Stress and Health

Twenty years ago in Japan, cardiologists first described a unique form of heart failure called Takotsubo cardiomyopathy. Cardiomyopathy is a weakening of heart muscle and can be caused by a number of pathological processes including viral infections, diabetes, and most commonly, coronary artery disease. But in the case of Takotsubo cardiomyopathy, the only causal factor that could be consistently found was extreme emotional stress such as the loss of a spouse or loved one. As a result, the base, or apex, of the heart balloons out and causes pain and reduced pumping capacity. And as a result of it's only apparent cause, this cardiomyopathy has also been referred to as "the broken heart syndrome". It has been estimated that up to 1 to 2% of admissions to US coronary care units can be attributed to this pathologically enigmatic disease. http://www.mayoclinic.com/health/broken-heart-syndrome/DS01135

But how can stress alone cause acute cardiac decompensation? It appears that there is a substantial decrease in microvascular circulation as well as an associated increase inflammation-- both of which have been associated with such problems in other cardiomyopathies. In my own clinical practice I've seen patients with no risk factors whatsoever develop sudden heart attacks when informed of catastrophic loss. As I tell patients, we are not simply biomechanical entities. Our emotions and our responses to the environment around us have an enormous impact not only on how we feel, but also how we respond physiologically or pathophysiologically to external stressors.

If acute emotional stress can precipitate a cardiomyopathy, what impact can long-standing stress have on overall health of individuals? Or more specifically, in the context of the stressful unpredictability of healthcare in the United States, what impact might this have on the overall health of our population?

These sorts of questions have been on my mind recently as it has become apparent to me that not only are the New Zealand patients I am seeing less stressed about their healthcare, I too, am feeling less stressed in this place. Maybe it all has to do with a less adversarial and more cooperative society, or maybe it's simply due to a far lower population density than I'm used to, but I have the distinct impression that overall levels of stress here are lower. When you think about it, how could that not be? Patients here don't have to worry on a week-to-week month-to-month basis about their employment status and its impact on their ability to provide healthcare for their families or themselves. Nor do they have to worry about the impact of healthcare on a proposed job change, geographical move, or, for that matter, an entrepreneurial or creative endeavor. Ironically, a comprehensive socially-based health plan such as that found here in New Zealand affords its citizens far greater social mobility than that found in the United States. There is no "job lock" due to pre-existing conditions, no impact of health insurance on career choices. So much for Tea Baggers' concerns about "freedom". As with so many other things, they've got it backwards.

When I think about stress and its impact on the health of specific populations, I can't help but reflect on the seven years I spent in Beaufort County South Carolina caring for a significantly African-American population. Over and above the contributions of diabetes,obesity, and smoking, I saw a disproportionate number of people who had remarkably high blood pressure that was often treatment resistant, despite progress in treating the other associated problems. At the time, an occasional patient would tell me that it was all due to stress, to which I often gave less credence than the presumed physiological causes. But now I'm less sure that those patients weren't right. Generations of poverty, lack of access to healthcare, and yes, racial oppression may well have had a far greater contributing role than I was willing to admit or address.

I now wonder whether the same can't be said for the entire USA. Certainly we spend more money per capita on healthcare than any other country on earth, but in spite of that we have significantly worse outcomes. This can be broken down ethnically, geographically, and socioeconomically but I still wonder whether the stress of life in a country where many people are, to use Barbara Ehrenreich's term, "nickeled and dimed", (or worse...) doesn't play a far greater role than is appreciated by the purely biomechanical research paradigm most often utilized to investigate such medical problems.

Just maybe, if we were to embrace a more comprehensive, universal, humane health system such an overarching adverse risk factor for collective bad health could well be reduced or eliminated. Studies clearly show that one of the greatest predictors of the health status of a population is distribution of wealth. Perhaps the corrollary, collective stress, is equally important.

As for me personally, I will be monitoring my borderline elevated blood pressure to see if my personal perception of reduced stress translates into something physiologically demonstrable. I think it might....I'll keep you posted.