Uncovering the link between emotional stress and heart disease - Harvard Health
1. Asian Cardiovasc Thorac Ann. Feb;22(2) doi: / Epub Jul When stress is constant, your body remains in high gear off and on for days or weeks at a time. Although the link between stress and heart disease isn't clear. The relationship between stress, heart disease and sudden death has been recognized since antiquity. The incidence of heart attacks and.
These are characteristic of Type A coronary prone behavior, now recognized to be as significant a risk factor for heart attacks and coronary events as cigarette consumption, elevated cholesterol and blood pressure.
While Type A behavior can also increase the likelihood of these standard risk factors, its strong correlation with coronary heart disease persists even when these influences have been excluded.
How Stress Increases the Risk of Cardiovascular Disease (CVD)
However, there is considerable confusion about how to diagnose and measure Type A behavior and numerous misconceptions about which components are the most as indicated in the Interview with Dr.
Ray Rosenman, one of the co-authors of the Type A behavior concept. The following discussion is designed to clarify these and other aspects of the role of emotions and behavior in heart disease and how this may relate to the explosive increase in job stress.
References have also been provided to obtain additional details on items that may be of special interest.
Emotions, Behavioral Traits and Heart Disease: Some Historical Highlights The appreciation that different emotions could have powerful influences on the heart and the recognition of some intimate but poorly understood mind-heart connection is hardly new. Aristotle and Virgil actually taught that the heart rather than the brain was the seat of the mind and soul and similar beliefs can be found in ancient Hindu scriptures and other Eastern philosophies.
Broken-hearted, heartache, take to heart, eat your heart out, heart of gold, heart of stone, stouthearted, are just a few of the words and phrases we still use that vividly symbolize such beliefs. William Harvey, who discovered that the circulation of the blood around the body through vessels was due to the mechanical action of the heart also recognized that the heart was more than a mere pump.
Osler, He later wrote that he could make the presumptive diagnosis of angina based on the appearance, demeanor and mannerisms of the patient in the waiting room and how he entered the consultation room. Osler, In the s, the Menningers suggested that coronary heart patients tended to be very aggressive. Dunbar, Kemple also emphasized fierce ambition and a compulsive striving to achieve power and prestige.
Stress and Heart Disease – The American Institute of Stress
Wolf, In Greek mythology, Sisyphus, the king of Corinth, was doomed by the gods to a life of constant struggle by being condemned to roll a huge marble bolder up a hill, which, as soon as it reached the top, always rolled down again.
Wolf characterized people who were coronary prone as constantly striving against real but often self-imposed challenges, and even if successful, not being able to relax or enjoy the satisfaction of achievement. Blood cholesterol level, blood clotting time, incidence of arcus senilis and clinical coronary artery disease.
Neither of these two cardiologists had any expertise in psychology, which may have been fortuitous, since they had no preconceived notions.
What they did have was an unusual combination of curiosity, diagnostic acumen and a bio-psychosocial approach to the patient as a person, rather than someone to be treated in a cookbook fashion based on laboratory tests, symptoms or signs.
As noted, psychiatrists and others interested in psychosomatic disorders had previously described certain personality characteristics in heart attack patients. However, it was not possible to prove that these had any causal relationship since such idiosyncrasies could have resulted from the illness rather than vice versa. Friedman and Rosenman were the first to explain why specific behaviors could cause heart attacks and contribute to coronary artery disease.
Associations between stress disorders and cardiovascular disease events in the Danish population
At the time, animal studies had led to the widespread assumption that heart attacks were due to occlusion of a coronary artery by atherosclerotic deposits resulting from elevated blood cholesterol levels. This, in turn, was primarily the consequence of increased fat and cholesterol intake. Support for this was reinforced by research showing that the significant variation in mortality rates from coronary heart disease in different countries showed a clear correlation with fat consumption.
The greater the amount of saturated fat and cholesterol in the average diet the higher the blood cholesterol and death rate from heart disease in that country. However, Friedman and Rosenman could not confirm this close relationship with serum cholesterol and high fat diet in their heart attack patients and looked for other possible contributing factors.
They were intrigued by the observation that two-thirds of the heart attacks in the United States occurred in men, while in Mexico the incidence was equal between men and women. The same equal split appeared to exist in southern Italy but not in northern Italy, where the ratio was four men to one woman. Self-imposed standards that are often unrealistically ambitious and pursued in an inflexible fashion. Associated with this are a need to maintain productivity in order to be respected, a sense of guilt while on vacation or relaxing, an unrelenting urge for recognition or power, and a competitive attitude that often creates challenges even when none exist.
Certain thought and activity styles characterized by persistent vigilance and impulsiveness, usually resulting in the pursuit of several lines of thought or action simultaneously. Type A persons often nod or mutter agreement or use short bursts of laughter to obliquely indicate to the speaker that the point being made has already been anticipated so that they can take over.
Unsatisfactory interpersonal relationships due to the fact that Type As are usually self-centered, poor listeners, often have an attitude of bravado about their own superiority, and are much more easily angered, frustrated, or hostile if their wishes are not respected or their goals are not achieved. Increased muscular activity in the form of gestures, motions, and facial activities such as grimaces, gritting and grinding of the teeth, or tensing jaw muscles.
Often there is frequent clenching of the fist or perhaps pounding with a fist to emphasize a point. Fidgeting, tapping the feet, leg shaking, or playing with a pencil in some rhythmic fashion are also common. Irregular or unusual breathing patterns with frequent sighing, produced by inhaling more air than needed while speaking and then releasing it during the middle or end of a sentence for emphasis. It was also noted that coronary prone patients tend to be very competitive and often overly aggressive.
They are usually in a hurry and consequently eat, talk, walk and do most other activities at a more rapid pace. How did the Type A Concept Originate? How the Type A coronary prone behavior hypothesis evolved is a fascinating story, especially since it began because of an interest in cholesterol metabolism rather personality characteristics.
Our Harold Brunn Institute for Cardiovascular Research building adjoined the hospital and following early hospital rounds we spent full mornings in the research lab and afternoons in the office. Byalthough fat and cholesterol had long been fed to rabbits to produce vascular lesions, little was known about where plasma cholesterol came from or how it was metabolized. We also noted that this type of vascular damage was quite different from that seen in patients with coronary artery disease.
We obtained Public Health Service and other grants to begin animal studies and Mike was able to solve many fundamental aspects of cholesterol metabolism. I was later able to delineate the mechanisms underlying low and high plasma cholesterol respectivelyi in hypothyroidism and hyperthyroidism and what caused elevated lipids in patients with nephrosis.
Aroundbecause of our growing interest in cholesterol, we obtained blood samples from private patients at every visit for no-cost accurate analyses at our research lab. We soon realized that that there were surprising fluctuations in their cholesterol levels that were unrelated to diet or weight, and had little relationship to subsequent coronary events. We subsequently recognized and reported serious errors and omissions in papers by Keys and others about the contribution of diet to plasma cholesterol.
The prevailing dogma, which still persists, was that coronary heart disease was due to elevated cholesterol, which in turn resulted from increased dietary fat intake. Our own and other data that Keys had ignored in reaching his conclusions did not support this and reinforced our belief that socioeconomic influences played a more important role in the increased incidence of coronary disease as well as gender differences.
These chairs also had to be reupholstered far more often than others because the front edges quickly became worn out.
Associations between stress disorders and cardiovascular disease events in the Danish population
They looked at their watches frequently and acted impatient when they had to wait, usually sat on the edges of waiting room chairs and tended to leap up when called to be examined. Her astute observations significantly reinforced our own awareness of similar behaviors in our coronary patients, then mainly males, that you summarized so well over two decades ago. Occupational pressures and other sociocultural stresses headed the list.
When Rosenman and Friedman subsequently asked the wives, relatives, friends and co-workers of heart attack patients to list possible contributing factors, they were surprised at how often their assessment similarly ranked job stress right at the top. The cluster of behaviors and activity patterns previously described that also emerged from these sources was far more common in males than female.
It was also was evident that the current marked increased incidence of coronary disease had occurred mainly in men without any significant change in their diet, increased prevalence of diabetes, hypertension or other risk factors. Even when combined, the standard Framingham coronary risk factors of smoking, hypertension and cholesterol accounted for only about one third of coronary disease patients in prospective studies.
It became increasingly clear that these risk factors were merely markers that might predict coronary events but did not cause them. And, whereas simultaneous presence of two or more risk factors is associated with extremely high risk of coronary disease, such situations only predict a small minority of cases. A broad array of recent research studies point with ever increasing certainty to the position that certain psychological, social and behavior conditions do put persons at higher risk of clinically manifest coronary disease.
Southern Europe and the U. After a site visit the grant was approved for two years. The methodology of the Western Collaborative Group Study, including the Structured Interview SI for assessing behavior patterns was described in my first follow-up paper.
Rosenman, Friedman, Straus et al. We became good friends many years later through you, your annual Congress and other activities of the American Institute of Stress. The significant contribution of Type A behavior to coronary heart disease CHD was subsequently acknowledged by a committee of authorities assembled by the National Institutes of Health The Review Panelwho noted, The Review Panel accepts the available body of scientific evidence as demonstrating that Type A behavior. This increased risk is greater than that imposed by age, elevated levels of systolic blood pressure, serum cholesterol, and smoking and appears to be of the same order of magnitude as the relative risk associated with the latter three of these other factors [p.
One problem was that like stress, Type A meant different things to different people. More importantly, researchers also used different assessment or measurement methods so it is not surprising that they reached conflicting conclusions. What they meant by this were observable traits and characteristics that could be readily detected by others, such as the vocal stylistics, breathing patterns, facial grimaces, body movements, hyperresponsiveness and accelerated pace of activities previously described.
In their extensive study of employees of several large Western corporations, Rosenman and colleagues were able to predict susceptibility to coronary disease by behavioral characteristics such as a tense, alert and confident appearance; strong voice, clipped, rapid and emphatic speech, laconic answers; evidences of hostility, aggressiveness and impatience, and frequent sighing during questioning.
As they noted, Rosenman, Friedman, Straus et al Before and during the personal interview, the following observations upon each subject were made and recorded by the interviewer. In clinical practice, accurate assessment of Type A behavior requires a structured personal interview by a trained investigator using standardized challenges to elicit these tell tale characteristics. For example, one such challenge might be conducted as follows: The investigator begins the interview by asking the following question in a deliberate and painfully slow, monotonous manner.
Smith, two second pausemost people, when they go to work during the week — that is, Monday through Friday- get up early two second pause— say around 6: That is probably because it necessary to provide enough time for them to shower, brush their teeth, two second pause and so forth, get dressed, have something to eat, and then they travel by car, bus or train so they can get to work by a certain time two second pausewhich is often between 8: How do you travel to work and what time do you usually get there?
A flaming Type A would interrupt almost immediately before the question was finished to quickly explain his usual daily routine. Again, the interviewer is not as interested in the content of the response as much as the manner in which it is conveyed and how the subject acts during the interview with respect to facial expressions, gestures, evidence of impatience, time urgency, and other typical Type A traits.
Each of these has a certain value and is rated as to severity to obtain a final assessment.Stress & the Heart – What You Need to Know - Mayo Clinic
Interviews are videotaped so that several reviewers can carefully review the responses and reach agreement on the significance of each component. These Type A characteristics have been described in detail to emphasize that this complex behavioral pattern can only be accurately assessed by personal observation of the subject by an investigator who has been trained to elicit and evaluate typical responses.
Type A behavior is almost impossible to detect in someone who is very sick, bored, depressed, or frightened, such as in a patient recently hospitalized for a heart attack or some other serious medical condition.
Reliable ratings therefore require considerable expertise, making large-scale studies quite time consuming and costly.
As a consequence, a variety of questionnaires have been devised to detect such aspects of Type A behavior as competitiveness, ambition, impatience, hostility, preoccupation with work, or a constant sense of time urgency. However self-reports fail to capture the stylistics and psychomotor behaviors that are essential to the construct of Type A and its assessment. Self-report questionnaires were rarely validated by those who used them in so many published Type A studies, which also led to considerable confusion in this field.
The most commonly used instrument, the Jenkins Activity Survey, detects three main behavioral syndromes: The diagnosis has been criticised for being unreliable and including people with a variety of symptomatology and experiences which do not meet criteria for depressive, anxiety or other disorders.
Strengths of the current study include a large population-based cohort sample with a substantial follow-up period and no selection bias. Even with the large, well-characterised sample, some limitations must be kept in mind when interpreting our results.
Owing to sparse subgroup sizes, we were unable to examine precisely the associations between PTSD and three of the CVD events among those with depression diagnoses. We were unable to adjust for behavioural risk factors for CVD events and other potentially important confounders, which may have biased observed associations.
Importantly, the bias analysis we conducted to evaluate the potential impact of uncontrolled confounding due to smoking on the associations between PTSD and CVD events indicates that this uncontrolled confounding did not account for our entire observed association. Data from the DNPR are frequently used for the study of CVD events; 12 41 42 however, validation studies comparing stroke and VTE diagnoses obtained from the DNPR with medical records have found the positive predictive value of the diagnoses contained in the registry to be moderate and variable across diagnostic subgroups, treatment departments eg, emergency room, specialty department and type of diagnosis primary vs secondary.
Finally, it is important to note that the size of SIRs across PTSD and adjustment disorder exposure groups may not be directly comparable because these have been standardised to slightly different populations; however, the current study is consistent with circumstances under which these differences would not have a meaningful impact on observed associations.
Future research utilising population-based samples is needed to further elucidate the mechanisms that underlie the associations between stress diagnoses and CVD events. All authors made substantial contributions to the design of the study, and interpretation of the data. DKF and ES made substantial contributions to the acquisition and analysis of data.
All authors contributed to the drafting of the current manuscript, and gave final approval of this version. Provenance and peer review: Not commissioned; externally peer reviewed. No additional data are available. Prospective study of posttraumatic stress disorder symptoms and coronary heart disease in the Normative Aging Study. Arch Gen Psychiatry ; Anxiety disorders increase risk for incident myocardial infarction in depressed and nondepressed Veterans administration patients.
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