Medical Effects of Chronic Stress Jeffrey P Schaefer MSc MD FRCPC November 17, 2015 dr.schaeferville. com Conflicts of Interest none Objectives Participants will... define stress and learn its ingredients gain an understanding of stress physiology consider clinical implications consider remedies Case 42 year old female weight loss (20 kg / 9 months) poor appetite, nausea, insomnia no medication, no tobacco, no alcohol, married exam normal labs all normal imaging including pan CT, GI, normal colonoscopy endoscopy normal Diagnostic Procedure? Case Resolution Q: What happened in your life around the time you became unwell? A: My sister was diagnosed with lymphoma and my mother got deported from Canada. Q: Is it possible that these events caused you to lose your appetite? A: Ive never thought about that before... is that possible? Objectives Participants will... define stress and learn its ingredients gain an understanding of stress physiology consider clinical implications consider remedies Stress... Acute Stress Response Fight, Fright, Flight, Frolic Hans Selye ( ) Stress Non-specific response of the body to any demand for change decons truct acute stress Stress Stimuli Experience the Stimuli Physiological Response Hormones Neurochemistry Immunochemistry Metabolism Experience of the Physiological Response Good Stress (absolute stress) Eustress Gap between have and want is just beyond... Motivating! Relative Stress Interpretation of the world Hans Selye ( ) General Adaptation Response Alarm Failure to adapt Exhaustion Stress & Recovery Allostatic Load Recipe for Stress Novelty Unpredictability Threat to ego Loss of control Objectives Participants will... define stress and learn its ingredients gain an understanding of stress physiology consider clinical implications consider remedies Stress Hormones Corticosteroids Cortisol Catecholamines Adrenaline Nor-adrenaline Cortisol Regulation Brain emotion, pain, memory Hypothalamus autonomic function Pituitary stimulating hormone Adrenal Gland cortex Happy Sad Disgust Mind Body Connection: neural and hormonal Immediate Effects of Cortisol Response to Absolute Stress increase vigilance respond to emotion dont think raise blood sugar increase psychomotor activity obtain food Prolonged Effects of Cortisol increase appetite increase blood sugar increase fat stores redistribute fat salt retention BP + reduce acid barrier menstrual cycle problems male impotence bone calcium loss muscle wasting insomnia irritability depressed mood memory loss* immune dysfunction Catecholamines Adrenaline (Epinephrine) Nor-adrenaline (Nor-epinephrine) Effects of Catecholamines increase heart rate increase cardiac force of contraction narrows blood vessels increase blood pressure dilates pupils dilates airways reduces flow of blood to GI tract reduces saliva production increases platelet adherence stickiness increases sweat production Stress also... stimulates Vasopressin release ACTH Growth Hormone release (depletes in chronic) suppresses insulin production gonadotropins suppresses TSH Objectives Participants will... define stress and learn its ingredients gain an understanding of stress physiology consider clinical implications consider remedies Acute Stress and MI Mortality in Widowers 40% increase within 6 mo of spouses death Myocardial Infarction Onset Study incidence of AMI 14X among recent widows / widowers Self-report AMI Trigger 412 reports from 849 AMI Cardiovascular Disease: 3.1 ( ) Coronary Heart Disease: 3.5 ( ) Myocardial Infarction: 6.4 (1.8 22.3) Psychobiological Framework Non-Stressed Mice: 32 tumours Stressed Mice: 84 tumours Non-Stressed Mice: 32 tumours Stressed Mice: 84 tumours RR Persistent Positive Depression = 1.34 (1.01 1.76) Mice 8 months of stress Sperm Concentration: 38% Sperm Count: 32% Semen Volume: 15% Nov 2015 Sperm Concentration: 38% Sperm Count: 32% Semen Volume: 15% Nov 2015 Chronic Stress & Immune Dysfunction Influenza Vaccination Difference between stressed and non- stressed group. Lancet 1999 Wound Healing Punch Biopsies 13 Care Givers vs 13 Controls Complete wound healing Caregivers 48.7 vs 39.3 days (9 day diff) Age and income did not effect outcome Medically Unexplained Symptoms Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation. MUS Prevalence 30% of primary care visits 13.6 visits in the previous year Psychosomatic Med 2005;67:123-9 Highest Frequency Clinics GI 54% Neuro50% Rheum33% ENT27% GIM10% Medically Unexplained Conditions Non-CardiacChest Pain Headache Syndromes Fibromyalgia Irritable BowelChronic Fatigue Infertility Dizziness Do functional symptoms cluster in a way that support multiple conditions? Cross sectional survey of patients with functional symptoms Screened 2,300 patients 978 were judged functional Median Number of Symptoms Men 4 Women 6 Men & Women 5 Bodily Distress Disorder Fink et al. Psychosom Med 2007 Chest Pain Group GI Symptoms Group Musculoskeletal Group < 3% of patients had symptoms confined to their predominant group 3 group model explained 36% of the variance Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Multiple Chem Sensitivity Syndrome Sick Building Syndrome Hypoglycemia Gulf War Syndrome Undocumented Labels Headache Syndromes Asthma Painful Conditions Various Bodily Distress Disorder So now what? Objectives Participants will... define stress and learn its ingredients gain an understanding of stress physiology consider clinical implications consider remedies Recognize the Source of Stress Novelty Unpredictability Threat to Ego Sense of Loss of Control Have a Plan B n=109 Chronic Pain Clinic Patients randomized: Mindfulness Meditation (8 weeks) Wait List 33 completed / 54 meditation 40 completed / 55 wait list Unhappiness is Patients Feel Unheard physician centered approach 69% of MDs interrupt at 18 sec into the interview Ann Int Med 1984:101 physician patient incongruence longer the patient talks more likely to prescribe Psychosomatic Med 2007;69:571-7 Why reassurance fails? PLOS Medicine 2006 MUSDepressedControls P(Disease)15%10%5% 25 Goodwill Mother Theresa Effect improved self-esteem CMBM Approach symptoms are psychobiological real & explainable & diagnosable management cognitive reassurance is insufficient uncovering a psychological trauma is insufficient psychotropic medications are counterproductive success lays in self-regulation 290 patients Objectives Participants will... define stress and learn its ingredients gain an understanding of stress physiology consider clinical implications consider remedies