Let’s talk about stress…

1. Let’s talk about stress… Edith Henry Study Day May 13, 2009 Jeffrey P Schaefer MSc MD FRCPC

2. 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).

3. websitedr.schaeferville.com

4. Conflicts of Interest • none

5. 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

6. Case • 46 year old health care provider total body pain and fatigue x 5 years assessed by GIM, Neurology, Gastroenterology investigations  normal

7. Problem List • daily occipitofrontal headache • chest pain, episodic, at work • abdominal pain • fatigue • poor concentration & dizziness • work issues

8. What’s your diagnosis? Diagnosis: ______________________

9. Hopefully, uptodate.com has something…

10. 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

11. Medically Unexplained Symptoms • Physical symptoms that prompt the sufferer to seek health care but remain unexplained after an appropriate medical evaluation.

12. Medically Unexplained Symptoms Headache Chest Pain Fibromyalgia Irritable Bowel Chronic Fatigue Dizziness Infertility

13. Are Medically Unexplained Symptoms Common?

14. MUS Prevalence • 30% of primary care visits • 13.6 visits in the previous year Psychosomatic Med 2005;67:123-9

15. Most Frequent Visitors 5th percentile GI……………. 54% Neuro…….. 50% Rheum……. 33% ENT…………. 27% GIM………… 10%

16. This is a problem!

17. This is a big problem!

18. 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

19. 25

22. One condition or many?

23. 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

24. 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

25. Median Number of Symptoms Men  4 Women  6 Men & Women  5

26. 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 “Bodily Distress Disorder” Fink et al. Psychosom Med 2007

27. 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.

28. Psychobiology‘the mind-body connection’

30. Talk about Stress...

31. Acute Stress Response Fight, Fright, Flight, Frolic Response

32. Hans Selye (1907-1982) General Adaptation Response • Alarm • Failure to adapt • Exhaustion

33. Absolute Stress

34. Relative Stress Interpretation of the world

35. Recipe for Stress • Novelty • Unpredictability • Threat to ego • Loss of control

36. stress

37. Stress Stimuli

38. Experience the stimuli

39. Physiological Response(Body Chemistry Response) • Hormones • Neurochemistry • Immunochemistry • Energy Metabolism

40. Stress Hormones • Corticosteroids • Cortisol • Catecholamines • Adrenaline (Epinephrine) • Nor-adrenaline (Nor-epinephrine)

41. Cortisol

42. Cortisol Regulation • Brain • emotion, pain, memory • Hypothalamus • autonomic function • Pituitary • stimulating hormone • Adrenal Gland • cortex

43. 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.

44. Immediate Effects of Cortisol • Response to Absolute Stress • increase vigilance • respond to emotion  don’t think • raise blood sugar • increase psychomotor activity • obtain food

45. Prolonged Effects of Cortisol • bone calcium loss • muscle wasting • insomnia • irritability • depressed mood • memory loss* • immune dysfunction • increase appetite • increase blood sugar • increase fat stores • redistribute fat • salt retention  BP + • reduce acid barrier • menstrual cycle problems • male impotence

46. Pituitary Tumor & Cushing’s Disease

47. Disease States • Moon facies

48. Catecholamines • Adrenaline (Epinephrine) • Nor-adrenaline (Nor-epinephrine)

49. 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