Before signing off, I would like to present some of the evidence pointing to the fact that stressors, other than social dislocation, cause heart disease. Also, that short-term stressors, e.g. cocaine use, trigger the final, fatal thrombosis.
What follows is a rather eclectic list of stressors. The main point I am trying to get across here is that – in the end – everything links back to the impact that stressors have on the HPA-axis. And when I say everything, I mean everything.
POSITION IN SOCIAL HIERARCHY
With psychological stress, some people have found it useful to define damaging stress as the type of stress that makes you feel trapped, that you have no control over. This has been lumped under the heading ‘man in a box’. This means that the worst types of psychological stress are often found in those low down the social hierarchy. Untouchables in India, or migrants living in another country, or Australian Aboriginals, or people who do jobs that are held in contempt by others in society, e.g. traffic wardens. These are ‘situations’ that are reactive, and oppressive, and crushing to the spirit.
On the other hand, a CEO of a company, or a prime minister, has a lot to deal with, but each can always, if they wish, stop doing it. They have money, they have status, they can get another job at any time. People defer to them, listen to them, treat them with respect. They sit atop the pile, and those who sit atop the pile are in charge of their own destiny.
It’s not just human beings who are better off if they sit at the top of the pile, either. There are many studies demonstrating that dominant monkeys are protected against heart disease, while subordinate monkeys are not. Here is a quote from just one study on macaque monkeys, ‘Effects of gender and social behavior on the development of coronary artery atherosclerosis in cynomolgus macaques’, published in Atherosclerosis:
Males had significantly more extensive coronary artery atherosclerosis than did females. Further, among both males and females, submissive animals (low in competitiveness) had more extensive coronary artery stenosis than did their dominant (highly competitive) counterparts.
In the monkey world, at least, it seems that Type A monkeys do rather better than Type Bs.
There is also very clear evidence that humans who sit at the top of the pile are protected against heart disease (and many other type of disease as well). The Whitehall Study, which has been going on for years, has found that civil servants in higher-ranking jobs suffer much less heart disease, and live far longer, than those further down the pecking order. This seems to be modulated, primarily, by a lack of job control. Here is just a short section from one of the many papers on the Whitehall Study, published in the BMJ in 1994:
Low control in the work environment is associated with an increased risk of future coronary heart disease among men and women employed in government offices.
If you care to, you can find hundreds and hundreds of papers on the topic of social hierarchy, social status and heart disease. You will always find the same thing. Those low down on the ladder, be it rats, monkeys, or humans, are at far greater risk of dying of heart disease. It seems that social inequality leads, inevitably, to health inequality.
However, the Whitehall Study reveals something else rather interesting, which is that position in social hierarchy is much more important to men than it is to women:
Although the Whitehall II cohort is an office-based occupational cohort there seems no reason why these results should not generalize to the population at large. Altogether, the results of this study support the existing evidence that psychological distress is a risk factor for CHD, in men, if not in women [my emphasis].
I have not, up to this point, suggested any reason why women suffer less heart disease than men – in most populations. However, at this point I am going to explain why women get less heart disease than men – in most populations.
A pedant would say that women do not get less heart disease than men, they just tend to get heart disease about ten years later. In other words, for every man that keels over of heart disease at 50, there is a women keeling over at 60. And for every man dropping dead at 60, there is a women dropping dead at 70 – and so on. Until, of course, there is no one left to drop dead of anything.
This is not true of all populations everywhere, but it is generally true. Which suggests that there is something going on in most populations that makes heart disease develop far more slowly in women. Is this caused by a difference in their ‘stress response?’ I believe so.
As a wise man once said – and if he didn’t, he probably should have – if you watch a riot, or protests, or fights at football matches, or wars, you don’t tend to see that many women involved. Major acts of hostility and aggression – they’re kind of a man thing. Don’t blame us, though, I think we were made that way. And while all this aggression was a good thing to have in our primitive past, it doesn’t work quite so well when your most fearsome enemy is a parking attendant, or the plastic wrapper on a child’s toy. Or, in fact, many of the hugely frustrating things that make up life today.
Beating the living daylights out of a sabre-toothed tiger was probably enormously exciting and satisfying. But we successfully beat the living daylights out of the last sabre-toothed tiger years ago and now there are none left. PlayStation is not quite the same. Which is why we men have taken to racing cars, gambling, sky-diving, boxing, rioting at football matches and suchlike. Of course there are men who don’t do such things, and women that do, but it’s a pretty good generalization to say that women, in general, do not react in such hostile and aggressive ways to stressors – or life in general.
In fact, I think that there are three interconnected reasons why women are protected from heart disease:
1: They are less hostile/aggressive to start with.
2: They are better at developing social support networks.
3: They respond in a physiologically different way to stressors.
Or, to put this another way, women are made of sugar and spice and everything nice. Men are made of slugs and snails and puppy dog’s tails. However, is there any evidence for a real, measurable difference? Only a few hundred thousand papers, or so. Just to give you a feel for this area.
To start with, the British Heart Foundation looked at the social support, or the lack of it, between various social classes, and between men and women (see Fig. 31). As you can see, people in lower social classes felt that they had far less social support. And in all social classes, a far higher percentage of men reported a severe lack of social support.
And social networks are important. The Stockholm Female Coronary Risk Study looked at women who had suffered heart disease with a particular emphasis on integration and depression among this group. They found that women who lacked social integration – and had two or more depressive symptoms – had four times the rate of serious heart disease recurrence (up to and including death) as women who were free of these characteristics. The actual figures were 35 per cent vs 9 per cent.
Fig. 31 Percentage of people who report severe lack of social support in the UK
The importance of social support was strongly supported by another Swedish study (what is it about the Swedes and stress?):
The results of our study suggest that lack of emotional support, social isolation, and lack of interpersonal social relations are important risk factors for accelerated progression of coronary atherosclerosis in middle-aged women.
Wang HX. ‘Influence of social support on progression of coronary artery disease in women’, Soc Sci Med, 2005
And, yes, social support is also important for men:
In this prospective study of men, we found two dimensions of low social support – low social integration and low emotional attachment – to be predictive of coronary morbidity, independently of other risk factors.
Rosengren A, ‘Coronary disease in relation to social support and social class in Swedish men. A 15 year follow-up in the study of men born in 1933’, Eur Heart J, 2004
In short, social support is very important at protecting against heart disease. In general, women have much better social networks than men. But I don’t suppose that you needed me to tell you this.
Apart from having better social networks, women also seem to deal with stress in a different way.
Why are men more susceptible to heart disease than women? Traditional risk factors cannot explain the gender gap in coronary heart disease (CHD) or the rapid increase in CHD mortality among middle-aged men in many of the newly independent states of Eastern Europe.
However, Eastern European men score higher on stress-related psychosocial factors than men living in the West. Comparisons between the sexes also reveal differences in psychosocial and behavioral coronary risk factors favoring women, indicating that women’s coping with stressful events may be more cardioprotective.
Weidner G, ‘The gender gap in heart disease: lessons from Eastern Europe’, Am J Public Health, 2003
Few studies have focused on risk factors in women’s lives concerning psychosocial factors and coronary heart disease (CHD)… Significant differences appeared concerning five areas: work content, workload and control, physical stress reactions, emotional stress reactions and burnout. All showed that the relative sensitivity was larger for women than for men.
Predictive psychosocial risk factors for women with respect to CHD were physical stress reactions, emotional stress reactions, burnout, family relationships and daily hassles/satisfactions, and they were on approximately the same level as biomedical risk factors.
Women appear to be more sensitive than men with respect to psychosocial risk factors for CHD, and the predictive ability of psychosocial risk factors shows great importance. Actions against unhealthy psychosocial conditions are recommended. Both presumptive CHD patients and others might benefit from preventive actions, and since women are more sensitive they will probably gain more than men.
Hallman T, ‘Psychosocial risk factors for coronary heart disease, their importance compared with other risk factors and gender differences in sensitivity’, J Cardiovasc Risk, 2001
However, it is not just better social networks and superior coping mechanisms that make the difference. It is clear that men, when exposed to the same type of psychological stressor, have a much more violent HPA-axis reaction.
A study in Germany published in the Journal of Clinical Endocrinology and Metabolism showed that, when stressed, men produce nearly twice as much ACTH as women. (ACTH is the precursor hormone that triggers the release of cortisol (see Fig. 32)).
Fig. 32 Comparison of ACTH produced by men and women in stressful situations
You see, us poor men are at the mercy of our hormones too. The difference is that our hormones kill us – if we haven’t killed someone else first. ‘Get your finger off that button, Mr President.’
For whatever reason, and I can think of many, men respond more dramatically to stressors. We fire up our stress hormones far more powerfully and we find it harder to get things back under control again. By way of illustrating this, here’s a quote from a study called ‘Gender differences in hypothalamic-pituitary-adrenal (HPA) axis reactivity’:
Following the psychological stressor, adrenocorticotropin (ACTH) and cortisol responses were significantly greater in male subjects compared to female subjects.
In summary, women are better at recognising that they are stressed and have better coping mechanisms. Their HPA-axes are not provoked into such a violent reactions by stress, and if they are, they have a better network of social support then men to cope with think. Maybe it’s time for us guys to get in touch with our feminine side?
COCAINE USE
Cocaine has a major impact on the heart. It causes sudden cardiac death, angina and myocardial infarction. While this is an undisputed finding, most authorities do not know how, or why, this happens.
What they ought to do is type the words ‘cocaine and HPA-axis dysfunction’ into a search engine of their choice. They would then find all the information they need. For example:
Scientists have been aware of the existence of a complex relationship between stress and the subsequent activation of the hypothalamic-pituitary-adrenal (HPA) axis and the endocrine and neurobehavioral effects of cocaine for many years now.
Goeders NE, Psychoneuroendocrinology, 2002
The fact is that cocaine is one of the most powerful stimulants of the HPA-axis known to man. Cocaine use burns out the HPA-axis, it causes depression, it creates blood clotting abnormalities. Taking it is almost the perfect way to kill yourself from heart disease, and it can occur very quickly. To quote from www.ScienceDaily.com:
During the first hour after using cocaine, the user’s risk of heart attack increases nearly 24 times, according to the first large study of the long-suspected relationship between cocaine and heart disease. The research is reported in today’s Circulation: Journal of the American Heart Association.
And some people try to tell me that stress doesn’t cause heart disease, or trigger fatal heart attacks.
FOOTBALL – A MATTER OF LIFE AND DEATH
Rather surprisingly, some researchers decided to look at the impact of football on the rates of death from heart disease. In 2003, a study was published in the Journal of Epidemiology and Public Health called ‘A matter of life and death: population mortality and football results’. And what did they find?
On days when the local professional football team lost at home, mortality attributable to acute myocardial infarction and stroke increased significantly in men. No increase was observed in women.
However, when France won the World Cup in 1998, there was a considerably lower mortality from heart attacks the next day – as written up in a paper called ‘Lower myocardial infarction mortality in French men the day France won the 1998 World Cup of football’, and published in Heart.
By the way, this is not fringe research. A study was published in the BMJ in 2002 called ‘Admissions for myocardial infarction and World Cup football: database survey’, which revealed that:
Risk of admission for acute myocardial infarction increased by 25% on 30 June 1998 [the day England lost to Argentina in a penalty shoot-out] and the following two days. No excess admissions occurred for other diagnoses or on the days of the other England matches.
To misquote Bill Shankly:‘Football isn’t just a matter of life and death… It is life and death.’
Golly, you mean that the stress of watching your football team lose can kill you? Well, so can getting up on a Monday morning…
MONDAY MORNINGS – DON’T GET OUT OF BED
As published in the European Journal of Cardiology in 2003:
The incidence of sudden cardiac death is markedly increased on Monday, more pronounced in non-hospitalised patients. Our results may point to the relevance of naturally occurring rhythmic fluctuations in human physiology, and socially determined rhythms in human behaviour as underlying mechanism.
So the number four doesn’t wipe out us westerners, but Mondays do. In Japan, though – if you are a woman – Saturdays are deadly. I wonder why? Isn’t marriage a wonderful thing…
Leaving Monday mornings behind for a moment, wherever you look you will find the same things. Stressful events, be they physical or psychological, greatly increase the risk of dying of heart disease. For example, a study published in the British Heart Journal in 1975 found the following:
The deaths of 100 men due to coronary artery disease which occurred so suddenly and unexpectedly as to merit a coroner’s necropsy have been studied, with special reference to the exact circumstances of their occurrence. The most significant relationship of sudden death was with acute psychological stress.
Here follows a short list of some of the other things that have been found to increase the risk:
• Shovelling snow after a blizzard
• Being a fighter-jet pilot
• Earthquakes
• Squash
• Exposure to congestedtraffic (three-fold increased risk of MI in the next 24 hours)
• Rapid temperature change
• Cold weather
• Episode of severe anger (risk increased 15-fold in the following hour)
Wherever you look, you will find that hundreds, even thousands, of studies have been done. They all show exactly the same thing. Stress causes heart disease. It can be long term, it can be short term, it can be physical or psychological. It doesn’t matter, the HPA-axis converts all types of stress into the same deadly mix.
Ironically, of course, this was all recognised hundreds of years ago. In 1628, William Harvey, the man who first worked out how the cardiovascular system worked, described a man with heart disease as: ‘Overcome with anger and indignation and unable to communicate it to anyone.’ In 1793 John Hunter, the most famous physician of his time, believed that angina was related to ‘agitation of the mind’. He died suddenly in a stormy board meeting the very same year. It is thought that he died of a heart attack. At the start of the 20th century, William Osler, another eminent physician, described the typical victim of heart disease as:
A well set man from forty-five to fifty five years of age, with military bearing and iron grey or florid complexion. Robust and vigorous of mind and body whose engine is always at full ahead.
Oh yes, heart disease has been with humanity for many years. It is not new. In fact, it was perfectly described by the 18th-century London physician William Heberden. In 1772, he first outlined the condition that he called angina pectori:
Heberden’s description of angina
But there is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned at more length. The seat of it and the sense of strangling and anxiety with which it is attended, may make it not improperly be called angina pectoris.
Those who are afflicted with it are seized while they are walking (more especially if it be uphill, and soon after eating) with a painful and most disagreeable sensation of the breast, which seems as if it would extinguish life if it were to increase or to continue. But the moment they stand still, all this uneasiness vanishes.
In all other respects the patients are, at the beginning of this disorder, perfectly well, and in particular have no shortness of breath, from which it is totally different. The pain is sometimes situated in the upper part, sometimes in the middle, sometimes in the bottom of the os sterni (breast bone), and often more inclined to the left than the right side. It likewise very frequently extends from the breast to the middle of the left arm. The pulse is, at least sometimes, not disturbed by this pain, as I have had opportunities of observing by feeling the pulse during the paroxysm. Males are more liable to this disorder, especially such as have passed their fiftieth year.
After it has continued a year of more, it will not cease so instantaneously upon standing still: and will come on not only when the person is walking, but when they are lying down, especially if they lie on the left side and oblige them to rise out of their beds. In some inveterate cases it has been brought on by the motion of a horse, or a carriage, and even by swallowing, coughing, going to stool or speaking, or any disturbance of the mind
Such is the most usual appearance of this disease; but some varieties may be met with. Some have been seized while they were standing still, or sitting, also upon first waking out of sleep; and the pain sometimes reaches to the right arm, as well as to the left and even down to the hands, but this is uncommon; in a very few instances the arm has at the same time been numbed and swelled. In one or two persons the pain has lasted some hours or even days; but this has happened when the complaint has been of long standing, or thoroughly rooted in the constitution; once only the very first attack continued the whole night.
I have seen nearly a hundred people under this disorder, of which number there have been three women and one boy twelve years old. All the rest were men near or past the fiftieth year of their age.
The termination of angina pectoris is remarkable. For if no accident interferes, but the disease goes on to its height, the patients all suddenly fall down, and perish almost immediately.
And perishing almost immediately is what I am trying to help you avoid.
POSTSCRIPT
By now, I hope you know what causes heart disease, and what you may be able to do to prevent it. Some things that I have outlined are the same things that the medical mainstream has been saying for years. Do not smoke cigarettes. If you do not smoke cigarettes you will live longer, and more happily, and be considerably better off. Cigarettes are, quite frankly, pointless and deadly.
Also, take exercise. Take the type of exercise that you enjoy, join a club, go walking, do something – anything – to avoid sitting doing nothing. Human beings need some exercise; if they don’t get it, they degenerate. They also become depressed, anxious and unhappy.
If you don’t drink alcohol, start. If you do drink, drink regularly – don’t binge drink – and make sure you enjoy what you drink. Drink with friends, drink sociably; don’t drink to get drunk.
If you hate your job, try and find another one. If you have a bully for a boss, take them to an industrial tribunal and sue their ass. Don’t let anyone push you about. Don’t be a victim. Don’t feel trapped. Assert yourself and ensure that people give you the respect that you – indeed, all of us – deserve.
Make a new friend. Join a club. Find an area of life that you enjoy and can enjoy in the company of other people. Praise other people, and try to compliment people more often. As ye sow, so shall ye reap. Look forward to something enjoyable every day, every month and every year.
Does this sound like a list of homilies? A tea towel for the soul? I hope not, or if it does, I hope it does not put you off doing what you need to do. What you always knew you should do, in fact.
Everyone has always known that stress kills. The medical profession, which has a horrible aversion to accepting that there is any connection between the mind and the body, has tried to crush this ‘knowledge’ using western scientific methodology as its weapon of choice. ‘We can’t measure stress, so it doesn’t exist.’
Ironically, it is western science that proves the connection – if you choose to accept the evidence of your own eyes. The Catholic Church wouldn’t look through Galileo’s telescope – a fact that ‘scientists’ regularly use to castigate religion. Well, guys, the second half of this book has been a telescope focused on stress. All I ask you to do is look through it.