Stress: The Silent Killer

Dr. Vladimir Bernik, M.D.

In July 1997, the world was taken by surprise with the news that the Russian spaceship Mir (which means "peace") had a sudden failure of its power supply, due to a wrong command issued by Commander Vladimir Tsibliev. The physician whoís in charge of the crew, Dr. Igor Goncharov, explained very naturally that "the mistake resulted from the Commanderís high level of stress". Never this word had gained so much notoriety in so dramatic a circumstance.

And what is stress ? There is still no clear definition in the medical pathology textbooks, but a current dictionary defines it as "the set of all organic reactions to physical, psychic, infectious, or other, aggressions, which are capable do disturb homeostasis (the internal body equilibrium)".

Today, the word stress is widely used in common language and in the media. It designates the aggression itself, leading to discomfort, or the consequences of it. It is our organismís response to a challenge, be it right or wrong.

It is important to understand that stress always corresponds to a relation between the environment and the individual. It means that an aggression and a response have occurred, and that a interaction took place, as it has been proposed by the Canadian physician Hans Selye, the creator of the modern concept of stress. According to him, the so-called physiological stress is a normal adaptation syndrome, or a fight-or-flight situation (when faced with a enemy, animals either try to escape, or remain to fight). However, when the response is pathological, such as in a ill-adapted individual, or in a situation where the stress stimulus persists for a long time, then an organic mal-function takes place, which may lead to transitory disturbances or to severe manifestations of disease. At least, excessive stress may worsen pre-existent diseases or may provoke diseases in persons who are genetically predisposed to them. A medical case ensues.

According to what Selye said in a conference held in Munich, in 1988. "stress is the result of a civilization which men himself no longer can withstand". The incidence of stress in the general population has been increasing at a rate of 1 % per year, and in some professions, such as in executives, it can affect up to 60 % of all individuals. This, alone, would made stress the "disease of the century", or perhaps the "disease of the third millenium". It is recognized as a serious social and economial problem, and a public health concern, because it affects relatively young people, who are still in their productive years, occupying posts of responsibility. Thus, the productive forces of a nation are at risk; particularly in developing countries like Brazil, where there is a larger percentage of young people. By being adversely affected by a high incidence of stress, these persons may be excluded from the activities which contribute to economical growth and social well being. In the US, from 50 to 75 billion dollars are lost each year, directly or indirectly, due to stress: this represents ca. 750 dollars per year per worker !

The hereditary vulnerability, plus the concern about the future in a time of economical or political uncertainties, of decreasing quality of life, of looming unemployment, of fear of the old age, and of becoming destitute; has lead to a general increase of persons who report stress. Other contributing factors are the lack of regular leisure or physical activity, bad or scarce food, an inadequate family structure and support, etc. These personal, social, economical and professional factors interact with the biological factors to make stress a leading cause of several ailments, from a simple heartburn to a decrease in the immune resistance, and from this to cancer and other diseases.

The Boston University has created a quick self-administered test (see annex) which you can use to "measure up" your level of stress. If your rating is low, you are free of stress and does not need to read further. However, if your profile is found to be similar to that of persons with stress, even at a low level, please follow carefully what is written below.

What Are the Causes of Stress ?

In general, acute or chronic stress can be attributed to the biggest problems we have during our life courses. For instance, several researchers have noted that change, any kind of change in our daily lives, either good or bad, are among the most effective causes of stress. The intensity of stress will depend on the nature and on the degree of change, which can go from major ones, such as the loss of a child or conjugal separation; to relatively trivial life changes, such as small misdemeanours or the well-deserved vacations.

Certain events in our lives are so severe in terms of stress, that they are characterized as a trauma (lesion or damage) of a psychic origin. Recently, the mental health sciences have recognized the existence of a new syndrome called Post-Traumatic Stress Disorder (PTSD), a real disease, classified in the area of the major anxieties. Its study really began in the USA, after the return of the veterans of the Vietnam war, the so-called "viet-vets".

PTDS causes acute, severe and invalidating episodes of anxiety or mental anguish, when the victim is exposed to situations similar to that one which had installed the disease. The symptoms appear as a kind of "flash-back", i.e, they live again the traumatic situation of violence, over and over.

This does not apply to war veterans, only. It is enough to see what happens to the victims to the increasing levels of urban violence, who are doomed to suffer permanent despair, when they are not taken care of adequately or in time by competent and trained psychiatrists. Bombings, automobile accidents or aircraft crashes, earthquakes and floodings, kidnappings, rape, child or spousal abuse, etc., are often the cause of post-traumatic stress. Therapy is generally very long, but its results are usually good.

What Are the Functional Basis of Stress ?

Da Silva, an American surgeon of the last century, was one of the first to note that wounded soldiers would fall writhing in pain only after reaching their goal. In other words, they were fighting under the influence of what we know today as "adrenaline". The American physiologist Walter Cannon observed in animals that the reactions of alert and flight would provoke a massive increase in the levels of catecholamines (substances which are the result of the metabolism of adrenaline) in the urine.

The scientist who has described for the first time the phenomenon of stress, Hans Selye, has described a generalized physiological response to stress, according to the following sequence:

There responses are normal in any situation of damage, danger and disease. Thus, we say that there is a normal level of stress (called eustress), which is important for our organismís defense. The problem starts when the activation of the hypothalamus-hypophysis-adrenals axis is repeated many times over a short period or when it becomes chronic (over extended periods of time). Pathological changes begin to appear in the body, by virtue of the constantly raised level of these hormones.

Physicians have recognized that chronic stress has three distinct phases, one after the other, in case the stressing agents are not suspended:

The treatment of stress depends on the phase of its course.

Problems Caused by Stress

Stress can cause or make worse a great number of disease conditions, such as asthma, skin diseases, allergy and other immune dieseases, etc., All of them are related to a pathological or excessive activation of the hypothalamus-hypophysis-adrenal axis.

In the digestive system, we all know that stress can provoke the inflammation of the stomach lining or mucosa, which is called gastritis; or even a peptic ulcer. The famous Brazilian surgeon Dr. Alipio Corrêa Neto, a professor of the University of São Paulo and of the Paulista School of Medicine, in São Paulo (now the Federal University of São Paulo), has written that, if someone said 20 years ago that the peptic ulcer was psychosomatic (or somatoform) in origin, he would be laughed at. Nowadays, if he failed to say it, he would be laughed at, all the same !

But is mainly when acting on the heart and vascular system, particularly on the coronary arteries (the arteries which transport blood to the heart muscles), that stress can be a silent but very powerful killer.

In a repeated and long-term activation of the autonomous nervous system, the heart and the coronary arteries are subjected to successive dilations and contractions, and to the increase in frequency and strenght of the heart beats. When the affected person has a genetic predisposition, or if he/she has lesions in the walls of the coronary arteries (plaques of fat tissue, called atherosclerotic plaques), provoked by smoking, excessive fat in the food intake, obesity or elevated cholesterol), many health problems may occur:

Other Symptoms

Stress also may cause many other clinical changes in the body (somatic alterations), commonly designated as "neurovegetative" symptoms (another title for the autonomous nervous system), such as a sensation of weakness and fatigue (called asthenia), increased tension in the muscles, with cramps and the appearance of hard painful knots (called myofibralgia), trembling hands, intense sweating, with cold hand palms, headaches provoked by psychic tension, migraine, back pains and pains in the upper arms and shoulders, increase in the blood pressure (hypertension), diseases of the bowels (changes in absorption and movement, such as diarrhea and/or constipation) and even pains in the urinary system, in absence of infection. When several of these symptoms appear at the same time, severe stress should be considered as the main cause.

Blood chemistry evaluation also provides other telltale signs of intense, pathological stress, such as the increase in blood concentration (density), the amount of blood particles called platelets (which are responsible for blood clotting mechanisms, among other functions), alteration in the level of cortisol and urinary catecholamines, alterations in the level of pituitary and sexual hormones, and the increase of sugar and cholesterol levels in the blood.

Psychic Symptoms

Stress may also be accompanied by a wide range of disorders of the mind, either temporary or by the exarcebation of neurotic, psychopathic or sociopathic disorders which were previously existent.

Problems related to an increased or sometimes unbearable level of anxiety are: irritability, weakness, nervousness, fears, obsessive thoughts, failed acts, compulsive rituals, etc. Anguish is very common, and there is a increase in emotional sensitivity to small, unimportant events, which usually provoke unjustifiable violent discussions or aggressive behavior

On the other hand, there are also depressive symptoms associated to stress, such as the decrease of appetite, sleep disturbances, apathic behavior, affective bluntness (emotionless people) and loss of libido and sexual interest.

There are also the typical "escape behaviors", when the persons under constant stress make use of all kinds of pills (such as pain killers, sleeping pills and other prescription medicines, some of them which are very dangerous for self-medication), tobacco, alcohol and illicit drugs. These habit-forming behaviors may lead to the final defeat and ruin of weak or hyperactive people.

How to Decrease Stress ?

In a excellent article about stress, particularly in the work environment, Brazilian psychiatrist Cyro Masci (who has a WWW site too), suggests several preventive measures, in initial, intermediate or final levels.

The main point is that we should have time enough in our lives to pause, to think about ourselves, and to provide more freedom to reflect about our environment, our social and family life, our work, study and even financial conditions. Stressed out persons should rethink their lifes, mostly by identifying the sources of stress and trying to eliminate them. A good clinical psychologist of psychiatry may be of great help in this process of discovery and recovery.

It may happen also that the concomitant use of a prescription drug is required, generally by using an antidepressive pill, on the basis of serotonine metabolism, with or without anxiety reducers and the so-called beta-blockers (a drug which acts on a kind of cell receptor for adrenaline). This should always happen as the result of close clinical follow-up, and for a limited period of time, in order to avoid other problems caused by the lenghty use of medication.

When organic disease is already installed as a result of stress, be it a simple gastritis, a cardiac or lung disease, asthma, allergies, etc., it is crucial to seek medical help, as soon as possible. Specific treatment may be required for these ailments, but sometimes simple changes, such as doing more exercise, getting more free time for leisure, or changes in life habits are enough to do good.

The true and old wisdom, however, says that our main attitude towards avoiding stress should be to learn how to deal sensibly with our own emotions, and how to live well and without tension, at home as well as at work.

See: Internet Resources on Stress

VLADIMIR BERNIK, a Board-certified psychiatrist (both by the Brazilian Association of Psychiatry and the Federal Council of Medicine), and director of the Stress Clinic of São Paulo, Brazil. He is a former lecturer on Psychiatry of the Medical School of Santos, and advisor of the Centre for Health Economics of the World Health Organization, New York University, a former president of the Medical Hypnosis Society of São Paulo, and former vice-president of the Brazilian Society for Hypnosis. Other professional activities of Dr. Bernik are related to Occupational Medicine and Forensic Medicine. Author of the first "Course of Psychiatry for the General Practitioner", Dr. Bernik has more than 150 published papers and articles. He is a member of the Editorial Board of "Brain & Mind" Magazine.