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Let’s talk about stress… Edith Henry Study Day May 13, 2009 Jeffrey P Schaefer MSc MD FRCPC Title: Sod-turning ceremony, General Hospital, Calgary, Alberta. Date: September 24, 1954 Dr. L.O. Bradley (hospital administrator); Miss G.M. Hall (director of nursing); Alice Gehman, (associate director of nursing education); Miss M.M. Street (assistant director of nursing); Mrs. W. Lupypciw (president alumnae association); Lorraine Digney (president of class of 1955); Eva Austen; Joan Nicholls (president of class of 56); Jeanne Gammon; Mrs. Edith Henry (association director of nursing service); Dorothy Cannon (home matron). website dr.schaeferville.com Conflicts of Interest • none Objectives • Session participants will learn that: – the current paradigm is insufficient – a psychobiological framework fits observations – there is more to stress than stress – we can reduce the effects of stress Case • 46 year old health care provider total body pain and fatigue x 5 years assessed by GIM, Neurology, Gastroenterology investigations normal Problem List – daily occipitofrontal headache – chest pain, episodic, at work – abdominal pain – fatigue – poor concentration & dizziness – work issues What’s your diagnosis? Diagnosis: ______________________ Diagnosis Menu • What’s your diagnosis / diagnoses? – – – – – – – – – – Chronic Fatigue Syndrome / Idiopathic Chronic Fatigue Fibromyalgia Tension Headache Irritable Bowel Syndrome Multiple Chemical Sensitivity Syndrome Interstitial Cystitis Hematuria Loin-pain Syndrome Depression and Anxiety Conversion Disorder Somatization Medically Unexplained Symptoms • Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation. Medically Unexplained Symptoms Headache Chest Pain Irritable Bowel Infertility Fibromyalgia Chronic Fatigue Dizziness Are Medically Unexplained Symptoms Common? MUS Prevalence • 30% of primary care visits • 13.6 visits in the previous year Psychosomatic Med 2005;67:123-9 Most Frequent Visitors 5th percentile GI……………. 54% Neuro…….. 50% Rheum……. 33% ENT………….27% GIM………… 10% This is a problem! This is a big problem! Unhappiness is… • Patients Feel Unheard – physician centered approach • 69% of MD’s 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 P(Disease) MUS Depressed Controls 15% 10% 5% 25 One condition or many? Chronic Fatigue Syndrome Fibromyalgia Irritable Bowel Syndrome Multiple Chem Sensitivity Syndrome Sick Building Syndrome Hypoglycemia War Syndrome BodilyGulf Distress Disorder Undocumented Labels Headache Syndromes Asthma Painful Conditions Various • 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 • associated with anxiety • preoccupied with symptoms • preoccupied with illness • low threshold to request consultation • difficult / impossible to reassure Multiplicity of diagnostic labels is an artifact of medical specialization. Psychobiology ‘the mind-body connection’ Talk about Stress... Acute Stress Response Fight, Fright, Flight, Frolic Response Hans Selye (1907-1982) General Adaptation Response – Alarm – Failure to adapt – Exhaustion Absolute Stress Relative Stress Interpretation of the world Recipe for Stress • • • • Novelty Unpredictability Threat to ego Loss of control stress Stress Stimuli Experience the stimuli Physiological Response (Body Chemistry Response) • • • • Hormones Neurochemistry Immunochemistry Energy Metabolism Stress Hormones • Corticosteroids – Cortisol • Catecholamines – Adrenaline (Epinephrine) – Nor-adrenaline (Nor-epinephrine) Cortisol Cortisol Regulation • Brain – emotion, pain, memory • Hypothalamus – autonomic function • Pituitary – stimulating hormone • Adrenal Gland – cortex Mind Body Connection: neural and hormonal Left: Areas of the brain that ‘light-up’ during strong emotion. (happy, sad, disgust) These correlate to Vagus Nerve mediated Heart Rate Variability. Immediate Effects of Cortisol • Response to Absolute Stress – increase vigilance – respond to emotion don’t 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 Pituitary Tumor & Cushing’s Disease Disease States • Moon facies 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 Experience of the Physiological Response 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 Chronic Stress & Immune Dysfunction • Influenza Vaccination • Difference between stressed and nonstressed group. – Lancet 1999 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 Stress & Recovery Allostatic Load Psychobiological Framework So now what? www.calgaryhealthregion.ca/cmbm/ 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 Self-regulation • Somatic Awareness – experiential – link emotional state with body symptoms – effortless breathing • Medication Reduction / Elimination – group therapy – education – heartmath – guided imagery Don’t forget to breathe… Dr. Sonia Lupien • Work on yourself – improve problem solving – learn to appreciate others – learn to appreciate yourself – practice goodwill • Work on your Body – breathe – move – power of laughter and smiles Recognize the Source of Stress • • • • Novelty Unpredictability Threat to Ego Sense of Loss of Control Have a Plan B Goodwill • Mother Theresa Effect – improved self-esteem • 290 patients 2004 - 2009