Volume 2 Number 8, 1989

2nd International Montreux Congress on StressNovember 19-21, Hotel Excelsior, Montreux, Switzerland

State of the art presentations on Stress and Cardiovascular Disease include the Pathogenesis of MitralValve Prolapse in AnxietyDisorders and Stress, The Stress Connection to Sudden Deaith, Stress-Related Cardiovascular Hypeneactivity in thePathogenesis of Atherosclerosis and Coronary Heart Di€ease, The Role of Stress and the Sympathetic Neruous System in thePathogenesis ol Hypertension, and Hypertension.as a Disorder af Communication. Other sessions are devoted to Stress,Emotions, Personality and Health, and include an update on Personality Traits As Predictors of Mortality from CardiovascularDisease and Cancer and the Beneficial Effects of Stress Reduction Strategies. Other segments are devoted to the StressReduction Effects of Spa Therapy, How to Design and Deliver an Effective Stress Reduction Program, Psychophysiologic StressAssessment Techniques, etc. The concluding presentations are devoted to the Biobehavioral Effects of Low EmissionElectromagnetic Energr and their use in the treatment of insomnia, depression, anxiety and addictive disrders.

In respone€ to a nurnber of requeste, we will be devoting certain iseuec of the Newcletter to apecifictopics. The forraat will include an introductory general overview followed by curnlnary articleareporting on recent relevant reeearch reporte. Thie issue focuses on 9tress and Sudden Deatt.

Stress and death" in cases where expiration takes place inless than five minutes, If one adheres to the WorldHealth Organization definition, then it is quite clearthat sudden death is the leading cause of mortality inthe United States. Almost one-half million individualsare affected annually, with men having a four- tofivefold gireater risk than wom€n.In most instances death is due to anabrupt disturbancein heart rhythm, or severe fall in blood pressure, andsometimes both. Sudden death may also result fromdamage to vital centers in the brain because ofmassive cerebral hemonhage in patients with hyperten-sion, congenital blood vessel defects, or followingsevere trauma. However, in these latter instances,death is not as likely to be as instantaneous ordramatic. Deaths which occur within an hour or twoof onset of symptomsare usuallytheresult of failure ofthe heart's ability to function as a pump. This is mostcommon in patients with severe coronary artery

Sudden Death

For further inlormation on the original source of abstracts and otherreprints available on similar subjects, please send a self-addressedstamped envelope to: Reprint Division, American Institute of Stress,124 Park Avenue, Yonkers, NY 10703.

The Newsletter of THE AMERICAN INSTITUTE OF STRESSNEWSLETTER is published monthly by The American InstituteofStress. Subscription rates: $35.00 annually. Copyrighto 1987by The American Institute of Stress. All rights reserved.

Sudden death is usually viewed as an unexpectedexpiration occurring within 24 hours of onset ofsymptoms, in a previously ambulatory individual. TheWorld Health Organization defines it as an "unex-pected nontraumatic, non-self-inflicted htality in patientswith or without preexistingdisease, whodie withinsixhours of onset of the terminal ev€nt." Other authori-ties believe that the term should be reserved forfatalities that occur within an hour after the onset ofthe terminalevent and use the phrase "instantaneous

ALSO INCLUDED IN THIS ISSUENervous System Pathways of Sudden Death ........................., 3

Heart Attacks and Sudden Death .........3

Who Is At Risk for Sudden Death....... . .4

Scared to Death..,....,... .....,.....4

Cultural Shock and Sudden Death........... ........5

Personality, Emotions and Sudden Death ..,........................... 6

Stress and Sudden Death in Animals ......,.........6

Stress and Sudden Death in Japan ...................7

Sudden Death and Circadian Rhythms ............,.7

2 7he Newsletter of THE AMERICAN INSTITUiE oF STRESS

Paul J. Rotch, M.D., F.A.C.P.Editor-in-Chief

Contributlng Editon lrorn The Board of Trurtecr olThe Arnericnn lnetltute of Strecef,obert Ader, Ph.D., Rochester, NYHerbert Bcnlon, M.D., Boston, MANorrnan Courine, Los Angeles, CAMichael E. DeBakey, M.D., Houston, TXJoel Elker, M.D., Louisville, KYJohn Laragh, M.D., NewYork, NYJarnec J. Lynch, Ph.D., Baltimore, MDKenneth B. Pelletier, Ph.D., M.D., Berkeley, CARay H. Rotenrnan, M.D., Menlo Park, CACharlea F. Stroebel, Ph.D., M.D., Hartford, CTAlvin Toffler, New York, NYSue Thomar, nN, Ph.D., Baltimore, MD

Stress and Sudden Death(Continued from page one)disease who suffer a myocardialinfarction. Autopsystudies r€veal that three out of four sudden cardiacdeath victims have advanced arterioscleroticchanges in their coronary vessels, compared withan incidence of only 38 percent for autopsy patientsin all categories. However, in such sudden deathpatients, the location and extent of coronary arterydisease is not distinctive or even particularly remark-able. Quite often it appears compatible with manyfuture years of a satisfactory cardiac function andlife. This suggests the possibility that the fatal blowmight have been severe coronary vasospasm causingprolonged occlusion of a major vessel that wasalready narrowed by atherosclerotic plaque. Muchmore severe coronary disease is often seen inindividuals dying from accidents or non-cardiacdisorders, who have never experienced any signs orsymptoms of heart disease.These observations suggest that emotional stressmay trigger sudden cardiac death in patients whowould otherwise have enjoyed many future years ofactive life. Further support comes from autopsystudies of patients who died suddenly followingextreme, but non-physical stress. In most instan-ces, there is no evidence of coronary occlusion oreven significant atherosclerosis. However, caref ulexamindtion will usually disclose typical discreteareas of damage, which, under the microscope,reveal characteristic "contraction bands" consis.tent with chemical destruction of heart muscletissue. These findings are identical to those ob-served in laboratory animals following injections oflarge amounts of adrenalin and nor-adrenalin. The

only other situation in which these microscopicfindings are seen occurs in patients with tumorsthat secrete large amounts of these catecholaminechemicals. These hormones can also caus€ ventricu-lar fibrillation, a severe disruption in heart rhythm,which if not corrected, will result in death in amatter of minutes. In such instances, there may belittle evidence of heart muscle damage since atautopsy, it seems quite likely that the mechanism ofmost sudden cardiac deaths is due to the effects ofthese stress-related hormones.

Ancient Veraue Modern StreccOur responses to stress are automatic and stereo-typed reflex reactions. They are the consequenceof exquisite adaptive changes which have beenprogressively refined over the lengthy course ofman's evolution. Originally, they were purposefuland life saving for our primitive ancestors, whensuddenly confronted by a potentially lethal physicalthreat, The great physiologist, Walter Cannon,labeled these complex but coordinated activitiesthe "fight or flight" response. His careful researchstudies demonstrated that they were the conse-quence of a marked stimulation of the sympatheticnervous system and an outpouringof adrenalin-likesubstances from the adrenal glands. These exertedpowerful and widespread influences affecting almostevery organ and tissue in the body. There was anincrease in heart rate and blood pressure anddilatation of the vessels supplying blood flow to thebrain, to aid in decision making. The pupils widenedand vision was improved. Body fuel stores wererapidly metabolized to boost levels of blood sugarand nutrients for increased energy. The bloodclotted more quickly, reducing loss from lacera-tions or internal hemorrhage. Blood flow and tensionwas increased in the large muscles of the arms andlegs, providing greater strength to fight, or speedierflight away from a scene of potentialperil.However, the nature of stress for modern man is nolonger an occasionalphysicalthreat from a sabre-tooth tiger or ferocious assailant. Contemporarystresses are more apt to be of emotional origin, andare frequently experienced several times a day.Unfortunately, our responses continue to remainthose that existed hundreds of thousands of yearsago. While life-saving for primitive man, they havenow become not only inappropriate, but potentiallyharmful. Repeatedly called into play, it is not difficultto understand how theycancontribute to hyperten-sion, heart attacks, cerebral hemorrhage, and suddendeath. Major psychosocialstresses, such as the lossof important emotional relationships, persistent frus-tration, feelings of helplessness and hopelessness,are apt to be more insidious and chronic than theacute challenges which trigger the "fight or flight"response. Nevertheless, as we shall see, they are(continued on page 3)

THE AMIRICAN INSTITUTT OF

The Newsletter of THE AMERICAN INSTITUTE OF STRESS

Stress and Sudden Death(continued from page 2)also associated with an increased incidence ofsudden death, via similar and other neurohumoralactivities. As our understanding of the pathogenesisof sudden death due to stress has expanded, it hasbeen possible to develop avariety of preventive andstress-reduction strategies that have been able toprovide significant protective benefits.

"The older a man grows, the faster he could run as aboy."

Red Smith

Nervous System PathwaysOf Sudden Death

Acute stress activates the frontallobe of the brainwhere thought processes originate, alerting thehypothalamus to signal the sympathetic nervoussystem and the adrenalgiandsto produce noradrena-Iin and adrenalin. Simultaneously, the vagus nervewhich exerts opposing parapsympathetic influ-ences on the cardiovascular system, is suppressed,blocking activities that would normally be activatedto maintain the normal balance of physiologicprocesses. If sympathetic stimulation is intenseandunopposed, the heart beats very rapidly, and severedisturbances in rhythm may result in sudden death.However, under certain circumstances, counterreg-ulatory rebound parasympathetic and vagal influ-ences may supervene. In such situations, suddendeath may actually result from a marked slowing orcomplete cessation of the heart beat (asystole).This produces the same effect as ventricular fibril-lation, namely a marked and sustained fallin bloodpressure that interrupts the flow of blood to vitalorgans, causing irreversible damage and suddendeath,

"The future is no more uncertain than the present."- Walt Whitman

Heart Attacks andSudden Death

Sudden death is the major cause of mortality amongAmericans between the ages of 20 and 65. Mostsudden deaths are of cardiac origin, and are usuallyassumed to be due to a "heart attack." lndeed,two-thirds of heart attack victifis die "suddenly."

However, "heart attack," like "sudden death" is aterm that can have different meanings. Patients oftenuse it to describe an episode of severe and prolongedchest pain due to coronary vasospasm. Physicians

are apt to rcfer to such symptoms as severe orprolonged angina or coronary insufficiency, Theprimary distinction is that the interruption of bloodflow to heart muscle is temporary and not associ-ated with structuraldamage. There are permanentchanges in the electrocardiogram or elevation inblood enzymes indicative of tissue destruction.Most often, the term "heart attack" usua[y denotesthe occlusion of a coronary artery (coronary thrombo-sis)with resultant permanent heart muscle damage(myocardial infarction). These terms were formerlyoften used interchangeably since it was assumedthat all myocardial infarctions were the result ofcoronary artery occlusion and permanent interrup-tion of the flow of blood to the affected muscle,Similarly, sudden death was usually assumed to bethe result of a massive heart attack. That is stillaptto be the diagnosis physicians record on deathcertificates when an autopsy is not performed.However, this is more a social convention, ratherthan a careful judgment based on scientific evi-dence. In point of fact, pathologists report that atleast half of such sudden death patients show noevidence of myocardialinfarction. In addition, largenumbers of patients have been resuscitated inrecent years from what would have otherwise beenfatal arrhythmias and sudden death. In the vastmajority there was no chest pain or electrocardio-graphic and serum enzyme changes to suggest amyocardial infarction.Over the past few decades, it has become increas-ingly evident that coronary occlusion may occurwithout myocardial infarction, and that myocardialinfarction can occur without coronary occlusion.Often, time has permitted the development ofcollateral circulation to the tissue fed by the oc-cluded vessel. Conversely, under situations ofsevere stress, the sympathetic fibers innervatingthe heart muscle (myocardium) secrete excessamounts of nor-adrenalin, causing severe localmuscle necrosis, in the absence of any relevantvascular obstruction. Severely stressful situationscan also cause prolonged constriction and spasm ofcoronary vessels, causing significant interruption inthe flow of blood to heart muscle tissue. This maybe of sufficient magnitude to cause myocardialin-farction without evidence of permanent structuralcoronary occlusion at autopsy.Heart attacks or myocardial infarctions are mostapt to occur in the early morning period before 8a.m. Sudden death tends to be more commonduring waking hours. Several large surveys haveconfirmed a preponderance of sudden death eventson Mondays, the day one usually returns to workafter a weekend of presumed relative relaxation.Such observations suggest that stressful activitiesand behaviors represent important risk factors forsudden death above and beyond their acknowl-edged contribution to heart attacks per se.

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Who Is At RiskFor Sudden Death

Ever since history has been recorded, there havebeen descriptions of sudden death in associationwith severe stress. There is probably no phenome-non as popular or pervasive in the folklore of everyculture as sudden death while in the throes of anger,humiliation , f.ear, rage, grief, depression or anxiety.While such accounts are anecdotaland apt to beembellished and exaggerated with repetition, theirvalidity is supported by modern scientific research,The availability of ambulatory electrocardiographicmonitoring, electrophysiologic testing and improvedmeasurement techniques for evaluating stress respon-ses have expanded our understandingof the mechan-isms of action involved. Common risk factors forsudden death include:

1. Coronary artery disease2. Hypertension3. Alcoholabuse4. Smoking5. Obesity6. Age7. Sedentary lifestyle (not enough exercise)8. Low blood levels of potassium or magnesium

Certain types of electrocardiographic abnormali-ties, myocarditis, valvular and congenital vascularabnormalities or enlargement of the heart are alsoassociated with sudden death. Of all of these,coronary artery disease is the most important. In20-25 percent of sudden cardiac deaths, this eventrepresents the first manifestation of any knownheart disorder.The important role of psychologicalstress has longbeen recognized. Sudden death has frequentlybeen observed as a consequence of a violentargument, witnessing a tragedy, learning of thedeath of a loved one, sudden and severe financialdisaster, etc. However, as will be seen, evenemotionally charged happy events, such as a familyreunion with long lost relatives, or a wedding can besufficiently stressfulto cause sudden death.

"If we had to tolerate in others all that we permit inourselves, life would become completelyunbearable." - Georges Courteline

Scared to DeathIt is not unusual to hear or read about someone whodied suddenly following a severe fright. That associa-tion is so wellrecognized, that being "scared to death"is actually part of our language. In one report whichexamined the circumstances surrounding 275 news-

paper reports of sudden death, eight life settings wereidentified:

1. hearing news of the collapse or death of a closeperson (2L7');

2. experiencing the threat of immediate loss ofsuch a person (97o);

3. during mourning, or on the anniversary of thedeath of a close person (3%);

4. experiencing public humuliation and loss of selfesteem (6%);

5. during periods of extreme personal danger orthreat of injury (27'/');

6, shortly after the danger has passed and therealization of its significance becomesapparent (7%h

7, during the excitement of a reunion, hiumph, orhappy ending (67o).

In analyzing the data, it became apparent that thecommon denominator in allof these situations wasthat they represented circumstances which wereimpossible for the victim to ignore, and to which theonly response was an overwhelming feeling of markedexcitation or a sense of complete resignation and"giving up," or both.Some illustrative examples which have practicalimplications follow.A 44-year-old female who had no medical problemswas seen for purposes of a routine physicalexamina-tion, which included obtaining a sample of blood.Because the patient was very fearful of this andusually fainted, the precaution was taken of havingher lie down during the procedure. However, within afew seconds of the needle puncturing the vein, shecomplained of feeling weak, broke into a cold sweat,turned pale, and went into cardiac arrest. No heartsounds could be heard, no pulses felt, there was nospontaneous breathing and her pupils became widelydilated. Cardiopulmonary resuscitation was institutedimmediately and she regained consciousness approxi-mately two minutes later, Recwery was completewithin fifteen minutes. She refused hospitalization andleft the office on her own power. When examined ayearand ahalf later, she was perfectlynormaland hadremained quite well during the intervening period.A 5S-year-old man with a history of a prior heartattack, was being examined in the emergency roomfor complaints suggestive of a second infarction, whenhe suddenly went into ventricular fibrillation andcardiac arrest. Fortunately, he was successfullyresuscitated in a few minutes. When interviewedseveral days later, he reported that he was pain freeand relatively comfortable untilthe intern began whatproved to be an unsuccessfulattempt to perform anarteriai puncture. The patient became extremelyapprehensive and concemed about the physician'scompetence and overwhelmed with the realization ofbeing powerless to do anything about his situation. In(continued on page 5)

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Scared to Death(continued from page 4)a few minutes, he felt flushed and the chest painreturned and persisted. It was when the intern leftthe room to find someone to help with the pro-cedure, that he suddenly went lnto cardiac arrest.A forty-year-old father slumps dead as he cushionsthe head of his son lying injured in the street besidehis motorcycle.A man aged 43 dies four hours after his lS-year-oldson, faking a kidnap callover the phone says, "lf youwant to see your son alive, don't callthe cops."A 3S-year-old man accused of robbery tells hislawyer, "l'm scared to death," then collapses anddies.In one case, a desk clerk in a motelwas suddenlyconfronted by a deranged looking young man whodemanded she fill a brown paper bag with money.Terrified, she gave the robber what she had andthen called the police, They took her to the stationhouse where she began gasping for breath andclutching herchest and she was immediatelyrushedto a nearby hospital. Although there was no priorhistory of any heart disease or high blood pressureshe suddenly expired, less than two hours after therobbery. One year later, the robber found himself incourt faced with a murder charge. The jury wasinformed that autopsy studies showed damagedheart muscle tissue, consistent with the chemicalinjury caused by adrenalin-like substances that aresecreted in massive amounts in individuals who areunder severe stress. This and the testimony ofother expert witnesses was deemed sufficient bythe jury to find the 2O-year-old robber guilty offelony murder by literally "scaring someone todeath."

"Everyone has a right to his opinion, but no man hasa right to be wrong in his facts."

- Bernard Baruch

Cultural Shoch andSudden Death

Abrupt changes in socialstatus and cultural normshave also been associated with increased suddendeath in various groups of individuals. The Hmongtribe in Laos were allies of the United States in thewar against the North Vietnamese. They weretough warriors, loyalfriends, and helpful collabora-tors in hiding downed U.S. airmen. When theUnited States withdrew fromlndochina, the Hmongbecame the victims of a brutalrevenge campaign bythe victors who reportedly resorted to toxic chemicals and nerve gas to exterminate them. Manyescaped to refugee camps in Thailand and from

there, many immigrated to the United States, livingmainly in large cities. Shortly after their arrival, asurprising number of healthy young men diedsuddenly in their sleep, leaving no physicaltrace ofany cause. Such sudden death has occurred inindividuals as young as twenty, with an average ageunder thirty-five. In one report of sixty such victims,alihad been in excellent prior health, had no cardiachistory, and died suddenly in their sleep betweenthe hours of 11 pm and 8 am,Some authorities believe that these deaths "will

prove to be the result of the interaction of psycho-logical culture and physical factors" still poorlyunderstood. The Hmong have only had a writtenalphabet for thirty years. However, even well-educated Southeast Asians experien ce severestressafter arrival in the United States. Severaltheorieshavebeen proposed. Some believe that the Hmongare particularly susceptible to stress and died offright, homesickness, and srief. Of particular inter-est with respect to psychological-cultural influ-ences, is that Hmong traditions and languageembrace concepts and terminology closely parallel-ing the nocturnal anxiety crises we call "night

terrors" or nightmares, One of these oneiric experi-ences which may be accompanied by significantphysiologic reactions, includes attack by anincubus, da chor that presses on the dreamer'schest. Relocating from the remote deserted moun-tain jungles of Laos to the crowded highrises ofmetropolitan cities must obviously result in variousextr eme emotional demands and shocking culturalchanges that many of these individuals are not ableto tolerate for any sustained period of time.This pattern resembles a series of unexplainedsudden deaths among young Fil ipinos andHawaiians reported several decades ago. Thatphenomenon was called "bangutgut" after theFilipino word for nightmare. In Japan, there hasbeen a recent increase in a different form of suddendeath due to stress known as sudden death differentform of sudden death ("pokkuri byo") known as"karoshi." These victims are primarily middle-aged,workaholic executives, who feel perpetually drivento perform and excel for their companies. Inaddition to cardiac deaths, stress-related immunesystem depression may also contribute to mortality,

"Despair is a sickness in the spirit, in the self, and soit may assume a tiple form: In despair at not beingconscious of having a self . . . in despair at no beingwilling to be oneself; in despair at willing to beoneself'"

-s. Kierkegaard

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Personality, EmotionsAnd Sudden Death

AL7-year-old bridesmaid dropped dead during theprocessionalfrom the wedding altar. A lS-year-oldcontestant in a Miss Teenage America contest diedsuddenly in front of an audience in a departmentstore. Neither had a prior history of poor health,drug use, or evidence of heart disease.In patients who have had a heart attack within thepast two months, it has been possible to predict thelikelihood of future sudden death solely on the basisof psychological evaluation. At particular risk arethose with extreme Type A behavior patterns,severe depression, and what has been labeled the"Sisyphus" reaction, This term describes an effort-oriented person who strives against odds with verylittle sense of accomplishment or satisfaction, InGreek mythology, Sisyphus, a Corinthian king, wascondemned to Hades where he was required topush a large boulder to the top of a steep hill, only tohave it roll down just as he reached the summit. Insome ways, Sisyphus can be likened to an extremeType A, working harder and enjoying it less, andnever being able to experience a sense of fulfillmentor satisfaction.Anthropologists studying primitive cultures havereported many tales of sudden death as a resuit of acurse or hex put on the individual by a medicineman or tribal leader. The famous stress physiolo-gist, Walter Cannon, was intrigued with theseaccounts and personally investigated the phenom-enon of "voodoo death." A typical example herecounted was that of sudden death brought aboutby superstitious fearin an African tribesman deep inthe Congo."The young Negro on a journey lodged at a friendbhouse for the night. The friend had prepared fortheir breakfast a wild hen, a food strictly banned bya rule which must be inviolably observed by theimmature. The young fellow demanded whether itwas indeed a wild hen. When the host answered,'No,'he ate of it heartily and proceeded on his way.A few years later when the two met to dine agan, theold friend asked the younger one if he would eat awild hen. He answered that he had been solemnlycharged by a wizard not to eat that food. There-upon, the host began to laugh and asked him whyhe refused it now, after having eaten it at his tablebefore. On hearing this news, the Negro immedi-ately began to tremble, and so greatly was hepossessed by fear, that in less than 24 hours, hewas dead."Cannon also recounted instances of "bone point-ing" deaths, in which the victim was accused ofhaving violated an important taboo, Guilt wasestablished by a tribal ritual using animal andchicken bones which were shaken up and thendispersed on the ground to see in whose direction

they faced. Once identified, the doomed victimretreated to his hut, and was inevitably found deadshortly thereafter. As Cannon stated, "the sug-gestion which I offer, therefore, is that 'voodoo

death'may be real, and it may be explained as dueto shocking emotional stress - to obvious orrepressed terror."

"The deepest need of man is to overcome hisseparateness, to leave the prison of his aloneness."

- Erich Fromm

Stress and Sudden DeathIn Animals

There are many kinds of reactions to emotionalstress. Animal studies have demonstrated both the"fight or flight" mechanisms of Cannon, but alsowithdrawal activities that give the appearance ofdeath. Charles Darwin observed this latter phenom-enon in birds, and it is common knowledge thatsome animals, such as the opposum, use pseudo-death withdrawal reactions for protection, hencethe term "playing possum," When apes are placedin stressful experimental situations, such as re-quiring the use of a lever to prevent electricalshock,prolonged activity may produce frustration andcomplete resignation, resulting in sudden death,Soviet researchers were able to produce vascularlesions and sudden death in monkeys by disruptingtheir socialrelationships. In one study, a dominantmale was removed from his colony and placed alonein an adjacent cage with a clear view of his formersubordinates feeding and engaging in sexualactiv-ity, The dominant male exhibited violent excite-ment, rushing about frantically, attacking the wirenetting, uttering furious and desperate cries andmoans, and ultimately expiring. The sudden deathof wild animals upon capture or caging, is wellknown to trappers and zookeepers. Experiments inwild and domestic rats, also demonstrate thatinducing a sense of hopelessness is accompanied byan increased incidence of sudden death. In cock-roaches, fighting can result in the death of sub-ordinates without any evidence of physicaldamageand has been described as "death from stress."

"You see, one thing is, I can live with doubt anduncertainty and not knowing I have approximateanswers and possible beliefs and dilferent degreesof certainty about different things . . . it doesn'tfrighten me."

- Richard Feynman (NobelLaureate)

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Stress and Sudden DeathIn Japan

Chief executives of at least 12 major Japanesecompanies died suddenly in 1988, more than threetimes as many comparable deaths as occurred in1986. Furthermore, most were in their fifties andsixties, in a country where the average male lifeexpectancy is 75. Although the causes of deathranged widely from pneumonia to heart attacks,many Japanese feel strongly that the realcause wasthe stress that resulted from a 40o/" rise in the valueof Japanese currency. This caused sales and profitsto decline because of decreased exports. Onepsychiatry professor commented that in Japan, theextreme obsession with perfection puts unusualpressure on executives. His prior research alsodemonstrated that the incidence of heart attacksamong managers was nearly four times higherduring the oil crises of 1974 and 1979, as in the highgrowth period oI L966 to 1968. Top Japaneseexecutives are often workaholics with little time forfamily and social life and even the latter activities areusually work related. Frequent business entertain-ing does not permit them to relax at home or adhereto diets but rather encourages increased alcoholicand high-caiorie food intake which may also contrib-ute to the problem.In 1969, there were ten sudden deaths in topexecutives compared to approximately 150 in 1987.Sudden death due to overwork ("karoshi") is notnecessarily confined to stressed executives. It alsooccurs among taxi drivers, teachers, journalists,salespeople and maintenance workers. In contrastto the United States, personal sacrifice and over-time spent on the job is looked upon as an essentialrequirement to demonstrate company loyalty. Thereare tremendous pressures to subordinate familyactivities and personal desires to work-relatedresponsibilities. Workers often feel that companyobligations are more important than their ownindividual rights. Researchers believe that manyfactors contribute to the increased rates of suddendeath, particularly the excessive competition thatpermeates work activities. One stated that "Japan

lost (World War II) so we feel we have to workharder than Americans and Europeans.One sudden death victim directed traffic on 24-hourshifts and sometimes longer every other day, withonly six hours allowed for naps and meals. Hisfamily was awarded compensation since it wasruled that he had died of overwork. However, inmore than 95ol' oI cases, workmen's compensationbenefits are denied because it is difficult to provethat the cause of death was work related, In the pastit rvas necessary to prove that the victim wasoverworked on the day of death, but that has nowbeen extended to cover the past week. In contrast.any police officer who develops a heart attack on or off

duty, on vacation or gambling in Las Vegas, isassumed to have a work-related disability and iscompensated accordingly!

"Some people are so concemed about the past thatthey are backing into the future."

- Charles Kettering

Sudden Death andCircadian Rhythms

Sudden death, as well as heart attack and stroke,are most likely to occur between the hours of 6 a,m.and noon than other times of the day. In one reportwhich analyzed changes in cardiac enzvme levelsreleased as a result of heart injury in over 700patients, three times as many heart attacks occur.red in the period between 9 and 10 a.m. ascompared to 11 p.m. and midnight. Another surveyof over 2,000 cases of sudden death showed asimilar pattern. It has been suggested that theprocess of wakingup is associated withthe secretionof increased amounts of stress-related hormones,like adrenalin and cortisone. These tend to causeplatelet clumping, accelerate blood clot formation,lower serum potassium, and produce fataldistur-bances in heart rhythm.There are a variety of rhythmic variations thatappear to govern certain body activities. Someoccur on a monthly basis as in the menstrualcycle,The secretion of certain hormones have 24-hourrhythmical cycles and are relerced to as circadianrhythms from the Latin circa dies (around the day).The fact that sudden death, strokes and heartattacks alloccur much more frequently during thesame hours, suggest they are alldue to mechanismsthat follow are influenced by smilarcircadian rhythms.This has important implications for treatment strate-gies since obviously medications prescribed toprevent abnormalheart rhythms should be taken ata time that produces maximal blood levels duringcritical periods, This is particularly true in the caseof beta blocker drugs which blunt the effects ofadrenalin. These agents have been demonstratedto offer protection against both heart attacks andsudden death.

"lf you are pained by any external thing, it is not thething that disturbs you, but your judgment about it.And, it is in your power to wipe out this judgmentnow."

- Marcus Aurelius

Book Reviews o Meetings and ltems of InterestBook Review

The Wornan'e World, Furct, M.L. and Morce, D.R.,(edc.). AMS Prece, New York, 19EE' 146 pp.' S32.50.This is another volume in the AMS Stress and Modem Societyseries. The authors had published a previous volume on thesame subject in 1982 at the height of the Woman's LiberationMovement and, in some respects, this represents an update orfollow-up. It begins with a brief overview of the stress concept,tracing its relationship to a variety of signs, symptoms, anddiseases. A subsequent section deals with common stressesencountered by various classes of modern women, particularlythose in the workplace. The concluding chapters are devoted tosuggestions on howto identifu stress andto manage it effectively.This includes psychological and physical coping mechanisms,the role of nutrition, social diversions, as well as standard stressmanagement techniques such as muscular relaxation and medita-tion are discussed. Distinctions between the nature of stress andstress responses between males and females are emphasized.However, surprisingly little discussion was devoted to Type Abehavior which seems to be increasing in females who have tocompete in a male-dominated work force where they still do nothave equal rights. Many authorities believe that this may be amajor cause of the significant increase in cardiovascular diseaseseen in certain female occupation settings. This volume is wellindexed and references, and its easy to read conversational styleappears to be directed primarily towards a lay audience ratherthan health professionals.

Meetings and Iterno of Interest

Sept.24, Healthy Pleasures, Bo516n, ffi (M.l.T.)lnstitute forthe Studvof Human Knowledge. Contact Margaret Caudill, M.D., ISHK/Boston. Box 1052, Cambridge, MA 02238.Oct. 2-4, Neuropeptides and Immunopeptides, New York, NY. NewYork Academy of Sciences, 2 E. 63rd St', New York, NY l@21' (212)83&0230.Oct. 11.15, American Academy of Child and Adolescent Psvchology,New York, NY. (202) 966-7300.Oct. 29-25, The Ecology of Work: Improving Productivity and theQuality of Work Life. Toronto, Ontario. Contact Tom Chase' R.R. *2'Box 44a, Northwood, NH 03251.OcL. 26129, Academy of Psychosomatic Medicine, Las Vegas, NE.Academy of Psychosomat ic Medic ine, 5824 N. Magnol ia ,

Chicago, IL 60660. (37217U-n25.Oct. t7-30, Fifth Annual Meeting of the Society for TraumaticStress Studies "Leaming from Victim/Survivors: Insights forPrevention, Intervention, and Care," San Francisco, CA. TheSociety for Traumatic Stress Studies, P.O. Box 1564, Lancaster,PA 17603.Nov. 2-4, Cardiac Wellness and Rehabilitation, St. Thomas, VI.Medical Education Resources, (800) 421'3756.Nov. 2.4, Neuroimmunology M: The State of theArt, Chicqgo,IL. University of Chicago School of Medicine. (312) 702'1056.Nov. 2-5, 1989 23rd Annual Convention of the Association fo'rAdvancement of Behavior Therapy, Washington, DC, (2121279-7970.Nov. 4-5, Teaching Humanistic Medicine: An Exploratiolt ofGoals, Teihniques and Experiences, New York, NY, NYU PostGraduaqe School. (2L2\ 340-5295.Nov. i.19, Topics in Psychopharmacology and BiolgglqrlPsychiatry Mosc6w, Samarkand, Tashkent, I enin$ad' USSR.kofessional Seminar Consultants, Inc. (800) 365-5357.Nov. 9-11, Addiction Medicine: State of the Art CaliforniaSociety for the Treatment of Alcoholism and Drug Addiction, SanDego, CA (415) 42&W91.Nov. U.20, 26th furnual Psychiatric Institute o4 Group Behaviorand Group Leadership, Peachtree City, GA, Emory UniversitySchool of Medicine. QAq 727 -ffi96..Nov. 19-21, Second Annual Intemational Montreux Congresson Stress, Montreux, Switzerland. American Institute of Stress(914) %3-1200.Dec. 3-7, Intemational Round Table on Silent MyocardialIschemia. For detailed information contact the Congress Secre-tariat, TelAviv; contact Kenes Ltd., P'O. Box 50@6, TelAviv61500.Dec. 7-9, Cardiac Wellness and Rehabilitation' Acapulco,Mexico. M-edical Education Resources (see above for details-same as August 4.)Dec. 10-30, Wellness and lts Relationship to Health Promotion'Protection and Dsease Prevention (Cruise: Rio De Janeiro toBuenos Aires, Argentina). Seminars and SSanposia Inc. (212)517-75n.Feb. 25-Mar 2, 1990, American Journal of Health Promotion,Cancun, Mexico. (313) 258'3754.Mar. 29-Apr. 1, 1990, American Society of ContemporaryMedicine arid Sursery (Stress and Hypertension), Phoenix,Arizona.

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