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Despite evidence like this, many clinicians are skeptical that emotions matter clinically. One reason for this skepticism is that although numerous studies have shown that stress and negative emotions reduce the effectiveness of various immunocompetent cells, it is not always clear that the range of these changes is large enough to be distinguished by medical indicators.
Even so, a growing number of physicians are recognizing the place of emotions in medicine. For example, Dr. Kamran Nezhat, eminent laparoscopic gynecologist at Stanford University, confesses: operated, I cancel the operation. And he explains further: “Every surgeon knows that extremely frightened people do not tolerate surgery very well. They lose too much blood, get more infections, and have more complications. And their recovery period is more difficult. Much better if they are calm.”
The reason is simple: anxiety and panic increase blood pressure, and veins swollen with blood bleed more when cut with a surgeon’s knife. Excessive bleeding is one of the most dangerous complications of surgery and sometimes leads to death.
In addition to such medical histories, there has been an ever-increasing body of evidence for the clinical importance of emotions. Perhaps the most impressive data on the medical significance of emotions came from a global analysis that combined the results of 101 smaller studies into one larger study of several thousand men and women. This study confirms that disturbing emotions are unhealthy—very bad indeed. People who experience constant anxiety, long periods of sadness and pessimism, relentless tension or endless hostility, ruthless cynicism or suspicion, have been found to double their risk of contracting some disease, including asthma, arthritis, headaches, peptic ulcers, and heart disease. (each disease represents the main, general categories of diseases). This high importance makes distressing emotions as much of a toxic risk factor as, say, smoking or high cholesterol for cardiovascular disease, in other words, a major health hazard.
This, of course, reflects a general statistical relationship, which, however, in no way proves that everyone who has such experiences has become chronic is more susceptible to illness. But there is far more evidence to support the role of emotions in disease than this study alone can provide. A closer examination of the data on specific emotions, especially the strongest ones such as anger, anxiety, and depression, has revealed several pathways for their influence on health, even though the biological mechanisms of emotions have not yet been precisely clarified.
When anger is suicidal
Recently, as one acquaintance told me, a hard blow to the side of his car caused fruitless and increasingly frustrating walks through the authorities. After endless red tape with insurance and going to different body repair shops, which only made his car look worse, he had $800 left. But this was not his fault. After all the ordeals, he was so tired of everything that, finally sitting in his car, he felt nothing but disgust. In the end, he sold the car, and even after many years, the memory of the abuse he had experienced made him turn purple with indignation.
These bitter memories were deliberately evoked, as required by the Stanford University School of Medicine Research Program on Anger and Its Consequences in Heart Patients. All patients, like that embittered motorist, survived the first heart attack and became the subjects of this study, so that doctors could finally find out whether anger really has a significant effect on the heart. The result was stunning: when patients re-told about events that had once made them furious, their heart’s ability to pump blood around the body was reduced by five percent. In some patients, this pumping capacity has decreased by 7 percent or more, to a level that cardiologists consider as a sign of myocardial ischemia, manifested by a dangerous reduction in blood flow to the heart.
The decrease in pumping capacity was not noticed either with other painful feelings, or with physical effort; Anger seems to be the only emotion that does the most harm to the heart. Resurrecting the incident that upset them, patients reported that they did not feel half the rage that seized them at the time of the incident itself, suggesting that in the actual collision that caused their rage, their hearts experienced an even greater load.
This finding is part of a larger body of evidence emerging from a plethora of studies indicating that anger can affect the heart. According to the old notion, the overwhelmed, tense Type A personality is not in great danger of getting heart disease, but a new conclusion followed from this untenable theory: it is hostility that puts people in danger.
A large body of factual information about hostility has come from the research of Dr. Redford Williams of Duke University. Williams, for example, found that doctors who scored highest on a hostility test while still in medical school were seven times more likely to die by the age of fifty than those who scored low on this test: was a stronger predictor of death in younger years than other risk factors such as smoking, high blood pressure, and high blood cholesterol. And results from his colleague Dr. John Bearfoot at North Carolina State University suggest that in patients with heart disease undergoing angiography, in which a T.e.a. is inserted into the coronary artery to assess pathological changes, there was a correlation between scores scored during the hostility test, and the volume and severity of the coronary artery lesion.
Of course, no one says that only anger leads to coronary heart disease; it is just one of several interacting factors. As Peter Kaufman, acting director of the National Heart, Lung, and Blood Institute’s Department of Behavioral Therapy, explained to me, “So far, we cannot figure out whether anger and hostility play a causal role in the early development of coronary heart disease, or whether they exacerbate the problem when heart disease has already started, or both. But let’s take for example a twenty-year-old man who often gets angry. Each episode of extreme irritation puts extra stress on the heart, resulting in an increase in heart rate and blood pressure. If this is repeated over and over again, it can cause damage, especially since the turbulence of the blood flowing through the coronary artery with each heartbeat can cause micro-ruptures in this vessel, in which platelets are formed *. If you have an increased heart rate and high blood pressure because you habitually become irritated, then in thirty years this will probably lead to accelerated production of platelets and, therefore, to coronary heart disease.
If heart disease has already occurred, it has been established during the study of the action of angry memories in heart patients that the mechanisms triggered by anger affect the very performance of the heart as a pump. The net effect of this exposure is that anger becomes a particularly deadly factor for those who already have heart problems. I’ll give you an example. The Stanford University School of Medicine conducted a study that included 1012 men and women who had their first heart attack and were then followed for a long time — up to eight years; as this study showed, the most aggressive and initially hostile men had the highest frequency of recurrent heart attacks. Similar results were obtained at the Yale University School of Medicine in a study of 929 male heart attack survivors who were followed up to ten years. Those who were rated as easily angered were three times more likely to die from cardiac arrest than more balanced people. If they also had high cholesterol levels, the additional risk from anger was five times higher.
Researchers from Yale University have found that not only anger is a factor that increases the risk of death in a sick heart, to a greater extent this is due to the manifestation of off-scale negative emotions of any kind when waves of stress hormones sweep through the body. However, the strongest relationship between emotions and heart disease, according to most doctors, is determined by anger. In a study conducted at the Harvard University School of Medicine, more than XNUMX men and women who had suffered multiple heart attacks were interviewed and asked to describe their emotional state shortly before the attack. Anger more than doubles the risk of cardiac arrest in people with an already diseased heart, and this risk persists for about two hours after the outburst of anger.
The results obtained do not mean that people should try to suppress anger if circumstances require it. On the contrary, there are many facts proving that attempts to completely suppress such feelings in the midst of their manifestation lead to an increase in the excitation of the body, and sometimes to an increase in blood pressure. What’s more, as we learned in Chapter 5, trying to contain your anger every time it flares up means you’ll simply feed it by memorizing it as the most appropriate response to any irritating situation. Regarding this paradox, Williams noted that it does not matter whether anger is expressed openly or not, it is only important that it does not take on a chronic form. One-time manifestations of hostility or hostility are not dangerous to health, the problem arises when hostility becomes a feeling that determines the antagonistic style of behavior of this person, which is characterized by constant suspicion and cynicism, a tendency to make gooey and stinging remarks, as well as more openly reveal irritation and fury.
It is encouraging to learn that chronic anger is not a death sentence, because hostility is just a habit that can be broken. To conduct a special study at the Stanford University School of Medicine, a program was developed that included a group of patients who survived a heart attack. The purpose of the program was to help them soften the attitudes that underpinned their irritability. Patients were taught to contain their anger, and as a result, the number of repeated heart attacks in this group was 44 percent less than in those who did not try to get rid of hostility. Williams’s studies yielded the same positive results. As in the Stanford University program, it aimed to introduce the main components of emotional intelligence, and, in particular, to teach to recognize anger at its very beginning, manage it if it manifested itself in one way or another, and instill empathy skills. Patients were asked to jot down cynical or hostile thoughts as soon as they noticed them. If thoughts stubbornly persisted, they would try to block them by saying (or thinking) «Stop!» They were advised to deliberately replace cynical, suspicious thoughts with prudent ones when they were trying to cope with situations, for example, if the elevator still did not come, to look for some extenuating circumstances, instead of harboring anger against some imagined nonchalant type who was supposedly to blame for this delay. As for encounters that leave a feeling of disappointment, people acquired the ability to look at things from the other person’s point of view, they learned empathy — a balm for anger.
As Williams told me, “The cure for hostility is to train your heart to trust people more. All it takes is the right motivation. When people realize that their hostility can drive them to the grave, they are ready to try to change something.”
Stress: disproportionate and inappropriate anxiety
“I feel anxious and stressed all the time. It all started in high school. I was a straight A student and constantly worried about grades, whether other children and teachers liked me, whether I was quick in the classroom, well, and the like. My parents put a lot of pressure on me to do well in school and be a good role model… I think I just succumbed to the pressure because I started having stomach problems in my second year of high school. From that time on, I had to be very careful with caffeine and spicy foods. I notice that when I’m worried or tense, my stomach starts to rebel, and since I usually worry about something, I always feel sick. ”.
Perhaps it is with regard to anxiety — the distress caused by the hardships of life — that the largest amount of scientific data has been obtained linking this emotion with the onset of the disease and the course of recovery. If anxiety helps prepare us to deal with some kind of danger (a supposed evolutionary benefit), then it has served us well. But in modern life, anxiety is most often disproportionate and inappropriate: distress arises in the face of circumstances that we must put up with or that our imagination throws at us, and not the real dangers that we have to face. Frequent bouts of anxiety signal high levels of stress. A woman whose constant anxiety gives rise to gastrointestinal upset is a textbook example of how anxiety and stress exacerbate health problems.
In a 1993 review of extensive research on the relationship between stress and illness, Yale University psychologist Bruce McEwenn noted a wide range of results in Archives of International Medicine: compromising immune function to the point that it can hasten the onset of cancer metastasis; increased susceptibility to viral infections; intensification of platelet formation, leading to atherosclerosis, and blood clotting, leading to myocardial infarction; accelerating the onset of type I diabetes and the course of type II diabetes; and triggering or exacerbating an asthma attack. In addition, stress can lead to ulceration of the gastrointestinal tract, causing symptoms in ulcerative colitis and inflammatory bowel disease. The brain itself is sensitive to long-term exposure to relentless stress, the results of which include damage to the hippocampus and hence memory. All in all, according to McEvenn, «the evidence is mounting that the nervous system wears out as a result of stressful experiences.»
The most compelling evidence for the impact of distress on health comes from research on infectious diseases such as the common cold, flu, and herpes. We are constantly under threat of attack from these viruses, but our immune system usually successfully repels all attacks, except for special conditions caused by emotional stress, when all defenses are often ineffective. In experiments designed to test the robustness of the immune system, stress and anxiety have been found to weaken the immune system, although in most cases it has not been possible to determine with certainty whether the level of decline is of clinical significance, that is, if it becomes large enough to open access to the body for pathogenic microbes. In order to obtain more accurate results that reveal the relationship between stress and anxiety and the body’s vulnerability to various diseases, a program was developed for the future, that is, quite healthy people were invited to participate in the study, who were constantly monitored, and above all, monitoring of increasing distress, which led to weakening of the immune system and the onset of the disease.
In one of the most scientifically rigorous studies, Sheldon Cohen, a psychologist at Carnegie Mellon University, collaborated with scientists from the Cold Research Unit in Sheffield, England, to carefully analyze how long and how much stress people experienced over the years. , and then systematically exposed them to the agents of colds. Observations showed that not all participants in the experiment caught a cold: a strong immune system is able to resist — and always resists — cold viruses. Cohen found that the more stressed people are in their lives, the more likely they are to develop colds. In the low-stress group, 27 percent of subjects got sick, and in the stressful group, 47 percent fell ill, providing direct evidence that stress itself weakens the immune system. (While the findings may be classed as one of those scientific results that confirm what everyone has constantly observed or always suspected, it is still worth considering as a discovery of notable importance because of its scientific rigor.)
Similarly, a direct relationship was established in experiments involving married couples who, for three months, filled out control observation forms, where they entered daily information about quarrels and upsetting events, for example, family battles: three to four days after especially strong frustrations spouses caught a cold or upper respiratory tract infection. This period of time exactly corresponds to the incubation period of many of the most common colds, proving that in moments of excitement or frustration, spouses became most vulnerable to viruses.
The same «stress-infection» scheme is valid for both types of herpes virus — and for the one that causes herpetic fever on the lips, and for the one that affects the genitals. One has only to get the herpes virus, as it remains in the body in a latent state, from time to time making itself felt by sudden manifestations. The activity of the herpes virus can be traced by the titers * of antibodies to it in the blood. Using this measure, herpes virus reactivation has been detected in medical students taking end-of-term exams, in women who have recently separated from their husbands, and in people who are constantly burdened with caring for a family member with Alzheimer’s disease.
A weakened immune response is not the only damage done by anxiety; another study points to its harmful effects on the cardiovascular system. While constant hostility and recurrent outbursts of anger seem to put men at great risk of developing heart disease, the deadliest emotions in women are anxiety and fear. In a Stanford University School of Medicine study of more than a thousand men and women who had had a first heart attack, women who also had a second heart attack had high levels of fearfulness and anxiety. In many cases, fearfulness took the form of paralyzing phobias: after the first heart attack, patients stopped driving, quit work, or avoided leaving the house.
The insidious physical consequences of neuropsychiatric stress and anxiety—those brought about by stressful work or a stressful life, such as that of a single mother torn between childcare and work—are precisely defined at the cellular level. University of Pittsburgh psychologist Steven Manuk subjected thirty volunteers to a crucible of endless anxiety in a lab by constantly monitoring men’s blood and analyzing a substance released by platelets called adenosine triphosphate, or ATP, which can cause blood vessel changes that lead to heart attacks and seizures. angina. While the volunteers were under extreme stress, their levels of adenosine triphosphate, as well as their heart rate and blood pressure, skyrocketed.
It is not surprising that those who have all the work “on their nerves” are at the greatest risk to their health: the need to work in stressful conditions with little or no control over how this work is done (an unpleasant situation, due to which bus drivers often have hypertension). For example, in a study of 569 patients diagnosed with colon and rectal cancer and an appropriately matched comparison group, it was found that those who reported that they had had a serious deterioration in their health at work in the previous ten years were more likely to develop cancer. five and a half times higher than those who have not experienced such stress in their lives.
Because the damage to health caused by distress is so visible, relaxation techniques that counteract the direct physiological manifestation of stress activation are used in the clinical setting to alleviate the symptoms of a wide range of chronic diseases, including cardiovascular disease, certain types of diabetes, arthritis, asthma, gastrointestinal frustration and constant pain, and that’s not all. Stress and emotional distress exacerbate any symptoms to some extent, and helping patients reduce stress, calm themselves, and manage their agitated feelings often brings some relief.
Medical costs of depression
She was diagnosed with metastatic breast cancer. It was the return and growth of a malignant tumor several years after a successful — as she thought — operation. Her doctor no longer talked to her about treatment and chemotherapy, because the best he could offer her was a few months of life. Understandably, she fell into a depression, and so deep that every time she came to the oncologist, she could not help crying. And each time, the reaction of the oncologist was the same: he demanded that she immediately leave her job.
Apart from the offensive dryness of the oncologist, does it matter from a medical point of view that he did not bother with the constant despondency of his patient? By the time the disease has acquired a virulent (dangerous) character, it is unlikely that any emotion could have had any noticeable effect on its course. And although the patient’s depression must have poisoned her last months of life, there has not yet been obtained accurate clinical data indicating that melancholia can affect the development of a malignant tumor. However, aside from cancer, some research suggests that depression plays a role in many medical outcomes, especially in worsening the course of the disease. There is mounting evidence that doctors whose patients are depressed must first treat them for their depression as well.
One of the difficulties of treating depression in therapy patients is that its symptoms, including loss of appetite and lethargy, are easily confused with signs of other illnesses, especially when the diagnosis is made by doctors who are not very experienced in psychiatry. Failure to diagnose depression often further confuses the picture of the disease, because in such a situation, as in the case of an emotional patient who suffered from breast cancer, depression is not detected and not treated, and as a result, the risk of a mental outcome from a serious illness increases.
Thus, out of 100 patients who received a bone marrow transplant, 12 out of 13 who were in a depressed state died in the first year after transplantation, and 34 out of the remaining 87 survived two more years after the operation. Patients with chronic renal failure treated with dialysis, that is, using an artificial kidney machine, who were diagnosed with a severe degree of depression, were at a greater risk of dying over the next two years, since depression is one of the most important predictors of death compared to any other other medical indicator. In this case, the connection between emotion and health becomes not biological, but attitudinal: depressed patients are much worse at fulfilling the requirements of the prescribed course of treatment, for example, they cheat on their diet, which only increases the risk of an exacerbation of the disease.
Depression also seems to exacerbate heart disease. In a twelve-year follow-up of 2832 middle-aged men and women, those who experienced ongoing despair and hopelessness were much more likely to die of heart disease. And among those three percent of the subjects who suffered from severe depression, the death rate from heart disease was four times higher than among those who did not feel any depression.
From a medical perspective, depression appears to be a particularly serious threat to heart attack survivors. A survey of patients discharged from the Montreal hospital who were treated there after their first heart attack showed that for patients suffering from depression, the risk of dying in the next six months was much higher. For one in eight severely depressed patients, the mortality rate was five times higher than for others with a comparable illness—an impact as significant as that of major medical risks of dying from heart disease, such as left ventricular dysfunction. or having a previous heart attack. One possible mechanism to explain why depression so greatly increases the likelihood of a subsequent heart attack is its effect on heart rate variability, which increases the risk of a fatal arrhythmia.
In addition, depression has been found to complicate recovery from a hip fracture. As part of a study involving older women with hip fractures, a psychiatric evaluation of several thousand such patients was carried out upon their admission to the hospital. Those who were depressed when they were hospitalized stayed an average of eight days longer in the hospital than patients with a similar injury but without the slightest depression, and only a third of them had any hope of ever regaining the ability to walk. However, women who were depressed but received mental health care for depression along with other medical care needed less physical therapy to walk again and had fewer readmissions within three months of their return home from the hospital. .
Similarly, in a study of patients whose condition was so dire that they were among the top 10 percent of people in need of medical care on a regular basis—often due to the presence of multiple conditions at the same time, such as heart disease and diabetes—about one out of six had severe depression. When these patients were freed from this problem, the number of days per year during which they were disabled decreased from 79 to 51 for those who suffered from severe depression, and from 62 to just 18 days per year for those who were treated for mild depression. degree of depression.