It’s Killing Me Stress as a Life-threatening Condition Michael S. Krasner, MD October 21, 2009 Perinatal Network of Monroe County Managing Stress for Healthier Babies, Healthier Lives, Healthier Neighborhoods

More than any other time in history, mankind faces a crossroads. One leads to despair and utter hopelessness. The other, to total extinction. Let us pray that we have the wisdom to choose correctly. Woody Allen

Stress Theory

Claude Bernard “milieu internal,” studied and conceptualized “homeostasis” Walter Cannon : “Fight or Flight” Hans Selye: Acute and Chronic Stress Richard Lazarus: Individual appraisal of stress McEwen : Allostasis and allostatic load Schwartz and Shapiro : “Intentional Systemic Mindfulness” – Intention leads to attention leading to connection leading to regulation leading to order leading to health

Stress Definition

Change needed, demand to be met (as appraised by the subject) That change may overwhelm (or “stress”) the subject’s resoures (the resources as appraised by the subject) Stressor: Anything that causes this reaction in the subject.

Stress Reaction Cycle

Stressors Internal Events Perception/Appraisal* Stress Reaction Internalization Maladaptive Coping Breakdown

Physiology of Stress

Sympathetic/Parasympathetic Imbalance Sympathetic Hyperarousal Low (relative) Parasympathetic tone

Activation of H-P-A axis – When chronic results in: Increased monoamine neurotransmitters, eventual depletion Increased pro-inflammatory cytokines (IL-1, IL-6, TNF alpha, Interferon gamma) Increased cortisol Amygdala activation leading to a threat relevant attentional bias and enhancement of negative memory networks Suppression of specific immunity (NK cells, humoral immunity)

Chronic cortisol stimulation – Impairs brain centers with high concentration of cortisol receptors – Suppresses specific immunity – Activates amygdala – Is neurotoxic – Inhibits trophic factors that help neurons grow and develop (Serotonin, BDNF, Estrogen) – Can lead to adrenal fatigue

Hyperactive systems – Sympathetic nervous system – HPA Axis – Cortisol – Amygdala – Cytokines – Right PFC (behavioral inhibition, negative emotions) Underactive systems – Parasympathetic influence – Hippocampus – Left PFC (behavioral activation, positive emotions) – Cingulate (attention, decision making) – Specific Immunity – Monoamine system burnout

Long-term physiologic and cognitive effects of sympathetic overload: – Thyroid/endocrine burnout – Obesity, DM – Immune suppression – HTN, CV Disease – Cancer – Negative mood – Negative attention and memory bias – Decision making difficulties – Inability to learn new associations – Attentional difficulties

Real or imagined threats induce the same stress response: – Imagined scenarios involving threat or failure – Perceived threat – Comparison of actual situation with ideal – Degradation of self or present situation – Recall of disturbing events – Self-criticism hostility – Rumination about a negative event – Emotional avoidance – Pessimism, denial

Stress-realted physiology and their reversal by meditation: – HPA axis hyperactivation – Hypercortisolemia – Decreased Hippocampal activity – Decreased PFC/Cingulate activity – Low parasympathetic tone – Serotonin depletion – Negative memory bias – Immune suppression

Stress-realted physiology and their reversal by meditation: – Sleep disruption – Cytokine elevation – HTN – Heart disease – Endocrine dysfunction – Hyperlipidemia – Chronic pain – PFC asymmetry

Responding versus Reacting Stressors Internal Events Mindful Perception and Appraisal* Stress Response

Research

Questions and ?Answers