Stress and the Broken Heart

     Gilbert and Sullivan were correct to have Ko-Ko sing in "The Mikado" that "a little tomtit" died of a broken heart. There is a broken heart syndrome well-known to cardiologists, who also refer to it as stress cardiomyopathy or takotsubo cardiomyopathy. Sudden stress, usually of an emotional nature, can cause sudden cardiac death, angina, and acute congestive heart failure. I will first discuss the effects of acute stress on the heart, and then the far-reaching effects of chronic stress on the heart and the circulatory system.

     The broken-heart syndrome, which usually affects women, is thought to be due to the effects of an acute surge of adrenalin on the heart. Such an acute surge can cause reversible spasm of the coronary arteries, ballooning of the left ventricle, and a stunning of the cardiac muscle syncytium. The precise mechanism is not known, but the effect is real, and has been observed many times. Cardiac enzyme tests for a heart attack are normal, but an echocardiogram will show a ballooning and dysfunction of a portion of the left ventricle, thereby causing acute heart failure. Coronary artery catheterization shows no sign of blockage, and the EKG changes are not those shown by a heart attack. Such an attack which can be manifested by acute chest pain and shortness of breath can look like an anxiety attack, but a cardiac exam will typically show signs of heart failure. In some cases, cardiac arrhythmias can also occur. Recovery with proper treatment tends to be rapid, typically within one week. The interval between the emotional shock (often caused by the death of a spouse) and the cardiac event is variable, and any severe emotional shock can be the trigger. There is even one (apocryphal?) story of a woman having such an attack after winning the lottery.

     Chronic stress caused by  anxiety or depression or problems at home or at work can also cause deleterious chemical changes in the bloodstream, with eventual effects on the circulation of coronary as well as peripheral arteries, and a possible fatiguing of the cardiac muscle. We know that the stress caused by these mental conditions can cause elevated adrenalin  and cortisol levels, as well as an elevated pulse rate and white blood count. This effect also raises blood pressure and makes the blood more liable to clot. There is a concomitant elevation of fatty acids, cholesterol and triglycerides. Whether or not chronic stress can lead to heart disease is not known, but, as indicated, chronic stress elevates all the chemicals in our bloodstream that we would prefer to be lower to protect against cardiac disease.

     Unfortunately, there is as yet little or no clinical data to show that lowering stress decreases the risk of developing a cardiac problem; even the type A hypothesis has not been well proven. And I doubt (but who knows?) that the effect of a daily glass of wine on lowering the risk of a heart attack is due to its relieving of stress. Since marijuana mellows most users, it will be interesting to examine the heart attack rates in Colorado and Washington State in 10 years, to see if there is any effect on the incidence of cardiac events that could be attributed to the chronic smoking of marijuana.

Stress, Part II

All of us, by being civilized by our parents, our schools and society, become stressed and, usually neurotic. Freud in his "Civilization and Its Discontents" showed that in his opinion, the best we can be after being civilized is a well-adapted neurotic. Huck Finn put it more succinctly when he talked about how he would no longer be the same person after being civilized by soap and water and schooling. Karen Horney discussed the problem at greater length in "The Neurotic Personality in our Time".

I am not going to discuss Rousseau's "noble savage" or the French view of the importance of the school system in instructing its citizens how to think, or even McKinley's bloody, misguided attempt to "Christianize" the Philippines after the Spanish-American War. I guess for McKinley the Philippines' being instructed in Catholic catechism and being converted from paganism didn't count, since he was a Protestant. And that's where we learned the virtues of waterboarding in getting prisoners to talk , only to turn around and try judicially and execute those Japanese POW commandants who waterboarded American POW's.I'll only mention in passing Jacqueline Kennedy's deathbed comment that she wished she had "drunk more champagne", and observe that few if any humans on their death beds
said that they wish they worked harder and did more things that they found emotionally distressing, rather than having more fun and more orgasms. (As an aside, I once had a girlfriend who felt that a night without an orgasm was a wasted night, but that is a different story, and from a different country.)(And no, the "wench" as Marlowe called her, is not dead.) At least we were never as brutally civilized towards a greater good for the greater end as were the Kulaks in Stalinist Russia, the Chinese peasants and intellectuals in the "Great Leap Forward", or anyone who wore glasses and might be an intellectual in the horrifying regime of Pol Pot in Cambodia. The Civil Wars in Africa defy anyone's explanation, except for the trite observation that there, God appears to be dead.

Let us note in passing that the rules in elementary school seem to be created by women for girls,, with its emphasis on neatness, minimal direct confrontation, the importance of group behavior, and the superiority of means over ends (might does NOT make right, unless the teacher in bawling you out). On the other hand,in the business world and the army rules are made by men for men, where the ends justify the means, the only people you may not lie to are close friends, and fellow workers (military, medicine), your word (but not your valuation on the stocks you are selling) is your bond, and cheating is forbidden only at the poker table (but not on the golf course, where many unofficial Mulligans are taken). The same is true of all colleges, where internet-driven plagiarism seems to be the norm, but the lines of battle are not as clearly marked out.

In thirty years, I have found that the more you do that is emotionally conflicting, the angrier you get. Since women are not allowed to show anger directly, this gets converted into depression,, or into anxiety or panic attacks when their subconscious is afraid that the anger will erupt in a socially unacceptable way. Men just grab the nearest M-16 or AK-47 and shoot up their workplace, so that if the flags fly at half-mast at the post office, it means they are hiring again.

But above all, this suppressed anger and depression transforms itself into bodily complaints. The pain threshold in every body organ gets lowered. It becomes an effort to get out of bed, you gain weight, stop exercising, drag yourself to work and back to home. Men nick themselves while shaving, women lose their appetite and sex drive, as do men, and both report (to me , when I ask) even a decrease of romantic/sexual dreams and masturbation. I will admit, however, that female masturbation has increased with good orgasmic results ever since the invention and sales of the Sybian.

Women are trained by society to never think of themselves first, and to feel guilty if they do. The majority cannot turn off their cellphones for one hour, in case an "emergency comes", and they must imagine that 911-EMT is not up to the job. If a daughter gets divorced, the father feels bad for the daughter and the mother feels guilty ("what did I do wrong?). It isn't a coincidence that ever since the Greek habit of capturing barbarians to be slaves died out that Hinduism, Orthodox Judaism, Rigid (Calvinist) Protestantism, and all Orthodox Moslem priests believe that a woman should be subservient to man, a fact that carried over into Napoleonic Law, when married women were not allowed to own property on their own.


If you continue to do what you don't want to do emotionally, you will eventually crash as the brain runs out of the psychic energy it needs to control and repress those "socially unacceptable" thoughts of your anger that you have been reduced to emotional slavery, never doing what you really want to do, and always feeling that YOUR feelings, wants, needs and desires don't count and we become abjectly depressed, which we continues until we feel free again.. And then people around you will ask why you changed, because they didn't. And the more "noes" you give, the happier you will be, and the more energy you will have.

I leave you with three thoughts: (1) "No" is a complete sentence not only where sex is concerned, but in all phases and activities of life, whether you are going away for a college reunion or baby-sitting, and needs no explanation. (2) You are always right, so if the play bores you, leave at intermission and read a book; the play rarely gets better.
(3) If you have an increase in psychic pain, or develop a new muscle spasm or headache or eye twitch or GI distress or--- you truly are under pressure, and need to "get out of Dodge" as rapidly as possible. You can always say you have to go to church or synagogue right now---people may think that is odd, but no one will criticize you. Then you can sit in a pew in quiet, recompose your thoughts, and meditate on how important you really are.


'More to come when I see the comments on this blog topic.

Mental Stress and Physical Discomfort

I have observed time and time again, that when your mind is stressed your body will start to hurt, or you will have some physical symptom. Mental stress almost always comes from doing something emotionally in a family situation, or physically in a non-work situation, that you do not want to do. As a rule, this is also connected with the thought of feeling guilty if you do not do the particular act, whether you want to or not. Boredom, for instance, is low-level anger,triggered because you do not want to be where you are (music concert, college class, visiting in-laws, etc. ), and typically occurs when you are doing something in a group/social situation where you feel you "have" to be. As you get older, you do fewer of these unwanted things, (a) because society puts less pressure on you, and (b) you feel more entitled to spoil yourself and be kind to yourself without feeling guilty or "selfish".

Your entire gut from the back of your throat to the top of your rectum is under autonomic control, i.e. the brain signals the spinal cord and the spinal cord signals the gut for digestion, peristalsis, and defecation. It is totally out of your voluntary control. Many of my working women, when they go away to a hotel on a business trip, are incapable of moving their bowels until they get home. Many men cannot relax enough to urinate when another man is standing at the neighboring stall. Many men also cannot get an erection when they are in bed with their wives if they have unconscious anger towards her. Most of my patients with irritable bowel syndrome have some degree of chronic stress or are suppressing anger or anxiety.

At the first and every annual visit thereafter I ask all my patients, male and female, the same two questions: (a) Do you look forward to going to work in the AM? and (b) Do you look forward to coming home at night? If I am seeing a non-working spouse, I ask a similar questions about the feelings when the other spouse leaves for work in the AM and returns home in the PM. I also ask teenagers if they look forward to going to high school (many girls and few boys do).

When it comes to school, many students see it as a form of jail. It is less of a problem with girls than boys, because girls seem to buy into the system at an earlier age. Hence, for instance, girls always have neater handwriting than boys do, because boys don't care. This persists into adulthood: in the hospital charts I can usually distinguish male student notes from female student notes by their penmanship. But it is not a matter of lack of fine motor control, or else men could not become watchmakers. As I often tell parents, many boys don't have ADD, but rather DGD (Don't Give a Damn) disease about school, especially when it comes to homework. Of course Adderall, Ritalin, coffee, and most other CNS stimulants help everyone focus better and do better on SAT's.

Men have a slight advantage in that most of their stress is work-connected, and therefore has finite boundaries. Women, however, feel responsible for the happiness of the whole family, and often feel guilty and responsible if any family member is unhappy. In general, I have found that if a daughter gets a divorce, the father feels sorry for her, and the mother wonders what she (the mother) did that was wrong in raising her. Often, if the husband has a problem with his mother, the wife takes care of all the social interactions with her mother-in-law, even when the wife has problems with her as well. Men seem to get a free ride away from many of the emotional stresses in the family: as Jerry Steinfeld infamously put it "We men are expected to be shallow.".

True love is overwhelming, and therefore makes parents and governments alike equally nervous, because they realize they are powerless to control it. Forget about Romeo and Juliet, or how Lancelot's and Guinevere's mutual love wrecked King Arthur's Court. If Julius Caesar had not been in love with Cleopatra, the history of the Roman world would have been different. Similarly with Marc Antony and Cleopatra, and King George of England and Wallis Simpson.

I leave the question of King David, Bathsheba and Uriah the Hittite to biblical historians, and just note it in passing. When teenagers fall in love, they see only the immediate present and their utter happiness, while the parents look 20 years down the road, and worry if their new in-law will fit properly into their society, both economic and social. For my married patients who are totally in love, the rest of the world always takes second place, and those who are not completely in love never quite "get it". Those totally in love seem to awaken every morning and say to themselves: "How can I spoil my loved one and myself today?", and never feel selfish about so thinking.

The anger at being "forced" socially to do what one doesn't want to do builds up slowly, but is more present than we allow ourselves to recognize. Every time you say to yourself I "should" do something, it is really the outside world, society, or your family (usually your parents) saying it. Men can partially discharge the anger through physical outlets, physical aggression or getting drunk, but women are more likely to suppress the anger, since anger is not a socially acceptable emotion for most women, and was probably discouraged from early childhood on, until the suppression of anger became automatic and internalized. The female child also starts to feel de-legitimized and ego-dystonic by being told that she should not feel a certain emotion. Suppressed anger almost always leads to depression. This is probably why almost all surveys show that single women are happier than married women, since married women are burdened by more social "shoulds".

Since many fatigue and pain states have an emotional basis, the next time you feel tired, or yawn, or feel bored, or have pain, or a GI upset, or a sore back, etc., try asking yourself: "What is stressing me? What am I doing or planning to do that I don't really want to do?". Then tell yourself that you are not being selfish if you protect your mental and emotional peace, and refuse to do or stop doing the unwanted action. If someone else is involved, and he/she really cares about you, they would want you to do what you want to do, wouldn't they?

Stress and Somaticism

I have often noticed how stress wears my patients down, and causes multiple somatic symptoms. If the mind is unhappy and/or stressed, it will always make the body hurt. If you are fortunate, the discomfort induced by stress is always the same: IBS, headache, low back pain, etc., so that you can use the physical symptom as a signal to you that you are under stress, and try to abort a full-blown attack of pain by minimizing or avoiding the stress. I am most concerned that the brain will get so used to pain that the pain circuit becomes self-perpetuating, as it can in post-herpetic neuralgia. It is more difficult to reduce or eliminate the stress when the stress is due to a dysfunctional relationship. I look for situations that can produce stress in my patients' minds by asking a few simple questions at their first exam and at annual physicals: what do you do that you most dislike doing? when was your last vacation? do you look forward to coming home at the end of the day? do you look forward to going to work?

I have found that a frequent cause of stress is due to living with a person with a character disorder, whose view of the world is impervious to logic, manners, or sensitivity. Often the patient is unaware of how permanent the dysfunctional situation is. The most severe case of this is in the borderline personality. I recall that psychiatry attendings would comment that they would never allow first year residents to treat borderlines, because they invariably sabotage their treatment, which can trigger unresolved anger in the therapist.

As I was preparing this blog, I received an e-mail which described what it was like to live with a borderline personality. I think the writer described the household situation extremely well. I am therefore posting the link here, in the hopes that you all will click on it:

http://www.bpl411.org/walkingoneggshells.html

The title of the article is "Walking on Eggshells", and this phrase is a perfect analogy to what life is like when you live with a person with a borderline personality disorder. (I personally think that these borderlines have a tremendous amount of unrecognized anger, but that is for another blog.)