PNI and the ABCD’s of Stress

1. PNI and theABCD’s of Stress Mind/Body Health RRCC Holistic Health Spring 2011

2. Psychoneuroimmunology • “The study of the intricate interaction of consciousness (psycho), brain and central nervous system (neuro), and the body’s defense against external invasion and internal aberrant cell division (immunology)” • Immune function can be classically conditioned • Just about every illness is influenced by how we think and feel- at least, if not caused by it • Psychological factors can modulate the stress response and trigger it

3. Anatomy • CNS linked to bone marrow, thymus, spleen, lymph nodes- immune tissues laced with nerve fibers • Changes in the brain and spinal cord affect immune response, and vice versa • WBC’s respond to neurochemicals and produce them • Emotions trigger hormone release • Epi, norepi, endorphins, GC’s, prolactin, growth hormone • Active immune cells send signals to CNS

4. Social Support • Transient stressors- less CV response when friend present • Higher GC levels among stepchildren • And in lonely people • The more social support, the lower the resting cortisol levels in women with metastatic breast CA • Social isolation- 2-5x greater risk of CVD • More active SNS (higher BP, more clotting) • And more likely to die younger once dz present • For ethnic minorities, the fewer members of your group in the neighborhood, the higher the risk of mental illness, psych hospitalization, and suicide

5. Social Support • The fewer social relationships, the shorter the life expectancy, the worse the impact of disease • Partnership, friends and family, church and other group relationships protective • Effect at least as large as smoking, HTN, obesity, and exercise • For the same illness (and age, gender, health status, etc), 2 ½ times the risk of death in the most isolated people versus the most connected • Confound- isolated people less likely to take meds, more likely to smoke, drink, etc. • But effect still there when these are controlled for

6. Social Support • Being cared for and loved, shared intimacy • Being esteemed and valued • Sharing companionship, communication, and mutual obligations with others, belonging • Informational support • Physical or material assistance • Social resources • Social network- size, durability, intensity, and frequency of social contacts • Social relationships- existence, number, and type • Social support- type, source, number, and quality of resources Help thy brother’s boat across, and lo! Thine own has reached the shore. -Hindu proverb

7. Social Support • CVD patients after MI • 2 or more sources of support- 12% died in hospital • 1 source- 23% died • No sources- 38% • Men and women, controlling for severity of MI, other dz, traditional risk factors, depression • “The higher the dose, the greater the effect” • Pregnancy • Teen moms with little support- more birth complications and 4x the neonatal complications • Female emotional support during delivery • C-section rates from 18% to 8% • Epidural 55% to 8% • Labor 2 hours shorter • Decrease in prolonged hospitalization of infants • Social support- 10% problems bonding with infant, vs. 55% • Touch- the most powerful predictor of child abuser is not history of abuse, it’s deprivation of healthy touch

8. Type A Personality • “Every affection of the mind that is attended with either pain or pleasure, hope or fear, is the cause of an agitation whose influence extends to the heart.” • William Harvey, 1628 • Neutral or ambiguous situation seen as stressful • 5 characteristics • Free-floating hostility • Insecurity of status- accomplishment to hide it • Hyperaggressiveness- domination at all costs • Time urgency • Drive to self-destruction- need for release

9. Type A Personality • Hostility the most important- increase in mortality across all diseases, not just CVD • Age, weight, BP, chol, smoking controlled for • Correlation in 10 US cities btw hostility and CVD mortality • Without hostility, competition, aggression, and impatience don’t create the CVD risk • At least as much CVD risk as smoking or cholesterol • More predictive of early first MI • Diet and smoking more important when older • Hostility tends to drive away social support, but SR also activated more often • Reducing hostility reduces CVD risk

10. Type A Personality • Toxic core • Hostility- deep-seated anger waiting to flare • Anger, irritability, and resentment with little reason • Antagonism and disagreeableness • Anger- particularly if unexpressed • Cynicism- mistrust of others, negative view of life • Suspiciousness- constant need to be on guard • Excessive self-involvement- “I, me, mine” • BP increases with references to self • Twice as often in type A speech • Inflexible addiction to work • Workaholism- people who love to work, usually not hostile • Type A- work to get recognition and approval

11. Type A Personality • Stress physiology • Increased catecholamines-microvascular drainage in vessel walls, allowing cholesterol to seep in • Increase in arterial spasm • Increased BP • Stickier platelets • All leading to oxygen imbalance in the heart • Psychology • Links to neurochemistry of depression • Lower marriage quality in type A • Half the angina in high-CVD-risk Israeli men with loving support from wives • Weaker social support networks

12. Type A Personality • At least as strong a CVD risk factor as smoking, cholesterol, high BP • Also synergistic • Type A with another risk factor = 4x increased risk • Two other risk factors = 8x risk • Type A men age 39-49 have 6.5x increased MI risk • Type A women 3-7x the risk • Also a risk factor for ulcer, asthma, rheumatoid arthritis, thyroid dz • And headache, cancer, genital herpes, vision problems • A general disease-prone condition • To heal, transform the hostility and cynicism while retaining the assertive, active characteristics

13. Type D Personality • D for “distressed” • Also linked to CVD • Increased cardiac death risk • Increased risk of another MI • Increased mortality by 4x among CVD patients • Experiencing negative emotions over time and in a variety of situations • Anger, anxiety, depression, worry, hopelessness • Bypass patients who are depressed at the time of surgery more than twice as likely to die in the next 5 years • Inability to express feelings to others- suppressing negative emotions • Social inhibition

14. Type C Personality • Galen- 2nd century- “melancholic” women more prone to breast CA than “sanguine” • Study of CA patients • Fastest-growing tumors in “consistently serious, overcooperative, overly nice, overly anxious, painfully sensitive, passive, apologetic” patients • Never express negative emotion • “Rock of stability,” not assertive, “I’m fine” • Appear happy, in control • Slower-growing tumors in pts who have better coping

15. Type C Personality • Type C melanoma patients thicker, more aggressive tumors, worse prognosis • Reaction to initial diagnosis- higher mortality in… • Women who were stoic • Men who were helpless or hopeless • Melanoma pts more likely than healthy controls or CVD pts to repress emotion • More wbc’s at CA site in melanoma pts who could express emotion • Collapse of usual coping style, overwhelmed with emotions they couldn’t resolve

16. Type C Personality • Lonely, emotionally repressed people (in one study) developed CA 16x more often than those who expressed feelings freely • Breast CA • Helpless-hopeless response- 20% 5-year survival • Also “stiff upper lip” • Denying the problem- 80% survival at 7 years • 50% at 12 years • “Fighting spirit”- do everything possible to recover • 80% survival after 12 years • Life events • Bleak childhood- lonely, isolated, unsafe, tense with parents • Strong emotional commitment as adults • Object of commitment taken away- CA 6-8 months later

17. Rheumatoid Arthritis Personality • Autoimmune attack on collagen in joints • Twin study- RA twin “seeks out” stressful situation • Unhappy marriages, put up with abuse without arguing • Poor ability to express anger • Moody, easily upset, nervous, tense, worried • Healthy twin- happy marriages, OK to argue and express emotion • People who like people, enjoy life • Solomon- could predict 100% who had RA based on watching them assert themselves in hostile situation • Immunoregulatory ratio (Helper T cells and suppressor T cells) disturbed in RA • Endorphins deficient in RA • RA personality traits in turn compromise the immune system

18. Other Personality Types • Ulcer personality • Same stress in ulcer pts, but perceive it as more severe • Expected the worst, felt more threatened • Excessive dependency on others • Fragile under stress, not resilient (break not bend) • Asthma personality • Anxiety, powerlessness • Angry and hostile but weak and out of control • Ready to strike out at others • Diabetic personality • Decreased alertness • Apathy • Depression • Immaturity, passivity, masochism

19. The Common Cold • Stress decreases salivary and mucosal antibodies • Stress = 3x the chance of getting a cold with equal exposure to virus • Prolonged social stressors the greatest risk • Stress 4x as likely to precede an infection as to follow it • Infection in 20% of low-stress families in one study • 50% in high-stress families

20. AIDS • Human wbc’s in petri dish more likely to be infected with HIV in the presence of GC’s • Norepi enhances viral entry into wbc’s and replication once there • Given same amount of HIV, faster decline and higher mortality if • Denial as coping style • Minimal social support • Social inhibition- elevated SNS activity • Other stressors, particularly loss of loved one • Lifestyle risk factors confound here

21. Chronic Pain • Emotion influences the anterior cingulate cortex, the brain’s pain center • Mind-body Tx effective in chronic pain • 100 patients given mind-body Tx • 10 weeks- pain, but less anxiety, depression, hostility • 1 year- pain and other Sx improve • 36% fewer clinic visits, continued drop in second year • As much as 95% of back pain psychogenic • Emotion makes muscles tense

22. Other Conditions • Allergies and asthma- heightened immune reaction, tied to emotional factors • Arthritis- false niceness, suppressed emotion, avoiding emotional support • RA- history of emotional upheaval • Turmoil, conscientiousness, fear of criticism, poor self-image • Anger turned inward • Cavities- meditation decreased bacteria in saliva • Gum disease too • Ulcer- hostility, resentment, guilt associated with increased stomach acid

23. Other Conditions • Irritable bowel syndrome • Worriers, anxiety and depression linked • Nagging concerns, other stress-related problems • Pregnancy • Low birth weight and prematurity associated with stressful events, particularly in last trimester • Sexual dysfunction- emotional stress causes CNS to reduce testosterone • Loss of desire in both men and women

24. Type B Personality • Lack of time urgency • Attention to present task • Not bored or eager to move on • On schedule most often, but not frenzied about it • Patient • Contemplative, sees whole more than parts • Values present and past as much as future • Ability to relinquish control • Delegation, working as part of a team • Celebrates differences • Inspiring leaders- encourage creativity in others

25. Type B Personality • High self-value, internal locus of control • Love of self based on being, not accomplishments • Self-acceptance • Value regardless of achievement • Failure doesn’t collapse or damage personality • Work for success not as competition-based • No free-floating hostility • No finding fault necessary to bolster ego • Accepts trivial errors of others • Enjoys empowering others • Rarely feels tense or makes others tense • Objectivity, ability to empathize • Feeling and expressing affection in intimate relationships

26. Stress Resilience • Stress buffers • Social support • Control • Physical fitness • Sense of humor • Self-esteem • Optimism • Effective coping style • Hardiness • Personality traits associated with the lowest frequency of illness • Stress response • Baseline as energized calm, state of choice • Activation including equilibrium and equanimity- maintaining awareness even when crazed and stressed

27. Stress Resilience • In catastrophe, denying and minimizing do help • In lesser troubles, find hope, protectively and rationally • Look for hope of improvement • But don’t deny the possibility of stasis • Hope for the best, prepare for the worst • Control in the present, not past and future • Fix when appropriate • Seeking predictable, accurate information • Unless too soon, too late, unnecessary, or overwhelming • Outlet for frustration • Benign to others • Social support- felt sense of warmth and affiliation • Disease-resistant behavior • Aerobic exercise • Relaxation- at least 15 minutes a day • Limit refined sugars • Limit stimulants • More consistent health habits in general, appropriate health-protective behavior when needed In the face of strong winds, let me be a blade of grass. In the face of strong walls, let me be a gale of wind. -Quaker saying

28. Stress Resilience • Hardiness- Suzanne Kobasa- three C’s (plus two more) • Commitment- curiosity and involvement in life events • Deep, abiding interest in life • Ideal greater than oneself • Control- power of response to influence events • Control of self and reactions to situations • Challenge- seeing change as exciting chance for growth • Confidence, self-determination, eagerness • Active coping style, expecting positive outcome • Coherence- pervasive, enduring, dynamic feeling that inner and outer environs are predictable and that things will usually work out as well as can be expected • Community- “plays well with others”

29. Relaxation and Fight-or-Flight • Qualities of the Fight or Flight Response • Increased heart rateIncreased blood pressureIncreased respiratory rateHigher pulse rateIncreased oxygen consumptionIncreased blood lactateIncreased muscle tensionRapid production of cortisol Production of noradrenaline • Unconsciously elicitedStress inducingOuter focus of attentionEyes wide openInvoluntaryExternal stimulusSurprise, unpredicted, stimulusUnplannedActive internal dialogNarrowing or focusing of attentionSensory Physical activityPhysical movementFrom non-movement towards movementUnlearnedElicited by loud noiseBuilds unhappinessIncreases rate of agingHelps the individual survive and evolveMost excitation of consciousnessReady for most effortRepeated elicitation may lead to use of narcotics and drugsExperience of being at odds with environmentAttitude of resistance • Qualities of the Relaxation Response • Decreased heart rateDecreased blood pressureDiminished respiratory rateLower pulse rateDecreased oxygen consumptionDecreased blood lactateDecreased muscle tensionReduction of cortisolReduction of noradrenaline • Consciously elicitedStress releasingInner focus of attentionEyes shutVoluntary Internal stimulusDaily routine or habit as stimulusPlannedQuiet, silent internal dialogExpansion of attentionSenses transcendedMental activityPhysiology at restFrom movement towards non-movementLearnedElicited by subtle sound then silenceBuilds happinessDecreases rate of agingHelps the individual progress and evolveLeast excitation of consciousnessLeast effortRepeated elicitation diminishes need to use drugsExperience of being at one with environmentAttitude of acceptance