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).
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: ______________________
Hopefully, uptodate.com has something…
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 Fibromyalgia Irritable Bowel Chronic Fatigue Dizziness Infertility
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%
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
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
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
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
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.
Acute Stress Response Fight, Fright, Flight, Frolic Response
Hans Selye (1907-1982) General Adaptation Response • Alarm • Failure to adapt • Exhaustion
Relative Stress Interpretation of the world
Recipe for Stress • Novelty • Unpredictability • Threat to ego • Loss of control
Physiological Response(Body Chemistry Response) • Hormones • Neurochemistry • Immunochemistry • Energy Metabolism
Stress Hormones • Corticosteroids • Cortisol • Catecholamines • Adrenaline (Epinephrine) • Nor-adrenaline (Nor-epinephrine)
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 • 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
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