPA) axis, the endogenous pain modulation system, and the ascending aminergic pathways. The feedback controlling the stress response is provided by the serotonergic (raphe) and noradrenergic (locus ceruleus) structures and by the levels of glucocorticoids in the blood stream, which provide inhibitory impulses to the medial prefrontal cortex and to the hippocampus. Corticotrophin releasing hormone (CRH) is the fundamental chemical substances mediating the stress response, which is secreted by PVN, amygdala, and locus ceruleus neurons. Acute or chronic stress can temporarily or permanently modify the level of responsiveness and output of the CNS to stress (Bennett et al., 1998).

Sharing Pathways, Sharing Outcomes

With this significant convergence of pathways, neurochemical activity and CNS structure activation, it should come as no surprise that acute stress can provoke physical pain, often in the head, the muscles, and the abdominal region. Equally unsurprising is that pain, especially when sharp and unexpected, is in itself a cause of stress that mobilizes the body into immediate action (think of the hand that immediately goes to cover the cut or the burn). Continuous pain, of any origin, is inherently stressful. Continuous stress can be, and often is, manifested by otherwise unexplained (thus psychogenic) physical pain.

Previously in this series: When Stress Hurts: Psychogenic Pain

Next:

  • The Neurochemistry of Psychogenic Pain and Stress
  • Psychological Stressors and the Sudden Appearance of Psychogenic Pain
  • Fibromyalgia, Severe Headaches and Other Stress-Related Misery
  • Medical and Non-Medical Treatments for Stress and Psychogenic Pain