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No-one can live without experiencing some type of stress all the time. You may think that only serious disease or intensive physical or mental injury can cause stress. This is false. Crossing a busy intersection, exposure to a draft, or even sheer joy are enough to activate the body’s stress mechanism to some extent.
. . . The same stress which makes one person sick can be an invigorating experience for another.
—Dr. Hans Seyle
It was just after 7:30, on what was a pretty regular morning. I’d done my usual routine in the shower of washing everything in exactly the same order, getting out and drying. As I started to fumble with my tie knot my attention was drawn by a piece on the BBC-TV morning news. The presenter was telling me that academics had found a link between anger and heart disease. Anger and heart disease in men—how on earth could that be the case? Anger is an emotion. Emotions are all in the head, in effect, they are imaginary. How on earth could anger be linked to the real physical problem of heart disease?
A few months later, there was another piece on the very same breakfast television BBC program. This time the presenter was telling me that there was a link between anger and heart disease in women. So even though we generally think of men as having “anger problems,” getting all riled up, being destructive and aggressive, we were now being told that women, whose displays of rage seem far less frequent and explosive than men’s, are also experiencing heart disease because of anger. Wow, my mind was blown; national television was going against everything that Western medical practice would teach us. But what did it mean, exactly? How could anger lead to heart disease, and what sort of an impact what this going to have on our healthcare system?
This information is revolutionary, when we think about the implications of it. If anger can somehow cause heart disease that means anger, and therefore all emotions, must actually be more than the “all-in the-mind” notion we have been led to believe. “It’s not clear what causes this effect. It may be linked to the physiological changes that anger causes to our bodies, but more research is needed to explore the biology behind this,” said Doireann Maddock, Senior Cardiac Nurse at the British Heart Foundation (BHF). Okay, so more research is needed. But more importantly mainstream science is now open to the idea that stress and disease are intimately connected.
Six months after this monumental revelation, I found myself reading an article in The Observer newspaper, a highly regarded London broadsheet. While sipping my steaming hot mug of black coffee, I came across a piece entitled, “Cancer Warning For Stressed-Out Men”. I put my coffee down on the table and stared intently at the page. “Prostate cancer kills one man in Britain every hour and 10,000 each year—the equivalent of a Lockerbie air disaster every week.” Professor Roger Kirby, chair of Prostate Cancer UK, a cancer research charity, said that many of these cases could be related to intolerable stress at work.
“We have to get men to look more to their feminine side,” said Kirby, who is also editor of the journal Prostate Cancer and Prostatic Diseases and founder of The Prostate Centre in London. “They need to think and act more like women; share their emotions and focus on home and family, and less on pure career success. The changes that induce cells to become cancerous are unknown, but lifestyle is critical and men are creating the lifestyles that are killing them,” said Kirby. I was certainly cognizant that research in the area was scant, and there would be those who would suggest that the views expressed by Professor Kirby were a little controversial. However, lack of sufficient data doesn’t mean something isn’t potentially true, it just means no one has bothered to research it yet, and there must be reasons for that.
This article transfixed me. It was 2007 and I had been working with sufferers of chronic health challenges for more than five years and it had felt like a complete uphill battle trying to get some recognition that mind and body were linked, that stress, emotion, and health were intimately connected. I was constantly told by people that the work I was doing couldn’t be relevant because the conditions I worked with were “real” physical conditions, not psychological problems.
While the notion put forward by Professor Kirby that men should be more like women seems reasonable at one level, it struck me as being so oversimplified that it might damage the profound suggestion that stress could cause cancer. Uncovering data that might suggest that stress could cause cancer would most likely be the outcome of a highly complex and sophisticated process. Ideally what follows is a solution that is equally as rigorous and comprehensive. The solution wouldn’t need to be complex; however, the suggestions of sharing emotions and focusing on home and family are too vague and woolly. First we need to understand stress and emotions and how they connect to health and disease.
The Origins of Stress
Stress in heath and disease is medically, sociologically, and philosophically the most meaningful subject for humanity that I can think of.
—Dr. Hans Selye
The origins of the word “stress” lie in the Latin word “strictus”, meaning tightness, compression, or a narrowness. Yet we have to come all the way into the 18th and 19th centuries before the word “stress” enters everyday vernacular, where in industrial engineering the word was used to mean an abstract physical force, a pressure, or to put emphasis on something. In these contexts, the word stress was frequently used in conjunction or in collaboration with the word strain—stress being what was applied, and strain meaning what was felt or experienced.
The word stress has found permanent residence in today’s parlance, but what does it actually mean, in the way we use it? The Oxford English Dictionary defines stress as: “Pressure or tension exerted on a material object.” Or, in something a little more aligned to our current investigation: “a state of mental or emotional strain or tension resulting from adverse or demanding circumstances.” If we turn our attention to a more healthcare-related definition, an online medical dictionary defined stress as: “an organism’s total response to environmental demands or pressures.”
One recurrent disagreement among researchers concerns the definition of stress in humans. Is it primarily an external response that can be measured by changes in glandular secretions, skin reactions, and other physical functions; or is it an internal interpretation of, or reaction to, a stressor; or is it both?
The term “stress” was originally used in the context of human experience by physiologist Dr. Hans Selye in 1926 to represent the interaction of the human body and the environment. Selye was born in Hungary in 1907, and came from a long line of physicians. He attended the German Medical School at age 17, and went on to attain a doctorate in organic chemistry. As a medical student, Selye learned that the primary focus in medical research was identifying specific markers for disease; this essentially means looking for measurable indicators of the presence and severity of a disease. Indicators would be identified and specific treatments and therapies would be developed or applied for specific diseases. Despite this system seeming like a perfectly sensible and logical approach to medical research, Selye was intrigued by patients who presented with symptoms and looked sick, without the specific markers. These patients would exhibit similar symptoms despite apparently having different conditions. Selye was fascinated by these “nonspecific” symptoms, and developed an interest in what were then called “nonspecific therapies”—meaning therapies that seemed to benefit a variety of health conditions. This was not a popular field of endeavor, and Selye faced significant resistance from his mentors and supervisors who suggested that pursuing this research interest would prove both futile and potentially career damaging. However, Selye’s mind was made up and in 1936 he submitted a paper to the journal Nature outlining his theory on the nonspecific response of the body to demands placed upon it, which he called General Adaptation Syndrome (GAS). There are three phases of GAS: Activation, Resistance, and Exhaustion.
Phase 1: Activation. This is where the body identifies or perceives a threat or stressor within the environment, and moves into the so-called “fight-or-flight” response—this is the body trying to retain homeostasis or balance by calling on the hormonal system. The first person to really examine the ability of the body to maintain constancy despite environmental changes and shifts was Claude Bernard, who delineated this in the 19th century. However, it was physiologist Walter Cannon who first coined the term homeostasis to describe the ability of the body to strive for balance, almost like the thermostat of your home’s central heating system.
Homeostasis is also what is responsible for healing, or self-healing. When a schoolboy falls over and grazes his knee, there is nothing he needs to do in order for his knee to effectively heal. The natural mechanism of self-correcting homeostasis will endeavor to return the body to its original blueprint, or template. The only thing that can prevent a return to a healthy, graze-free knee would be perpetual falls onto the same knee, picking at the “scab,” or some other process or mechanism that interrupts the body’s natural flow and its self-healing system. Selye considered disease states to be the body fighting to maintain homeostatic balance; “Disease is not mere surrender to attack but also the fight for health; unless there is a fight, there is no disease.”
During Phase 1, fight or flight, the stress hormones cortisol, adrenaline, and noradrenaline are released and move throughout the body and brain. Increases in heart rate are evident, blood pressure will rise, and the activity within the emotional processing centers of the brain will become activated.
Phase 2: Resistance. Following the initial activation phase, the body remains in a state of arousal and continues to adapt to the existence of the stressor. In this phase the body is “coping” and working hard to maintain homeostasis. One of the significant differences between Phases 1 and 2 is the level of awareness of the individual to the happenings within the body. Selye argued that in Phase 2 the individual might be completely oblivious to the fact that the body is in adaptation mode with the stress response locked on. This of course is what makes this phase particularly dangerous. The body is in a state of stress, fighting to maintain homeostasis, but if this resides outside the conscious awareness of the individual nothing will be done to change the circumstances or interaction with the environment. The body can remain in this resistance phase for some time but not indefinitely. When the body’s reserves have been depleted and can no longer maintain the “fight,” Phase 3 begins.
Phase 3: Exhaustion. During this final phase the body’s reserves are completely depleted and it loses its ability to maintain homeostasis and reduce the impact of the perceived stressors. Burnout sets in, and body systems begin to break down, as symptoms of illness and disease begin to present themselves. Selye was interested in the idea of “adaptation energy,” and more specifically that we only have a finite amount of it available to us, as we seek to navigate through changing and challenging life circumstances. Selye believed that depletion of this adaptation energy arises from faulty adjustment to the environment, and it is the struggle to adjust to a changing or unfavorable environment that is responsible for many chronic diseases that are apparent in Western societies. Selye’s conclusion was that stress plays a role in the causation of all disease, except those due to injury or infection.
The problem with Selye’s concept of stress and its impact on the body lies in obtaining repeated consistent measurements. As stress is a nonspecific response of the body in its interaction with the environment, the response can vary between individuals and also can vary within an individual. So sitting in a draft may trigger a measurable response within the body one day and the following week a different response could be observed. This measured response could also be trigged by a variety of different environmental contexts. So despite pioneering this groundbreaking work on stress, many questions remained unanswered, and arguments continue within medical and academic circles.
But What Does This Mean for Us?
The important understanding that arises from Selye’s work is that stress is much more than the overwhelming agitated body discomfort that we can experience on a daily or weekly basis. Our body can be in a state of stress-adapting in Phase 2 (Resistance) without us even being aware of it. That is the crucial issue. We are no longer living in the jungle being chased by tigers where the danger is pronounced and short lived. Modern life offers an entirely different breed of “threat.” What we experience is a whole range of low-level “stressors” that keep us locked in the stress response without being aware of it. And, let’s remember that we are going to look at stress as a symptom of our ability to adapt to our environment, that is our ability to be flexible in a number of ways. We are adaptable and flexible by nature. However, the irony is that the more stressed we become, the less adaptable and flexible we want to be, the more resistant we become.
The perspective presented in this book is slightly different from conventional views that seek to list external events that cause stress. We’re used to seeing lists of disastrous occurrences such as job loss, relationship breakdown, moving house, etc., as being the most familiar causes of stress. However, it is not the events themselves that cause stress, rather it is our level of adaptability to those events. We cannot control external events and we do not need to. Life is life and we need to flow and move with it rather than trying to control it. I’m not suggesting that we are not affected by external events because we clearly are; however, our body responses are not fixed, they tend to vary. So the feeling response that arises from a certain set of circumstances one day may be different from that to the exact same set of circumstances the following day or week. From a young age, we tend to assume that external events directly cause and control how we feel. What emerges from this unconscious belief is a desire to control these external events. We could look at this as something of a spectrum, where at one end we have the idea that our feelings are directly linked to external events, and that a particular event will then lead to a particular feeling. At the other end of the spectrum, we have the idea that all emotions and feelings come from inside us, and are not influenced or related to external events. In my view, neither of these polar opposites is quite right. There is a sweet spot somewhere in the midpoint of this spectrum, where we recognize that our emotional feelings arise from inside us, while at the same time recognizing that we cannot extricate ourselves from our environment, that we are connected to the world around us. The purpose of this view is that when looking to understand our feelings we need to bring our attention back into ourselves rather than trying to manipulate external events. We’ll talk more about this in the next chapter on emotion, but for now, let’s return to the topic of stress.
Stress, the Brain, and the Body
Advances in stress research have surpassed some of the original ideas of Selye, however his work was groundbreaking, and is absolutely vital in understanding the way that our body seeks to adapt internally to external changes. Stress is a hardwired physical response, a set of objective measurable biochemical events that takes place through your entire body and brain, and is part and parcel of everyday life. Stress is a reflection of the nature of our interaction with our environment. The stress response begins in the brain and body with the hypothalamic–pituitary–adrenal (HPA) axis. This is a collaboration between the endocrine glands in the brain and the adrenal glands that sit on top of the kidneys. When there is a perception of threat, the HPA axis is immediately activated. Short-term stress, which can trigger the fight-or-flight response in the body, is not problematic and does not negatively impact the body and brain. However, when the body remains in a state of stress, the adrenal glands release the stress hormones cortisol, epinephrine (adrenaline), and norepinephrine. These stress hormones course through your veins, affecting your blood vessels en route to your heart. Your heart will begin to beat faster and your blood pressure will rise. In the short term this “fight or flight” mobilizes you for action, preparing you to deal with a perceived threat. (Of course in the absence of an actual threat there is little need for these biochemical changes within the body.)
Over time if the stress response remains switched on these chemical changes can cause structural damage. Cortisol can lead to changes in the endothelium, where changes occur within the lining of the blood vessels. This can lead to atherosclerosis, where the lining of the arteries become clogged with plaque, or atheroma. Scientists believe that these changes can increase your chances of experiencing a heart attack or stroke. Chronic stress increases the neural connections within the amygdala, the brain’s fear center, and leads to a deterioration of the electrical signals and a reduction in the number of new cells created within the hippocampus, the area of the brain involved in learning and the creation of new memories. This inhibits activity of the HPA axis, which weakens your ability to control or respond to stress. Too much cortisol results in the loss of synaptic connections between neurons and a shrinking of the prefrontal cortex—the executive center of the brain. This negatively affects concentration, decision-making, judgments, and social interaction.
The stress response can cause a chain reaction affecting the immune system, the endocrine system, and the autonomic nervous system (ANS). Through the ANS, there is a direct connection with the gut or digestive system. The trillions of bacteria that live in the body are called the microbiome and the majority of these reside in the gut—commonly referred to as the gut microbiota. The gut microbiota has its own neural network, the enteric nervous system (ENS), which scientists call the little brain. The ENS comprises two thin layers of more than a hundred million nerve cells lining your gastrointestinal tract, from esophagus to rectum. Modulation via the ANS can cause physical changes within the gut and your ENS. You’ll be very familiar with the feelings of butterflies in the stomach. This is the mild impact of stress hormones impacting the stomach via the ENS. However, over time, chronic stress leads to irregularities within the stomach and digestive system which can manifest as symptoms of irritable bowel syndrome (IBS). The changes within the stomach leave it more sensitive to acid, which can result in heartburn or acid reflux. So stress can directly modulate or change the composition and nature of your gut bacteria and gut microbiota, which can have a massive impact on your health, through the immune system.
Stress hormones affect immune cells in a variety of ways, initially to fight infection or invaders and to facilitate healing. However, in the longer term with chronic stress, our body releases what are called inflammatory cytokines, little chemical messengers that bring a certain part of our immune system into high alert. In a sense, our body reacts to all stress as if it were an infection, and to chronic stress as if it were a chronic infection. The immune system does a great job with short-term inflammation to fight off pathogens like colds and flus; however, long-term inflammation is increasingly singled out as the primary contributor to a whole host of chronic health conditions, from depressive disorders to cancer.
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This has been an excerpt from It’s Not the Stress You Feel, It’s the Stress You Don’t by Kyle Davies. To download the full article, and more excellent material for the psychotherapist, please subscribe to our monthly magazine.