Janet Christie-Seely

Life Stress and Illness: A Systems ApproachSUMMARYThe link between stress and illness hasbeen forged by researchers like Holmes andRahe whose Social Readjustment RatingScale can be used by family physicians toassess their patients' stress. The concept ofstress has been clarified by the systemsapproach to illness. Stress and illness areembedded in a biopsychosocial matrix ofseveral systems levels, each of which maybe a source of stress as well as a supportsystem. Stress is not the end result of alinear chain of causes and effects, but partof a feedback system in a community orfamily. The family is the major source oflifestyle and personality, the health beliefsystem and modes of problem solving andcoping, as well as of stress and support.The family physician can have a major rolein educating the individual and familyabout stress and illness, and in altering themeaning of stress from catastrophe tochallenge and source of growth.Anticipatory guidance for the normal crisesof the life cycle and the crises of illness, lossand death can help prevent further familydysfunction and illness. (Can FamPhysician 1983; 29:533-540).

SOMMAIRELe lien entre le stress et la maladie a et e'tabli pardes chercheurs, tels Holmes et Rahe, dont l'Echellede mesure de readaptation sociale peut etre utiliseepar les medecins de famille pour evaluer le niveaude stress de leurs patients. Le concept de stress a eteclarifie par l'approche systemique de la maladie. Lestress et la maladie sont englobes dans une matricebio-psycho-sociale au niveau de plusieurs systemesdont chacun peut etre une source de stress aussibien qu'un systeme de support. Le stress n'est pas laresultante d'une chaine lineaire de causes et d'effets,mais fait partie d'un systeme de retroaction au seinde la communaute ou de la famille. La famille est laplus importante source du style de vie et de lapersonnalite, du systeme de croyances sanitaires etdes faqons de solutionner les problemes et de lesaffronter, de meme qu'elle est une source de stresset de support. Le medecin de famille peut jouer unrole majeur dans l'education de l'individu et de lafamille concernant le stress et la maladie, et dans lamodification qu'il peut apporter au sens du mot"stress", le transformant de catastrophe a defi etsource de developpement personnel. Des conseilsanticipatoires pour les crises normales des differentscycles de la vie et les crises survenant a l'occasion demaladies, pertes et deces peuvent aider a prevenird'eventuelles dysfonctions et maladies au sein de lafamille.

Dr. Christie-Seely is an assistantprofessor of family medicine atMcGill University, and FamilySystems Coordinator at McGillUniversity and Kellogg Centre forAdvanced Studies in Primary Care.Reprint requests to: Kellogg Centrefor Advanced Studies in PrimaryCare, Montreal General Hospital,1650 Cedar Ave., Montreal, PQ.H3G 1A4.

S TRESS IS A popular concepttoday. What is the evidence that

stress plays a role in illness, and moreimportantly, that physicians can doanything about it? Rhetoric about

CAN. FAM. PHYSICIAN Vol. 29: MARCH 1983

health and prevention is common inthe medical literature, but little isavailable in the way of practical sug-gestions for the family physician.Two major breakthroughs have

paved the way to a new perspective ondisease and medical practice:

1. Holmes and Rahel developed asimple questionnaire, easy to use andquick to apply (Table 1). This scalewas a subjective rating of stressful lifeevents and led to numerous retrospec-tive and prospective studies of almostevery common disease, providing im-pressive evidence that the incidence ofboth serious and minor illness in-creases following stress.

2. There is a new way of thinkingabout illness in its family and socialcontext, which reaffirms what all doc-tors know but deny in their practiceand medical terminology; mind andbody are one and illness must be de-fined in a psychosocial environment.Interactional, Systems, or "organis-mic" thinking or "the biopsychosocialmodel"2 are various names for look-ing at illness as part of a complex ma-trix in which culture, community,family, individual and organ systemsand genes play a role in defining, de-veloping and curing disease.

Medicine has been slow to leave thesimple, linear model of specific dis-ease causation (e.g., genes and diet

533

I

contribute to increased cholesterollevel which causes coronary atheromawhich produces an infarct). Engelcomments that "most lay people havetaken for granted that a person's frameof mind has something to do with hispropensity to fall ill and even to die.. . .This is a theme that has been com-monplace in popular thinking in folk-lore and literature throughout theages".3 He ascribes the loss of past in-sights to the tremendous break-

throughs in the biological sciences.These took place with the aid of pow-erful tools which could study only thebiochemical and physical alterations ofthe body, not the obvious connectionsbetween mind and body. Even thebrain was studied without reference toits psychological functions! Currently"the development of an organismicpoint of view is finally making it pos-sible to understand how the individualfunctions within an environment and

TABLE 1Social Readjustment Rating Scale1Rank Life Event Mean Value*

1 Death of spouse 1002 Divorce 733 Marital separation 654 Jail term 635 Death of close family member 636 Personal injury or illness 537 Marriage 508 Fired at work 479 Marital reconciliation 4510 Retirement 4511 Change in health of family member 4412 Pregnancy 4013 Sex difficulties 3914 Gain of new family member 3915 Business readjustment 3916 Change in financial state 3817 Death of close friend 3718 Change to different line of work 3619 Change in number of arguments with spouse 3520 Mortgage over $10,000 3121 Foreclosure of mortgage or loan 3022 Change in responsibilities at work 2923 Son or daughter leaving home 2924 Trouble with in-laws 2925 Outstanding personal achievement 2826 Wife begins or stops work 2627 Begin or end school 2528 Change in living conditions 2429 Revision of personal habits 2330 Trouble with boss 2031 Change in work hours or conditions 2032 Change in residence 2033 Change in schools 1934 Change in recreation 1935 Change in church activities 1836 Change in social activities 1737 Mortgage or loan less than $10,000 1638 Change in sleeping habits 1539 Change in number of family get-togethers 1540 Change in eating habits 1541 Vacation 1342 Christmas 1243 Minor violations of the law 11

* The mean value assigned to each item on the scale is based on theweighted value attached by the research population to each life event interms of its tendency to induce stress.

534

how mind and brain act as mediatorsand regulators of the body econ-omy 3

Stressful Life EventsStress is ubiquitous. Life is stressful

and challenging; Antonovsky4 said thesurprising thing is that we stay healthyin spite of the prevalence of patho-gens. Conversely, lack of stress meansmonotony and boredom. Selye5 coinedthe term "eustress" to remind us thatoptimal levels of stress are associatedwith health. Illness may. result fromlevels of stress that are too low, asdemonstrated in a Veterans' Adminis-tration study of 88 chronically ill, mar-ginally employed men, all of whomhad very low levels of recent lifeevents (19% had had no life event, ex-cept Christmas, in the past year6).Like the normal arousal curve for opti-mum performance level, both low andhigh levels of stress can be destructiveand impair performance.

Is change itself-good or bad-thestressor?7 Life events such as marriageor promotion may be desirable but re-quire a considerable degree of individ-ual adaptation. They can often be asso-ciated with the onset of illness ifdemands for adaptation are excessive.The Holmes and Rahe scale (Table

1) was developed by asking 394 peo-ple to rate the amount of social read-justment required for a series of 43common events.1 An arbitrary numeri-cal value of 500 (later changed to 50),was assigned to marriage. If an eventrepresented more intense and longerreadjustment than marriage, a largernumber was chosen. Death of a spousewas universally rated as the moststressful event. This scale has beenrated by many different cultures andage groups and the list remains consis-tent. Accumulated stress was evenmore likely to be followed by illness.For example, in individuals with ascore of 200-299 over two years, 51%reported significant health changes; inthose with a score over 300, 79% hadsuch changes.8The scale has been criticized for

being too simple and having poor con-tent validity. For example, 20-30-year-olds using the scale have twicethe number of stressful life events(SLE) of those over 60, while mostpeople feel that stress increases withage-as illness increases. However,its very simplicity has led to its exten-sive use in research studies. Rahe's

CAN. FAM. PHYSICIAN Vol. 29: MARCH 1983

group and others have studied theonset of tuberculosis,9 pneumoniasand other infections,10 cardiac disease(particularly myocardial infarction) ,1 1

diabetes,12 inguinal hernias,3 schi-zophrenia14 and lupus erythematosis15in Scandinavian and North Americanpopulations. A consistent correlationwas found between the total amount ofstressful recent life events and the oc-currence of a particular illness.

However, in those studies whichlooked at stressful life events alone,the correlation coefficients are onlyapproximately 0.3; only 9% of thevariance of illness is explained.16Many people experience terrible stresswith no signs of illness; illness oftenoccurs in the absence of apparentstress.The effects of stress are apparently

much greater when mediating and con-founding variables are considered.

Systems and StressStress is only one variable in a sys-

tem of interrelating variables. It can becaused by illness or cause illness. Itcan result from family interaction andbe relieved by family support. Re-search has been confused by the medi-cal linear approach where variables aretaken out of context for measurement.A cybernetic or interactional model ismore realistic and suits the family phy-sician who is aware of the context ofdisease. For example, it has beenshown that in 75% of cases, conges-tive failure with admission to hospitalfollows a stressful life event.17 Thismay represent organic changes as a re-sult of stress (e.g., the 'ripple effect'of disease following the death of aspouse or parent), or an escape fromstress into the sickness role. Hospital-ization may represent an adaptation toa partner's alcoholic binge, or a way toavoid a lonely Christmas after the lastchild has left home.

Holmes' and Rahe's Social Read-justment Rating Scale includes notonly external and uncontrollableevents such as accidental injury butalso events which are within the indi-vidual's control, such as marriage, jailterms and divorce. Twenty-nine of the43 on the list18 can be symptoms orconsequences of illness, which itselfcan be a major stressor, and part of adownward spiral that produces moreand more dysfunction in an individualor family.The source of stress as well as medi-

ation of stress can be from any of thesystems levels shown in Figure 1.Brody19 has illustrated the way inwhich a national decision has stressfulrepercussions throughout the commu-nity, resulting in organic illness at thecellular level. Conversely, cellulardysfunction (e.g., a genetic defect)can affect that individual, his family,and sometimes his community.

In one such family, the diagnosis ofmuscular dystrophy in an 18-month-old girl resulted in severe family dys-function. The family was vulnerable atthe outset because of the mother's tu-berculosis which has been called a dis-ease of isolation,20 and may have re-sulted from this woman's isolation in aforeign country with no one but herhusband and another sick child to com-municate with. Alcoholism in bothparents resulted from stress, lack ofphysician and community support, andthe couple's coping styles of denialand avoidance. A sister's obesity anddepression were outcomes of multiplestresses which did not affect anotherhealthy sister.

Thus, biomedical factors, the sick-ness role, individual and family copingstyles, the degree of family and com-

munity support, and the characteristicsof the stress must be considered whenthe stress-illness relationship isevaluated. Each factor interrelatesvith others.

Mediating FactorsMirsky21 did a pioneer study in

young army recruits showing that pep-tic ulcer developed under the stress ofbeing away from home for the firsttime. However, this happened only inthose recruits genetically predisposedby high levels of blood pepsinogen,and with particular personality vari-ables. Spilken and Jacobs22 found thatupper respiratory infections in collegestudents increased after events whichprovoked a sense of personal failure orsocial isolation coupled with helpless-ness.The concept of the '"giving

up/given up complex"3 or the feelingof hopelessness and helplessness fol-lowing a loss or stressful life event wasdeveloped by George Engel, WilliamGreene, and Arthur Schmale at theUniversity of Rochester. Greene23studied lymphomas and leukemias,and Le Shan24 and Schmale25 eachindependently observed that cancer

Fig. 1 Downward Spread of Perturbations: Stress-Related Illness ofAerospace Engineer1'

CultureV

SocialPsychicSomatic

Nations(societies)V

Communitiesand organizations >

Families

V

Individual poo

Body systems_+V

Organs ooVT

Initial perturbationchallenge to values: peace, andgeneral welfare versus war and fulldomestic employment

Policy decision to stop manufactureof aircraft

Loss of income, outward migration

Economic and emotional stress; rolerealignment

Reassess self-worth, need to learnnew skills and living patterns

Disruption of rhythm of environmentalinput

Signs and symptoms of organicdisease: lethargy, pain, nausea, etc.

CellsV

Molecules

CAN. FAM. PHYSICIAN Vol. 29: MARCH 1983 535

patients had a high incidence of thiscomplex. Schmale's study of cervicalcancer25 accurately predicted biopsyresults in 76% of patients based on

their helplessness/hopelessness rating.The increased mortality rate fromcancer and other diseases26 after losinga spouse has been documented many

times. Table 2 shows one of the earli-est studies by Kraus and Lillienfeld,27which demonstrates the increase inmortality rates of the widowed, aged25-35, compared to married people ofthe same age. The 12-fold increase oftuberculosis in men is striking.

In a study of prognosis of tubercu-losis, Holmes found that all treatmentfailures were in the lowest third of thesocial support scale.9 Alcoholism inyoung widowers might be one factor inthe high incidence of tuberculosis. Al-coholics who stop drinking without so-

cial support have a 20-fold increase intuberculosis incidence. Those whostop drinking with full social support,have an incidence of tuberculosislower than that of the general popula-tion.28Characteristics of stressor

The more intense the life event and in mte popithe longer the exposure to it, the personalityhigher the incidence and severity of ill- Family chaness that may result. In fact, very .i.severe stress such as war or disaster Individuawill cause breakdown in all those ex-

posed. For example, there is evidence TABLE 2that the Holocaust had irreversible ef- Averagefects on all survivors. 16 The WidoIndividual s characteristics 1949-1951

The ir dividual's response to stress group)depends on his or her genetic makeup,culture, family beliefs and use of the Causesickness role, upbringing and experi- Tuberculo

ences. A person's own behavior may

contribute to stress in himself and in Vascular I

others. central ne

Antonovsky4 has described a certens"sense of coherence" or meaning in a Hyperten,person's view of the world as a major heart dise

determinant of resistance to stress. InfluenzaLife experience, family and cultural pneumoniattitudes contribute to this. Culture Arterioscl4may also help define the response to heart disestress. For example, stonmach ulcer and Malignant

cancer are very prevalent in Japan,whereas heart disease is more common Diabetes

in North America. Factors such as dietare assumed to explain these dif-ferences, but it is of interest that the Motor Vetstomach is considered the soul or locus Accidents

of emotion for the Japanese, while Adapted v

terms like 'broken-hearted', at the aspects o'heart of things', cold- and warm- Dis 10:20

536

hearted reflect our own culture's em-

phasis on the heart and its vulnerabil-ity.

Early trauma, particularly a parent'sdeath, seems to predispose to the help-lessness/hopelessness response.2 It isthe individual's perception that distin-guishes a stressor from a stimulus. Themeaning of a stress or an illness hasbeen largely ignored in medicine, butis a major factor in determining a pa-

tient's response. Remen discusses howthe physician can help by relabel-ling or redefining the illness so that thestress produces growth rather than dys-function.29 For instance, a myocardialinfarction can mean the end of a career

or a reorientation of values and an op-portunity to get to know one's family.

Uncertainty, lack of knowledge or

understanding of the situation, lack ofresources and poor coping and compe-tence in the past all diminish copingability in the present.

Past efforts to identify personalitytypes with specific illnesses,30 con-

flicts with specific organ responses,3 1or organ inferiority32 are in disrepute.This tradition is maintained, however,

-&1u cxn_g_ p_ -AAoular concept iinKing type A

y33 with cardiac disease.

rracteristicslsupport systems

al's personalities are devel-

oped and maintained in families. Incontrast to the type A personality, thefamily types associated with cardiacdisease have not been studied. How-ever, the type A personality is sup-

ported by a spouse who encouragesworkaholism (sometimes by complain-ing about it!) and whose own familypattern was often type A.

For example, The C family pre-sented to the family physician throughtheir ten-year-old son who was de-pressed and had cried every night sincethe family dog had been sold. Themother had recently developed asthmaand this was the official reason the doghad been sold. It became apparent thatshe was in fact anxious to get a job,since her husband had recently had a

serious cardiac operation for triple ar-

tery disease. The child had not beentold of the operation and had been'protected' from worry by the generalfamily denial. However, his depres-sion represented the fear of losing thefather who was symbolized by thedog. The mother said her husbandwould be better off 'if he died in har-ness' since this was his personality andway of life. She and the patientclaimed he had slowed down consider-ably since the operation. The ten-year-old son and a 20-year-old son bothcontradicted her in a discussion with

Annual Death Rates for Selected Cases in the Married andwed, for the 25-to-35 Age Group, by Sex, United StatesI (Deaths rates per 100,000 population in each specified

sis

lesions of the0rvous systemsion withaseandiaerotic,aseNeoplasms

hicle

Sex MarriedM 11.2F 15.4M 3.6F 4.1M

F

M

FM

FM

F

M

F

M

F

1.72.32.62.78.62.8

16.220.91.41.7

32.37.8

Widowed141.876.129.317.418.310.920.113.442.116.537.552.44.64.2

88.219.8

Widwe-Widowed-Married

12.74.98.14.2

10.84.77.7

5.04.95.92.32.53.32.54.53.3

with permission from Kraus A, Lilienfeld A: Some epidemiologicf the high mortality rate in the young widowed group. J Chron17,1959

--

the family physician, and revealed thatthe couple's denial was continuing histype A behavior.

Although the wife was very suppor-tive, she clearly contributed to her hus-band's high risk behavior. Hoebel'sstudy34 of men with cardiac problemsthrough up to five interviews with theirwives, showed that by altering thewives' approach to their husbands' be-havior they altered the family systemthat was maintaining the high risk be-havior.

Family dysfunction can promote ill-ness. Minuchin's description36 of'psychosomatic families' explains howa family can trigger an asthmatic at-tack, anorexia nervosa or a diabeticcoma in a labile diabetic child. Thechild with a physiologic predispositiondevelops an exacerbation of the dis-ease in response to household tensionand becomes the focus of attention.Parental conflict-denied in theseoverly close, 'happy' families-isavoided when one parent takes thesymptomatic child to the doctor oremergency department.

In other families, sickness canmaintain the balance of power37 or amarriage that would otherwise breakup. In the N family there was a precar-ious balance between the domineeringartist wife and her ineffectual husbandwho had repeated business failures.These failures were similar to those ofthe wife's father. The couple colludedin the destructive myth that Mrs. Nwas the creative partner who had noneed for her dependent husband.When Mrs. N threatened to leave herhusband, the stress induced him to'pull a heart attack on me' so that shewas unable to leave. However, it laterbecame her turn to develop the sick-ness role to prevent marital disruption,revealing her need for the relationship.She developed incapacitating low backpain, and though she persuaded sur-geons to intervene twice, against theirbetter judgment, it only made thingsworse. When asked what would hap-pen if her back pain miraculously werecured, she replied, 'Oh, I guess Iwould leave my husband'; when herhusband was separately asked thesame question, he said, 'Oh, shewould be back in control again, I sup-pose'. The back pain enabled him tocontrol her clandestine affairs with stu-dent artists and to become the bread-winner again. Clearly a new familyhomeostasis, stabler than the first, had

evolved around the back pain. Mrs.N's need to be taken care of withoutlosing self-esteem was now answered,and Mr. N felt more of a man.

Despite families like this, whichgenerate more stress than support, oneof the chief mitigating variables forlife stress is that of social support. Forexample, a study by Nuckolls et al.38showed that stressful life events alonedid not predict the development ofcomplications of pregnancy. How-ever, when the pregnant women weredivided into groups with high, mediumand low social support, the occurrenceof complicatons after stressful eventsduring the pregnancy was 33% inwomen with high social support and91% in those with low social support(p>.001). Conversely, Lynch's bookThe Broken Heart, the Medical Conse-quences of Loneliness39 outlines nu-merous studies demonstrating the ef-fect of isolation on illness.

Cobb20 divides social support intothree components:1. Emotional support: the sense ofbeing cared for and loved.2. Esteem support: the sense of self-esteem, value and recognition.3. Network support: the sense of be-longing to one or preferably severalnetworks of mutual obligation andhaving a place in society.There is an extensive literature demon-strating positive effects of social sup-port on compliance,40' 41 recovery

from illness,42 and on preventing ill-ness from severe stressful life events.

Several studies demonstrate that thephysician's support is important.Chambers and Reisers17 found thephysician's emotional support had anextraordinarily beneficial effect oncongestive heart failure. Egbert et al.43showed that specific supportive careby the anesthetist to one group of sur-gical patients (the surgeons were un-aware which patients had the supportand which were controls) resulted inless pain medication and discharge 2.7days earlier than controls.

Biological MechanismsSeveral recent studies elucidate how

stress influences the body and supportprotects. A study of parents with chil-dren dying of leukemia44 revealed adrop in 1-hydroxy-ketosteroids prior tothe death in parents who seemed to begoing through a normal period of anti-cipatory grief. Parents who did notshow this developed a more precipi-tous hormonal drop after the death,which seemed to correlate with greaterdifficulty in adjustment. Bartrop andassociates45 studied the T-lymphocytefunction during bereavement andfound a significant decrease in func-tion that was greatest six weeks afterthe death. There is speculation aboutthe role of the immune system in in-creasing vulnerability to illness andabout the neuroendocrine axis as a

"Stress .. . can be caused by illness or c

CAN. FAM. PHYSICIAN Vol. 29: MARCH 1983 537

mediator of stress (Seyle's original"4general adaptation syndrome' '5).Gore46 studied a hundred men

whose jobs were eliminated; theyshowed changes in cholesterol, uricacid levels, norepinephrine in urineand serum creatinine. The same studyproduced a surprising finding; menwith low social support developed painand swelling in two or more joints in41% of cases, compared with 4% ofmen with high social support and 12%with medium social support.

Minuchin47 has studied labile diabe-tic children and their parents understress, monitoring free fatty acid levelsas ketone precursors and indicators ofemotional arousal. He demonstrated atransfer of stress at the biochemicallevel from parent to child, in thesepsychosomatic families. This phenom-enon could be predicted from systemstheory.

The Role of theFamily PhysicianAdvisor

The Social Readjustment RatingScale can aid both physician's and pa-tient's assessment of a situation. A pa-tient's increased awareness of the levelof stress and education about the pos-sible correlates of illness and dysfunc-tion may make a difference in his deci-sions. For example, a physician canadvise someone recently bereaved notto make any major changes in lifestyleor living arrangements for some timeafter the death. The patient can fill inthe SRRS himself and avoid precipi-tous moves that would increase thestress level. Conversely, it is oftenhelpful for people to recognize thatstress is a normal part of living, thattheir level of stress is not greater thanaverage and that improved methods ofcoping with stress are indicated. Thephysician can facilitate coping by ad-vising methods of relaxation (yoga,transcendental meditation, Christianmeditation), better pacing of timecommitments, organization, exercise,recreation, hobbies and communitygroups to foster improved wellbeingand better network support. Cobb says"We should start now to teach all ourpatients, both well and sick, how togive and receive social support"9. 20The statement may seem naive but infact it covers a range of advice that canmake a difference to family relation-

ships. If the physician acknowledgesto patients that they may find it diffi-cult to request help from the physicianand family members, patients may feelthey have permission to be more openin asking for help. Direct coaching onacceptable ways to obtain help fromfamily members can discourage thestoicism and martyrdom that impedesfamily communication and support. Inmeetings with the whole family-ahabit and skill that family physiciansshould develop48 -the physician cantake a non-judgmental interest in eachmember and facilitate open communi-cation. The physician might suggestthat family members exchange daysoff with neighbors with small children,take a vacation or time out from work(defining 'sick-leave' is a time-hon-ored task for the physician), or con-sider respite care for the elderly whenthe family's endurance is stressed tothe breaking point.

Educator'Heed nature's warning' is advice

often ignored and not given oftenenough. The physician has an impor-tant role in educating his or her pa-tients about the meaning of symptoms.For example, I found it useful to en-quire about recent stress in a man pres-enting with facial impetigo for the firsttime. He admitted to severe workstress and to a series of faruncles. Theinquiry added only two minutes to theinterview but helped him recognizehow stressed he felt and the need tomake some changes.The intensity of stress is increased

by lack of knowledge and uncertainty.The physician plays a major role in in-creasing the patient's and family'sknowledge about actual illness, aboutbiomedical effects of stress, and aboutwhat can be expected from a life crisis.Bereavement can be a terrifying expe-rience for people who are unaware thatphysical symptoms mimicking thoseof the deceased, auditory and visualhallucinations, personality changes (ir-ritability, extreme hostility), and fearsor isolation can all be normal compo-nents of mourning.49 The physician'sexperience with life stress can extendthe coping abilities of a family with anelderly person who has had a stroke orhas a newly diagnosed cancer. Achild's hospitalization has been shownto have no adverse effects when thechild is adequately prepared,50 while asingle episode of gastroenteritis has

been shown to have longterm conse-quences if parents' and pediatricians'worries were not adequately dis-cussed.51 In all these situations knowl-edge and understanding conveyed by atrusted personal physician decreasesinsecurity and improves coping.

FacilitatorThe importance of communicating

and expressing feelings cannot beoveremphasized as a coping mecha-nism that decreases stress. If the fam-ily physician does not take the oppor-tunity to see the whole family during aserious life event or medical crisis, heor she ignores a major resource. Deci-sion-making, problem solving, and ac-tion, with feedback to monitor suc-cess, are all more effective in thefamily setting. If the family decision-maker is the grandmother who livesnext door, it is inappropriate to discussdecisions only with the parents. Fami-lies function as units in which thewhole is greater than the sum of theparts;48 it is important to have the'whole' in the office when efficiencyand resources are needed. Discussionwith the patient alone will result inpoor compliance, poor understandingand will leave the stress of changingon the person already most stressed.A crisis often represents a family's

difficulty in problem-solving. Thephysician can facilitate family com-munication and problem solving. Asingle session can be- most effective,particularly at a moment of crisis whenfamily flexibility is maximal. A familyinterview before the death of a familymember can markedly alter coping re-sponses; counselling decreases themorbidity and mortality rate in thebereaved.52

Anticipatoxy Guidance'And Nonnal Life Crisis

I have previously described thestages of the life cycle as high riskstates in which vulnerability to illnessand family dysfunction increases.53Knowing the stages and tasks of thefamily life cycle is essential for thephysician who wishes to understandthe increased frequency of visits incertain stages; frequent minor illnessin young children or young mothersmay indicate family stress;54 a singlemother whose children are threateningto leave the nest may develop angina;

CAN. FAM. PHYSICIAN Vol. 29: MARCH 1983538

and a widow who lost her husband to aheart attack a year ago may have chestpains.

Intervention such as counsellingneed not take time and can be added tothe routine checkup or visits for im-munizations or upper respiratory infec-tions. Knowing each family is essen-tial for these to be effective. Otherfamily members often provide the cluethat will help the physician understanda situation. This occurred in the fol-lowing family:

A woman in her 50s began to expe-rience episodes of lightheadednessand palpitations that took her to theemergency department on several oc-casions. Referral to a cardiologist anda neurologist and two periods on aHolter monitor revealed no abnormal-ity. The family physician noted an in-creased frequency of visits by thewhole family, including the woman'sbrother, whose coping style was notedfor denial and lack of emotional ex-pression. However, when the physi-cian saw him with his wife, he re-sponded to a question about his sister'shealth with tears in his eyes which heimmediately tried to hide. His wife,whose chief complaint of her husbandwas that he was unemotional, quicklystated very protectively, "Oh he'snever worried about anything". Theman then hesitatingly asked the physi-cian if she knew of a pregnancy in hisunmarried sister's past; there were tenmonths during her forties that he hadbeen unable to account for because shewas overseas.

This couple's daughter, also thephysician's patient, had just had ababy. The birth had occurred just be-fore her aunt's onset of symptoms.Another clue in the development ofsymptoms was the twelfth anniversaryof their father's death from leukemia.He had experienced episodes of faint-ness and loss of consciousness whichhad been undiagnosed until just beforehis death-a fact for which the familystill resented the medical profession.The family's exasperation at the cur-rent difficulty in diagnosing the sis-ter's symptoms was thinly veiled andtheir worry manifested by frequent of-fice visits by all members.

Symptoms such as the above oftendisappear when the past events that arebeing relived become conscious, asthey did in this case.

Referral to Other ResourcesThe physician is often the only read-

ily available person to a patient who isaware of resources like legal aid, homehelp facilities, and support groups. Insome families the difficulty with prob-lem solving and communication re-quires more than a few sessions withthe family physician. In these families,stress is compounded by escalatingproblems, isolation, and frustration ofneeds and conflict. For these families,family therapy may markedly reducethe incidence of illness and the needfor the sickness role as an escape fromfamily problems.

The S family were referred for fam-ily therapy because of Mr. S's obesity,which was unresponsive to treatmentand was associated with hypertension,both of which he felt were caused byhis wife. She in turn was overwhelmedwith the family's financial problems, afamily business in which her husbandmade few of the decisions, a sickmother and mother-in-law, and herown history of recurrent illness, partic-ularly pulmonory embolus, hyperten-sion and occasional depression. Thecouple were locked into a patternwhere she was the boss. He resentedthis yet took so long making decisionsthat he colluded with her. He then ateto excess or developed a migraine inresponse. The extended family wereinvolved in the financial tangle andthree sons were triangled wheneverconflict developed between the cou-ple. Finally, the family's ability tomake any decisions ground to a haltand all three sons developed severeschool problems. This family requiredfamily therapy to clarify the collusionin the parental roles that resulted fromMrs. S's displaced anger towards herown abusive father, and Mr. S's angerat his mother who had run his life andwas now dying. As the power struggledecreased, weight and blood pressurecontrol improved and visits for physi-cal illness decreased.

Referral skills must be developedfor families who somatize theirstresses and difficulties. Referral in-cludes the art of relabelling a physicalsymptom or illness that is a result ofstress, and indicating that the stress re-sults from poor problem solving orcommunication. This suggestion tact-fully leads to the suggestion that fam-ily therapy is indicated. Normaliza-tion-'"communication is poor in most

families", "you're in good com-pany-most families could do with abit of help in problem-solving"-andremoving the stigma of counselling re-sults largely from the physician's reas-suring and non-judgmental attitude.As longterm family confidant, the

family physician is in an ideal positionto help the individual and family attimes of stress, and may play amajor-but as yet unresearched-rolein preventing disease. i)

AcknowledgementI would like to acknowledge the

work of my colleagues, Drs. YvesTalbot and Yvonne Steinert, in thedefinition and clarification of theskills of working with families in pri-mary care.

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16. Rabkin JG, Struening EL: Life events,stress and illness. Science 1976;194:1013-1020.17. Chambers WN, Reiser MF: Emo-tional stress in the precipitation of conges-tive heart failure. Psychosom Med 1953;15:38-60.18. Hudgens RW: Personal catastropheand depression: A consideration ofthe sub-ject with respect to medically ill adoles-cents and a requiem for retrospective lifeevent studies, in Dohrenwend BP, Dohren-wend BS (eds): Stressful Life Events: TheirNature and Effects. New York, John Wileyand Sons, Inc., 1974, pp. 119-134.19. Brody H: The systems view of man:Implications for medicine, science &ethics. Perspect Biol Med 1973; 17:71-92.20. Cobb S: Social support as moderatorof life stress. Psychosom Med 1976;38:300-314.21. Mirsky AL: Physiologic, psychologicand social determinants of psychosomaticdisorders. Dis Nerv Syst 1960; 21(suppl):50-56.22. Spilken AZ, Jacobs MA: Prediction ofillness behaviors from measures of lifecrisis, manifest distress and maladaptivecoping. Psychosom Med 1971; 33:251-264.23. Greene WH: The psychosocial settingof the development of leukemia and lym-phoma. Ann NY Acad Sci 1966; 125:794-801.24. Le Shan L: An emotional life-historypattern associated with neoplastic disease1966; 125:780-793.25. Schmale AH, Iker H: Hopelessness asa predictor of cervical cancer. Soc SciMedJ 1971; 5:95-100.26. Jacobs S, Ostfeld A: An epidemiologi-cal review of the mortality of bereave-ment. Psychosom Med 1977; 39:344-357.27. Kraus AS, Lillienfeld AM: Some epi-demiological aspects of the high mortalityrate in the young widowed group. JChronic Dis 1959; 3:207-217.28. Jackson JK: The problem of alcoholictuberculosis patients, in Sparer PF: Per-sonality, Stress and Tuberculosis. NewYork, International Universities Press,1954.29. Remen N: The Human Patient.Toronto, Doubleday and Co., Inc., 1980.30. Dunbar F: Psychosomatic Diagnosis.New York, Harper, 1943.31. Alexander F, French T, Pollack G:Psychosomatic Specificity. Chicago, Uni-versity of Chicago Press, 1968.32. Ansbacher H, Ansbacher R (eds): TheIndividual Psychology of Alfred Adler.New York, Basic Books, Inc., 1956.33. Friedman M. Rosenman R: Type A Be-havior and Your Heart. New York, AlfredA Knopf, Inc., 1974.34. Hoebel FC: Brieffamily-interactionaltherapy in the management of cardiac-related high-risk behaviors. J Fain Pract1976; 3:613-618.35. Medalie JH, Snyder M, Groen JJ, etal: Angina pectoris among 10,000 men: 5-year incidence and univariate analysis.

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E'lUhI X cephalexinDESCRIPION: Keflex is a semisynthetic cephalosporin antibioticintended for oral administration. It is 71(D-a-amino-a-phenylacetamido)-3-methyl-3-cephem-4-carboxylic acid monohydrate.ACION: Cephalexin is bactericidal against many gram-positive andgram-negative organisms. In vitro tests demonstrate that the cephalosporins are bactericidal through their inhibition of celltwall synthesis.INDICATIONS: Keflex may be indicated in the treatment of bacterialinfections of the respiratory tract, including otitis media, genitourinarytract. bones and oints, skin and soft tissue when the infection iscaused by susceptible organisms.CONTRAINDICAMONS: Keflex is contraindicated in patients withknown allergy to the cephalosporin group of antibiotics.PRECATIONS: Antibiotics, including Keflex, should be administeredcautiously to any patient who has demonstrated some form of allergy.particularly to drugs.

In penicillin-allergic patients. cephalosporin antibiotics should beused with caution. There is some evidence of partial cross-allergenicityof the penicillins and the cephalosporins. Of 7,450 clinical trialpatients. 291 had histories of penicillin allergy. Nineteen of them(about 6.5 percent) were among those in whom possible allergicreactions to cephalexin were observed.

Patients should be followed carefully so that any side-effects orunusual manifestations of drug idiosyncrasy may be detected. If anallergic reaction to Keflex occurs, the drug should be discontinued andthe patient treated with the usual agents (e.g.. epinephrine or otherpressor amines. antihistamines. or corticosteroids).

Prolonged use of Keflex may result in overgrowth of non-susceptible organisms. Careful observation of the patient is essential. Ifsuperinfection occurs during therapy. appropriate measures should betaken.

Keflex should be administered with caution in the presence ofmarkedly impaired renal function. Under such conditions, carefulclinical observation and laboratory studies should be made becausesafe dosage may be lower than that usually recommenided.

If Keflex is to be used for long term therapy, periodic monitoring ofhematology. renal and hepatic functions should be done. Indicatedsurgical procedures should be performed in conjunction with antibiotictherapy: e.g.. the incision and drainage of abscesses.

Safety of this product for use during pregnancy has not beenestablished.

Positive direct Coombs tests have been reported during treatmentwith the cephalosporin antibiotics. In hematologic studies or in transfusion cross-matching procedures when antiglobulin tests are performed on the minor side or in Coombs testing of newborns whosemothers have received cephalosporin antibiotics before parturition, itshould be recognized that a positive Coombs test may be due to thedrug.

In patients being treated with Keflex, a falsepositive reaction forglucose in the urine may occur with Benedict's or Fehling's solutionsor with Clinitest tablets, but not with Tes-Tape;.ADVERSE REACTIONS: Gasto-intestinal-Diarrhea has been reportedin only 1.5 percent of 7.450 clinical trial patients. It was very rarelysevere enough to warrant cessation of therapy. Nausea, vomiting,dyspepsia and abdominal pain have also occured.

Hypersewifivnty-Allergies (in the form of rash, urticaria and angioedema) have been observed. These reactions usually subsided upondiscontinuation of the drug.

Other reactions have included genital and anal pruritus, genitalmoniliasis, vaginitis and vaginal discharge. dizziness. fatigue. andheadache. Eosinophilia, leucopenia due to neutropenia, and slightelevations in SGOT and SGPT have been reported.SYMIPOMS AND TREATMENT OF OVERDOSAGE: No information isavailable on the treatment of overdose with Keflex. There is nospecific antidote.MICROBIOLOGY: Keflex is active against the following organisms invitro:

Beta-hemolytic and other streptococci (many strains of enterococci; e.g.. Streptococcus faecalis, are resistant)

Staphylococci. including coagulase-positive. coagulase-negative.and penicillinaseproducing strans (a few strains of staphylococci areresistant to cephalexin)Diplococcus pneumoniae Hemophilus influenzaeEscherichia coli Proteus mirabilisKlebsiella pneumoniae Neisseria catarrhalis

Keflex is not active against most strains of Enterobacter sp., Pr,morganii, and Pi. vulgaris. It has no activity against Pseudomonas orHerellea species. When tested by in vitro methods, staphylococciexhibit cross-resistance between Keflex and methicillin typeantibiotics.DOSAGE AND ADMINMRATION: Keflex is administered orally. Theadult dosage ranges from 1 to 4 g daily in divided doses. The usualadult dose is 250 mg every six hours. For more severe infections orthose caused by less susceptible organisms, larger doses may beneeded. If daily doses of Keflex greater than 4 g are required.parenteral cephalosporins. in appropriate doses should be considered.

The recommended daily dosage for children is 25 to 50 mg per kgdivided into four doses.Kelfei Suspension

Child's Weight 125 mg/5 ml 250 mg/5 ml10 kg (22 lb.) 2 to I tsp. q.i.d. -20 kg (44 lb.) I to 2 tsp. q.i.d. to I tsp. q.i.d.40 kg (88 lb.) 2 to 4 tsp. q.i.d. 1 to 2 tsp. q.i.d.

In severe infections, the dosage may be doubled.In the therapy of otitis media, clinical studies have shown that a

dosage of 75 to 100 mg per kg per day in four divided doses isrequired.

In the treatment of beta-hemolytic streptococcal infections, antibi-otic therapy should be administered for at least ten days.

To obtain maximum peak levels. cephalexin should be administeredon an empty stomach.DOSAGE FORMIS:

Tablets Keflex. equivalent to 250 mg cephalexin (No. 1894). Identi.Code 057. are supplied in bottles of 100. and 500.

Tablets Keflen, equivalent ho 500 mg cephalexin (No. 1895). Identi-Code 049. are supptied in botttes of 100. and 250.

Kefleo, for Oral Suspension, equivalent ho 125 mg cephalexin per5 ml teaspoonful. is supplied in a 100 ml size package (No. M 201).Identi Code W21.

Keflex, for Oral Suspension, equivalent ho 250 mg cephalexin perS ml teaspoonful. is supplied in a 100 ml size package (No. M.202),Identi Code W68.

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