It’s Killing MeStress as a

Life-threatening Condition

Michael S. Krasner, MDOctober 21, 2009Perinatal Network of Monroe CountyManaging Stress for Healthier Babies, Healthier Lives, Healthier Neighborhoods

More than any other time in history, mankind faces a crossroads. One leads to despair and utter hopelessness. The other, to total extinction.

Let us pray that we have the wisdom to choose correctly.

Woody Allen

Stress Theory

Stress Theory• Claude Bernard “milieu internal,” studied

and conceptualized “homeostasis”

• Walter Cannon: “Fight or Flight”

• Hans Selye: Acute and Chronic Stress

• Richard Lazarus: Individual appraisal of stress

• McEwen: Allostasis and allostatic load

• Schwartz and Shapiro: “Intentional Systemic Mindfulness”– Intention leads to attention leading to

connection leading to regulation leading to order leading to health

Stress Definition

• Change needed, demand to be met (as appraised by the subject)

• That change may overwhelm (or “stress”) the subject’s resoures (the resources as appraised by the subject)

• Stressor: Anything that causes this reaction in the subject.

Stress Reaction Cycle

• Stressors

• Internal Events

• Perception/Appraisal*

• Stress Reaction

• Internalization

• Maladaptive Coping

• Breakdown

Physiology of Stress

•Sympathetic/Parasympathetic Imbalance

•Sympathetic Hyperarousal

•Low (relative) Parasympathetic tone

• Activation of H-P-A axis– When chronic results in:

• Increased monoamine neurotransmitters, eventual depletion

• Increased pro-inflammatory cytokines (IL-1, IL-6, TNF alpha, Interferon gamma)

• Increased cortisol

•Amygdala activation leading to a threat relevant attentional bias and enhancement of negative memory networks

•Suppression of specific immunity (NK cells, humoral immunity)

• Chronic cortisol stimulation

– Impairs brain centers with high concentration of cortisol receptors

– Suppresses specific immunity

– Activates amygdala

– Is neurotoxic

– Inhibits trophic factors that help neurons grow and develop (Serotonin, BDNF, Estrogen)

– Can lead to adrenal fatigue

• Hyperactive systems– Sympathetic nervous system– HPA Axis– Cortisol– Amygdala– Cytokines– Right PFC (behavioral inhibition, negative

emotions)

• Underactive systems– Parasympathetic influence– Hippocampus– Left PFC (behavioral activation, positive

emotions)– Cingulate (attention, decision making)– Specific Immunity– Monoamine system burnout

• Long-term physiologic and cognitive effects of sympathetic overload:– Thyroid/endocrine burnout

– Obesity, DM

– Immune suppression

– HTN, CV Disease

– Cancer

– Negative mood

– Negative attention and memory bias

– Decision making difficulties

– Inability to learn new associations

– Attentional difficulties

• Real or imagined threats induce the same stress response:– Imagined scenarios involving threat or failure

– Perceived threat

– Comparison of actual situation with ideal

– Degradation of self or present situation

– Recall of disturbing events

– Self-criticism hostility

– Rumination about a negative event

– Emotional avoidance

– Pessimism, denial

• Stress-realted physiology and their reversal by meditation:– HPA axis hyperactivation

– Hypercortisolemia

– Decreased Hippocampal activity

– Decreased PFC/Cingulate activity

– Low parasympathetic tone

– Serotonin depletion

– Negative memory bias

– Immune suppression

• Stress-realted physiology and their reversal by meditation:

– Sleep disruption

– Cytokine elevation

– HTN

– Heart disease

– Endocrine dysfunction

– Hyperlipidemia

– Chronic pain

– PFC asymmetry

Responding versus Reacting

• Stressors

• Internal Events

• Mindful Perception and Appraisal*

• Stress Response

Research

Questions and ?Answers