Stress and Disease

Dr. Donald B. Giddon Harvard University,

Fall 2013

Introduction and Overview

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The Four Core Questions1. What factors are stressful for a given individual? (QI)

2. What direct and indirect neurohormonal or behavioral pathways are activated by stressors? (QII)

3. Why is a particular organ or system selected as the target of stress-related disorders? (QIII)

4. What are the cognitive, affective, and behavioral responses to disease? (QIV)

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CHANGES IN HOW DISEASE IS VIEWEDCHANGES IN HOW DISEASE IS VIEWED

TimeTime Etiology Etiology Disease PatternDisease Pattern Provider Provider PhilosophyPhilosophy

BCE BCE DemonsDemons Plagues (Black, cholera, typhus) Religion Purity-Plagues (Black, cholera, typhus) Religion Purity-Poor lifestyle Poor lifestyle TraumaTrauma Exorcism Exorcism Priests PriestsHippocratesHippocrates Shamans Shamans

IsolationIsolation Sanitation Sanitation HygieneHygiene air, diet, sleepair, diet, sleep

18501850 Biology Biology Infection Infection MedicalizationMedicalization (Virchow)(Virchow) 2/3 of deaths2/3 of deaths Social ControlSocial Control

1900 to1900 to Biopsychological CVD Biopsychological CVD Medical and Medical and Prevention Prevention1950+1950+ Degenerative Neoplasm Degenerative Neoplasm Psychosocial Psychosocial

(Cancer)(Cancer)

1970- CVD associated 1970- CVD associated presentpresent Life Style Life Style with agingwith aging WellnessWellness

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CHANGES IN HOW DISEASE IS VIEWED - continuedCHANGES IN HOW DISEASE IS VIEWED - continued

Time Time Acute Acute Communicable Communicable

BCEBCE

18501850

1900 to1900 to1950+1950+

Chronic Chronic Noncommunicable Noncommunicable

1970-present lifestyle (50-70%)1970-present lifestyle (50-70%)

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Demographics

• Sexo Gendero Age

• Race• National origin• Ethnocultural• BMI• Occupation

Changes in Physical, Social, Changes in Physical, Social, and Environmental and Environmental

Health ThreatsHealth Threats

From 20,000 BCE to Modern From 20,000 BCE to Modern TimesTimes

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• Food supplyFood supplyo StarvationStarvationo Nutritional statusNutritional status

• Water supply Water supply o Quality Quality o QuantityQuantity

• PredatorsPredators

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• New PathogensNew Pathogenso MicrobesMicrobes

BacteriaBacteria VirusesViruses FungiFungi OtherOther

o New allergensNew allergens• Environmental hazardsEnvironmental hazards

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• Religious and social attitudes

• Health–related behaviors

• Sanitation measures

• Availability of trained health care providers

• Socio-economic factors

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• Geographic factorso Climate o Locationo Population density

Crowding Psychological vs. physicalo Transportation

• Other quality of life issues

• Communicationo Masso Interpersonalo Doctor-patiento Health literacy

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Resulting Common Health Problems in Modern Times

• Starvation• Cancer• Stroke• Violence• Accidents• Suicide

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Resulting Common Health Problems in Modern Times – continued

• New infectious diseases• Auto-immune diseases• Allergies• Acute mental illness – e.g. anxiety,

depression, PTSD

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• Obsession with physical attractiveness o Narcissismo Body dysmorphic disorder

• Pain• Overuse of Medicationso Prescriptionso Over the Counter

Resulting Common Health Problems in Modern Times – continued

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• Antibiotic-resistant micro-organisms • Superinfection• National disasters• Changes in leisure activity• Changes in provider behavioro Medical mistakes

Resulting Common Health Problems in Modern Times – continued

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• Chronic disease associated with lifestyle and longevity:o Lifestyle

Heart disease HIV Addiction

o Computer Obesity Melanoma Respiratory – COPD, etc.

Resulting Common Health Problems in Modern Times – continued

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o Longevity Alzheimer’s and dementia Depression Osteoporosis Decreased sensory acuity

Eyes, Ears, Nose

Resulting Common Health Problems in Modern Times – continued

Resulting Common Health Problems in Modern Times – continued

o Longevity – continued Decreased motor ability including

balance

Skin problems

Diabetes Type 2 Disability

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Other Physical, Psychological Other Physical, Psychological and Sociocultural Variables and Sociocultural Variables

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Race and Age Differences

•Women live 5.1 years longer than men.

•This is the first time that the data indicate U.S. black males have a life expectancy of 70 years.

Rachel Anderson [rachelmiyoko@gmail.com]

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Pathways linking SES and Health

The solid lines indicate pathways studied by MacArthur Network on SES & Health; dashed lines indicate pathways of importance not studied. In: Adler and Stewart, 2010.

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Death rates correlate with income inequality across the 50 U.S. states and 10 Canadian Death rates correlate with income inequality across the 50 U.S. states and 10 Canadian provinces. (Adapted from Ross et al.)provinces. (Adapted from Ross et al.)

Death Rates and Income

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Looking at the Causes of Major Chronic Diseases

(Chronic refers to longterm responsibility)

Heart diseaseCancerStroke

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The State of Cancer

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BMI and Disease Risk

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Multivariate relative risk of death from cardiovascular disease, cancer and Multivariate relative risk of death from cardiovascular disease, cancer and all other causes among men and women who had never smoked and who all other causes among men and women who had never smoked and who had no history of disease at enrollment, according to body-mass index. had no history of disease at enrollment, according to body-mass index. The reference category was made up of subjects with a body-mass index The reference category was made up of subjects with a body-mass index of 23.5 to 24.9.of 23.5 to 24.9.

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Translocation

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47.5 million U.S. Adults Report a Disability: Arthritis Remains Most Common Cause

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Reducing Disability is a Major Problem

Increasing physical activity and reducing or preventing obesity and tobacco use can eliminate some of the underlying causes of disability and prevent secondary conditions in those already affected.

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Following arthritis, back, spine, and heart trouble are the top three causes of disability.

Common identified limitations were: climbing stairs, walking three city blocks, accounting for 10% of adults.

Disability increases with age. Women have a higher prevalence of disability than men.

Some Other Gender Differences

OSTEOPOROSIS – is 6-8 times more prevalent among women than men.

SYMTOMS OF CARDIAC DISTRESS – Women may experiene signs of cardiac distress differently from men. In addition to classic signs – chest pain, shortness of breath pain in arm -, symptoms such as chest discomfort with nausea, fatigue and lightheadedness are more common in women than in men.

HEART DISEASE – diagnosis of heart disease in women is more difficult than in men. EKGs conducted on women during exercise stress tests may provide misleading results. New ways – such as monitoring a 2nd type of EKG (QT dispersion) – to improve ability to correctly diagnose coronary heart disease are being developed/studied.

AUTO-IMMUNE DISEASES – Women have more auto-immune illnesses – lupus, MS, and rheumatoid arthritis – than men, suggesting that their immune systems may work differently from men’s.

DIABETES – Women have a higher risk than men of developing diabetes (major contributor to heart disease).

CHOLESTEROL – Cholesterol levels in men stay fairly constant during aging, while women’s levels rise after age 35. Low levels of HDL (“good “ cholesterol) are stronger predictor of heart-disease-related death in women than in men. High levels of triglycerides may be more important heart disease risk factor in women than in men.

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A large number of nurses reported seeing medical errors by physicians, but only a small

number ever reported them

States with Greater Than 10% of Population Lacking Basic Literacy

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Overuse of Antibiotics-An Additional Leading Cause of Death

• Enterocolitis due to Clostridium difficile (C. difficile), a bacterial inflammation of the intestines, is of growing public health concern because it is often acquired in hospitals or other health-care institutions with long-term patients or residents and accounts for an increasing number of deaths.

• In 2007, this cause was not among the 20 leading causes for the overall population. However, it ranked among the 20 leading causes of death for the population aged 65 years and older. Approximately 92% of deaths due to C. difficile occurred in persons aged 65 years and over in 2007.

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Role of SES and Dietary Choices in Relation to Health and Disease

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Diets

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Predisposing VariablesPredisposing VariablesAge, gender, SES, previous experiences: education, culture, race, religion, familyAge, gender, SES, previous experiences: education, culture, race, religion, family

Intervening Variables: Cognitive and AffectiveIntervening Variables: Cognitive and Affective Knowledge, attitudes, beliefs, values (significance of health)Knowledge, attitudes, beliefs, values (significance of health)

Objective need PerceptionsObjective need Perceptions Objective status of health care resources Objective status of health care resourcesfor health care (subjective) for health care (subjective) (facilities, finances, personnel) (facilities, finances, personnel)

Need for Health CareNeed for Health Care Health Care ResourcesHealth Care Resources - Therapeutic care (pain relief, appearance) - Therapeutic care (pain relief, appearance) - Availability - Availability treatment of disease) treatment of disease) - Accessibility - Accessibility - Preventive care (personal suseptibility, - Preventive care (personal suseptibility, - Acceptability - Acceptability seriousness of disease, preventability, seriousness of disease, preventability, salience relative to other needssalience relative to other needs self-efficacy)self-efficacy)

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Evaluation & Training of Evaluation & Training of Health Care ProfessionalsHealth Care Professionals

Dr./Pt. TreatmentDr./Pt. Treatment SituationSituation

SubjectiveSubjective NeedNeed

Objective NeedObjective Need

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Biological Factors

PSYCHOSOCIAL FACTORS

Human Resources