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What Is Stress?
Author: Cleaves M. Bennett MD FACP
Monday, January 07, 2008

“The mind is its own Place, and in itself can make a Heav'n of Hell and a Hell of Heav’n.”
~John Milton

The Fight or Flight Response

Let's talk about cats. We've probably all seen a cat lying around in the sun at some time or another, looking very relaxed, taking life easy. Those creatures can be so relaxed on a windowsill; you'd think they were in the Bahamas. And then a dog shows up.

Suddenly the cat is very, very alert. Its hair stands on end, maybe it begins to show its claws, its muscles are suddenly very tense, and it may even begin to hiss. A lot of changes take place in a very short time. If we could somehow analyze those changes we'd have a pretty fair picture of what stress, and in particular what we call the stress reaction, is all about. So let's see what's going on inside that cat.

First of all the cat is just lying there, relaxed. Then there's an emergency—the dog. The cat's blood pressure shoots up, its pulse rate rises, its breathing speeds up, and its blood sugar and fat levels increase, to provide fuel so its muscles can do what they need to do-right away. All this is a completely automatic reaction.

The cat can't just sit there and tell itself, "So what, there's a new dog on the block." When it sees (or smells) that dog, its vacation is over. Survival reaction instantly occurs. Any cat that didn't immediately alert itself when a strange animal appeared wouldn't last very long. And what's going to happen; one of two things. Either the cat is going to fight or it's going to run.

Over the millions of years that these animals have been developing, this response has developed too. It's known, for obvious reasons, as the fight or flight response—and if you want to think of the nervous system as operating like a computer, you would say that this response has been hard-wired in. Whenever there's an emergency, this part of the nervous system turns on, and the rest is automatic. I like to call it the ENS, because that describes it.

That's what's going on when the cat smells a dog. And we have the same response hard-wired into us. We have our own ENS—and when trouble threatens, we too go into the fight or flight response.

The Relaxation Phase

What happens when there isn't an emergency? There's another part of the automatic nervous system that keeps everything running smoothly. We don't notice it, any more than we notice every spark that jumps across the plugs in our car or the circulation of gas, or the constant movement of the pistons. And when that part of the automatic nervous system is working, our bodies relax, digest food, and heal themselves. We're at ease. Just like the cat sunning itself on the windowsill.

The Balance

How do these two parts of the automatic nervous system work together? Obviously, when there's an emergency, the ENS needs to know about it and to take over the running of the body. So it keeps watchful. It never entirely shuts down. On the other hand, when there's no emergency in sight there's no point in being all fired up and ready to go, so the ENS keeps a low profile, and the relaxation and maintenance system kicks in.

It's like a teeter-totter. At any time, one or other of these two systems will be more active and the other will be in reserve. It's a delicate balance. Both aspects are important.

If we were living in Africa three thousand years ago, we'd be pretty good at keeping that balance. We'd relax in the sun some of the time, but when we needed to become especially alert—because we were out hunting antelope, and a tiger suddenly showed up—we'd go into that same fight or flight response and be well prepared to handle the situation. I say well because we as a species ended up on top. We keep tigers in zoos, not the reverse.

Stress and Today's World

But we're not living in the jungles and veldts of Africa, and tigers aren’t the kind of trouble we run into. The boss calls us onto the carpet. New, tougher production quotas are set. Traffic makes us late for a dinner party. Or our teenager plays the stereo way too loud. It's stressful. And we respond in exactly the way we would if we met a tiger! Our bodies prepare us for fight or flight. I'd like to get one thing clear right now. When I talk about stress I'm not talking about the things that happen in our everyday lives that cause stress, such as the boss's carpet, the production quota, the traffic, the loud stereo. The snafus and problems and uncertainties in life, the tough decisions we have to make, and the pressures we are all under are problems we all face. I am talking about our own reactions to those pressures and problems.

Most everyone is under pressure of some kind or another. But it's the way we handle ourselves under pressure, not the pressure itself, that's important. We'll talk in a bit about the kinds of circumstances that often tend to trigger stress in us, but stress itself is something that happens inside us, and that's the important distinction to grasp here. Stress is the upset you feel, not the situations that upset you.

Even if you find that last statement a little hard to believe, bear with me and keep on reading anyway You see, it's important for you to realize that stress (not your boss) is your problem—because you probably can't do anything about your boss, but you can do something about yourself!

Now let's talk about cats again. The cat and you both experience the same fight or flight response when there's an emergency—and you are both prepared to respond to the emergency by fighting or running, and then (when you'd taken one of those two strenuous physical actions) go back into the relaxed phase.

When the cat scents danger, the danger is always a very real physical threat. Right there in front of him. Whereas, when you and I get all warmed up and ready for fight or flight, the threat is seldom a physical one. The loud stereo, the new production quotas aren't things you can actually fight or run away from. But we get ourselves all steamed up anyway, just like the cat. Our muscles are primed for fight or flight, our blood pressure has shot up, and all the rest… but there's no dramatic physical action for us to perform, and no point at which we've taken action and can relax again. Even if our teenager turns off the stereo, we’re likely to be fuming inside for quite a while.

Sound familiar?

And that leaves us with the ENS switched on, blood pressure staying up, doing its damage, and a whole batch of angry chemicals swirling around in our bloodstreams.

Acute Stress

This brings me to my next point. If some kind of emergency happens, your stress response will automatically switch on and you'll take an appropriate action to deal with the danger. Once it's over, you'll relax again. You've experienced what we call acute stress. And there's nothing wrong with that. If you turn a corner in town a couple of blocks from the zoo, and there's an escaped tiger padding toward you, with a bunch of guards and policemen running after it, trying to capture it—or even if you're on the freeway, and the drunk in the lane next to you decides to move his car right into yours—that acute stress response will take over. It isn't just appropriate, it's wonderful. You personally and we as a species wouldn't be able to survive without it.

We've probably all seen movies or TV shows about animals in the Serengeti, or some of the other wildlife parks in Africa. You know how the zebras all run away when a lion comes by, and then, when the danger's over, they all start grazing again? If they were still upset they wouldn't be able to eat, right? When you're really upset and your survival is threatened, your appetite just isn't there either. It has to be that way, because if you were running from a lion, and you felt hungry before the danger was over, and you stopped to eat, you'd get eaten yourself. So not only is the stress response useful for getting away from danger—but the relaxation phase is important, because once the danger's over you need to be able to get back to business as usual.

If we all switched on the stress response in emergencies, and then switched it back off again when the danger was past-if we could relax afterward, the way the cat does, or those zebras do—there'd be nothing to worry about (and very little high blood pressure anywhere around). But can you curl up on a windowsill in the sun, with one arm hanging down the wall, and just bask? Especially just after the boss has hauled you onto the carpet? Can you really relax-and I mean, relax like the cat? Most of us can't relax that completely even when we're on vacation-even when we're in the Bahamas! And yet that's the great secret.

If you could relax as readily as the cat, if you could turn your ENS on when you needed to, and switch it right back off again when you didn't need it anymore, stress wouldn't be a problem.

So that's the skill we need to acquire. We need to be able to turn the ENS on and off, according to the circumstances. If we’re going to speak to an audience of fifty or a hundred people, or run to catch an airplane or a bus that we're late for—switch on the ENS. And when we've caught the plane or finished that speech--switch it off. Relax.

Chronic Stress

Our problems really begin when we start to experience chronic stress- when the stress response stays switched on more and more of the time and we never reach the phase of relaxation. How does that come about? One of the differences between us and the cat (or the zebra the antelope, or the lion) is that we can think about the past and the future. We have very good imaginations. And when we start regretting or resenting the past, or worrying about the future, we experience the stress response—even though there's no real, physical danger to deal with.

We go over in our minds what we should have said or done, if only we'd thought of it in time. Or we're sure things won't work out tomorrow at that job interview we’ve scheduled. And while we're lamenting the past and trying to avoid the future at all costs, we're picturing disasters. And our bodies just react to these imaginary emergencies as though they were real. Listen. The ENS is dumb. It doesn't know whether we're imagining the whole thing or whether it's real.

So we may wind up spending a whole lot of time with the ENS switched on, when there's actually no real threat present. If there's no threat present, there's nothing much we can do about it, is there? Yet even though there's nothing much we can do about it, we don't usually get to the point where it feels safe to relax again. And over the years, what tends to happen to many of us is that, once we get the ENS switched on, it never really goes off. So instead of going from 0 or 1 on a scale of 1 to 10, up to 7 or 8 when there's a real challenge, and then relaxing back down to 0 or 1, most of us begin to live around 4 or 5 or 6. It's where we live. It feels normal to us.

We wake up in the morning after a night's sleep, and what usually happens? We start thinking about our problems. We remember something that happened yesterday that we didn't handle real well, or we start thinking about problems that are going to crop up over the next few days.—right?

I know. I'm human, so I can have fifty-seven varieties of wonderful things going on in my life, and one problem, and my mind will go right to the problem. I start thinking about it. The sun may be out, it may be a beautiful day, but there I am, "down in the dumps" and worrying. And I begin to get tense. If I was thinking about any of the other fifty-seven things, I'd be feeling fine. But I tend to pick on the one thing that's not going so well and concentrate on that. Dumb! And there's almost always that one thing.

I went to see my accountant a while back and found out that I'd mislaid a tax form I was supposed to have filed many months ago, and I hadn't filed it yet. I didn't have to send any money, just the damn form—and yet somehow it had gotten buried on my desk.

So what's the penalty? I found out they could actually fine me ten dollars a day for every day the form was overdue. It's much worse than having books out and overdue from the library. And you know I got real upset. I was driving along thinking "My God, that could come to fifteen hundred or two thousand dollars-for nothing!"

Now in fact the IRS would be most unlikely to penalize me that much. And in fact, even if they did, my getting upset now wouldn't improve things at all. So when I noticed I was worried and tense, I decided I'd better calm down. Look at the flowers, notice the sunset, listen to some music.

Isn't that what we all do sometimes? Get upset about the things that might possibly present problems and forget all about the things that are going well now? I know we all have enough things happening in our lives one way or another that there's always room for improvement. There's always something that could have been done better. There are always plenty of things that could go wrong. And if those are the things we tend to focus on, we tend to react as though our lives were in danger—with the stress response—more and more of the time. Then the ENS almost never gets to take a break. Now that's chronic stress—and it's a problem. It's a whole different kettle of fish from the acute stress we were speaking about earlier. Your body is perfectly able to tolerate your ENS being switched, on and off, on and off, many times a day. That's how it's supposed to be. But when you keep it switched on continuously, all day long, day after day, that's a different thing completely.

That's chronic stress, and it's a killer. And I'll tell you why. Partly, it's because chronic stress is so damn near invisible. By the time stress has become nearly continuous we may not think of it as stress anymore. As I said before, it can seem normal to us.

If we lived at 0 or 1 on the stress scale, and went up to 5, say, we'd really notice the difference. We'd think, "Wow, I'm really excited, I'm really enthusiastic," or "I'm really riled up about this, it makes me mad." But if we live at 4 or 5, that level of stress arousal just seems normal to us, business as usual. And we may not think of it as stress.

In fact we may not admit to feeling stress until we get up to 8 or 9, when there's a big blowup of some kind, a big argument, or a traffic accident, or something like that. Then we know there's something going on. Then we'll admit we're feeling stressed, that we're upset.

But imagine a world where most of us don't think 5 or 6 is anything special. We not only have become so used to 4 or 5 or 6 that we hardly notice it anymore; we also actively avoid noticing it. It's not a very pleasant feeling, living at 5 or 6 on the “Richter” scale of stress—in fact it's so unpleasant that after a while we become less aware of it.

You know how we tend to shut out an irritating noise if it goes on for long enough—we just don't hear it anymore? Well, the same thing can happen with the unpleasant effects of a stress level of 4 or 5 or 6. We may pay less and less attention to it, until we just don't feel it anymore. So lots of people, when I ask them if they have much stress, tell me, "No, I don't have any stress to speak of. Most of the time, I'm just fine." But I can tell from the kinds of diseases they have that they're suffering from chronic stress. They're under stress all the time. They just don't know it. Afterward, when we've worked together and they've learned to relax, they just can't believe how tense they were feeling all along, without knowing it—or how much better they feel, now that they've learned to let go of their stress.

Since you are reading this book and have gotten into it this far, I presume that you have high blood pressure. If you have high blood pressure, you have high stress. Probably eat a high salt diet too. Salt alone usually doesn’t do the job. But stress alone will send the blood pressure up, it just takes a whole lot longer to become and stay chronically up than if the diet is salty too.

So part of the problem with chronic stress comes from the fact that it's almost invisible to us. And the other part of the problem—the other reason why it's such a killer—is because of the things it does. We talked earlier about some of the things that happen when the stress response is activated. Let's look at it in a little more detail: The blood pressure goes up, the pulse rate increases, we breathe faster, there's more sugar in the bloodstream, and more fat, and our blood is more ready to clot—in case we get scratched or bitten, and need to heal in a hurry.

The digestion (and some other systems) shut down, because they can wait until the emergency is over. Often the skin turns pale, because blood is being shunted to the muscles, and we say that we've blanched with terror or turned white as a sheet. Some people flush, because when you start running from danger your muscles will generate a lot of heat, you’ll need to prepare to get rid of it somehow, and one way is to start sending blood to the skin. And you may perspire for the same reason. Think of all the people who sweat when they are very nervous. This whole response is orchestrated by the nervous system and the glands of the endocrine system—and particularly by two hormones that come pouring out of your adrenal glands, named adrenalin and a little later, cortisone. Adrenalin is mainly responsible for the acute stress response, and cortisone has more to do with chronic stress. What does all this lead to, when the stress response is on day in and day out? The answer is that it can lead to a number of different problems. What's your weak point? What's your "target organ"? Because that's where it'll probably get to you.

In some people, we might see what's known as an "acute anxiety attack" (or hyperventilation syndrome, to give it its medical name). Free-floating anxiety. You're scared to death—but you don't know why. The symptoms are palpitations, a pounding heart, sweaty palms, flushing, heavy breathing, and the blood pressure going up. It can happen again and again.

There was this beautiful scene in the movie, Starting Over, with Burt Reynolds and Jill Clayburgh. I’ll never forget it. Burt Reynolds was in Bloomingdale's department store in New York City, and he had an acute anxiety attack with hyperventilation. It was perfectly done, very authentic.

If you saw the picture you may remember that the doctor who attended him finally looked up and saw a whole crowd of people staring down at Burt Reynolds as he was having his attack, and he said, "Does anyone have a Valium?" And of course everyone in the crowd had a Valium! That's America for you, filled with lots of people with a whole lot of anxiety, and hypertension. It's very, very common. And it’s been that way for a long time.

An increase in blood pressure is a normal part of the stress response, and if you're under stress most of the time your blood pressure will be up most of the time too. And that in turn puts you at risk of heart attack and stroke.

Your blood sugar may be continuously up. So it can be a cause of diabetes. One day I was at UCLA-Harbor General, the hospital where I teach, and I told one of my students that a certain patient we had seen together was suffering from "worry diabetes." The student wrote this down and then looked up and said, "I've never seen that before. Is that a new kind of diabetes or something?" Well, it is and it isn't. To be honest, I just made up the phrase on the spot. But the relationship between stress and diabetes has been around a long time.

I remember in medical school there were internists (or diagnosticians) who were medical doctors—and there were psychiatrists. And they were worlds apart in terms of interests and expertise. And then there were some psychosomatic doctors, doctors who believed that the mind somehow can cause or worsen medical disease. The students were always a little cautious, even skeptical of them, and I know for my part I kept my distance. My view of disease was much simpler and more automatic than that. Well, you live and learn! I know I did. We doctors need to remember that people, human beings, get sick. It's not only their organs we need to know so much about, we need to know about their families, and their jobs, and the pressures they're under.

Stress can focus on your lungs and you can get asthma. It can make that particular weakness in your makeup much worse—in fact it can be really disabling. Maybe your lungs are a problem anyway—as a result of air pollution, or smoking now or in the past. Stress will attack you at your weakest point.

We've already seen that, when your ENS is on, your digestion is partially if not completely shut down. And that can get to be quite a problem. Lots of people have "nervous stomachs," and some researchers even talk about people who have peptic ulcer personalities.

Stress can lead to many gastrointestinal problems, all the way from constipation and diarrhea to colitis and ulcers. It can even get to the point that the entire inside of your colon can peel off and you begin to bleed to death. You can perforate a stomach ulcer and die, which we all know was brought on by stress. That's how destructive, even fatal, chronic stress can be.

When people are very sick, when they've had a heart attack or stroke or some other serious illness, and they're very frightened—they can literally die from stress ulcers. Bleed to death. Right there in the Intensive Care Unit. Stress can be and is a killer.

Women, who have been through a really upsetting and stressful event such as the death of a child, or a divorce, or the loss of one of their parents, may destroy their thyroid glands, just like that, zap! Destroy them. In fact, when a woman patient appears in my office with a destroyed thyroid (it's called thyroiditis), I'll usually find that she suffered a catastrophic loss sometime in the year before.

Stress can cause or worsen arthritis, first of all because it causes chronic muscle tension, and the muscle tension hurts the joint between the muscles, just beats it up again and again.

And again, stress can hurt the body so much that the immune system (that's the system that's supposed to fight against foreign viruses and bacteria, and kill them) becomes abnormal. Then we say, "My resistance is down," and we may get a cold, or boils, or a bladder infection. This weakening of the immune system can also lead to joint destruction and arthritis. That's called autoimmunity—the immune system destroys you instead of the foreign bodies.

Stress may also be the way that cancer gets its start. I was on a panel TV program, and the moderator was a doctor, a cancer specialist. We were talking about stress, and be pointed out that there's mounting evidence to suggest that cancer is certainly helped along by stress—if not actually caused by it in some instances.

And on and on, in fact, it's fair to say that any weakness you may have—any tendency you've inherited, or any weakness that's left over from an old injury, anything—can be the place where stress hits you. If you put the wing of an aircraft under a lot of stress and it has a hidden weakness, that's where it breaks. And it's the same way with us. That's where we break—at the weakest spot.

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